Longwood Manor Conv.hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4853 W. Washington Bl., Los Angeles, California 90016
- CMS Provider Number
- 055753
- Inspections on file
- 65
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Longwood Manor Conv.hospital during CMS and state inspections, most recent first.
Surveyors found that a resident on Enhanced Barrier Precautions (EBP) for wound-related concerns had multiple staff personal items, including purses, bags, and drink containers, stored on top of the closet in the resident’s room. The resident, who had cirrhosis, pleural effusion, and muscle weakness and required substantial/maximal assistance with ADLs, denied ownership of the items and could not identify who placed them there. The IPN confirmed that staff should not store personal belongings in an EBP room, as this practice conflicted with the facility’s EBP and infection control policies intended to prevent transmission of multidrug-resistant organisms and other infections.
Staff failed to keep the smoking patio door closed, allowing cigarette smoke to enter the building and be detected in hallways near resident rooms. A CNA was observed leaving the door open and acknowledged the issue, while the Infection Prevention Nurse confirmed that smoke in the building can cause annoyance and breathing difficulties for residents. Facility policy requires maintaining a homelike environment with neutral scents, which was not upheld.
A resident with muscle weakness, an artificial hip joint, and a contracture was not provided with physician-ordered bilateral knee splint application by the RNA as required. Documentation over a 30-day period showed no evidence that the splints were applied as ordered, despite the care plan and facility policy specifying the need for restorative nursing care to maintain function.
Multiple residents did not receive their prescribed medications, including metformin, gabapentin, and pain medications, at the times ordered by their physicians. Medications were administered late or missed entirely, and pain assessments were not consistently documented, contrary to facility policy. Staff interviews confirmed delays and omissions in medication administration and documentation.
A resident's insulin was not relabeled or discarded after a physician changed the dosing order, resulting in the medication cart containing insulin with outdated instructions. The nurse did not immediately notify the pharmacy or place a change of order label on the medication, contrary to facility policy, leading to a risk of medication administration errors.
Surveyors found that staff did not ensure call lights were within reach for two residents who required significant assistance with ADLs, and oral care was not provided for one resident after meals. Both a CNA and an LVN confirmed the call lights were not accessible as required by care plans and facility policy, and the CNA acknowledged oral care was missed following a room transfer.
A registered nurse lacked the necessary competencies to accurately assess a newly admitted resident, resulting in the resident receiving an unnecessary higher dose of Seroquel for an incorrect diagnosis and experiencing a delay in the identification and treatment of a significant pressure ulcer. Facility staff did not follow proper admission assessment protocols, leading to both medication errors and delayed wound care.
A resident was administered Seroquel, an antipsychotic medication, without documented assessment or adequate indication for its use. The medication was continued for a diagnosis of bipolar disorder that was not supported by clinical records, and behavior monitoring did not show symptoms warranting its use. Staff and family noted increased lethargy and reduced participation in therapy, while the physician confirmed the absence of a bipolar diagnosis and acknowledged the medication was continued without proper verification.
Several residents at risk for pressure ulcers were not provided with low air loss mattresses as ordered, and two residents with such mattresses had incorrect weight settings, contrary to physician orders and facility policy. Staff interviews and observations confirmed these deficiencies, with staff acknowledging the importance of proper mattress use and settings for pressure ulcer prevention.
Two residents with significant physical dependencies and physician orders for daily bilateral elbow splint application did not receive these restorative nursing services every day as required. Review of documentation and staff interviews confirmed that the splints were not applied daily, contrary to care plans and facility policy, placing the residents at risk for decreased range of motion and contractures.
Three residents were found to have accident hazards in their rooms, including vape devices with cannabis symbols, an improperly padded bed rail for a resident with a seizure disorder, and a lighter kept by a supervised smoker. Staff interviews and observations confirmed that these items were not properly secured or supervised, contrary to facility policy and physician orders.
The facility did not ensure that physician-ordered laboratory tests were completed for two residents, including missing a CBC, CMP, and Ammonia level for a resident with malnutrition and failing to perform weekly pre-albumin blood draws for another resident with encephalopathy and generalized edema, as confirmed by staff interviews and record reviews.
Surveyors observed that an opened box of pasta in dry storage was not labeled with an open date, contrary to facility policy, and the outside compartment of the ice machine was found dirty with hard water deposits. The Dietary Service Supervisor confirmed that staff were responsible for labeling opened food items and cleaning the ice machine, but these practices were not followed or documented as required.
Two residents with significant respiratory conditions and dependent on staff for care were not offered the influenza vaccine, and there was no documentation of the vaccine being administered or declined. Facility records, care plans, and the immunization registry all lacked evidence of vaccine offer or refusal, despite facility policy requiring such documentation.
A resident with cognitive impairment and dependence on staff for ADLs was found with all four bed rails raised without proper assessment or documentation of alternatives, as required by facility policy. Staff interviews and record reviews confirmed that alternatives to bed rails were not attempted or documented prior to their use.
A resident with a documented diagnosis of depression and prescribed antidepressant medication did not have this diagnosis coded in the MDS assessment under the appropriate section. The MDS nurse confirmed the omission, despite facility policy requiring accuracy in MDS completion. This resulted in incorrect data being sent to CMS and could have impacted the resident's care plan.
A resident with documented diagnoses of bipolar disorder and major depressive disorder was admitted without the facility completing and resubmitting a PASARR Level I screening to reflect these mental illness diagnoses. The initial screening from another facility did not identify serious mental illness, and as a result, no Level II evaluation or referral to the state mental health authority was made, contrary to facility policy and federal requirements.
A resident with significant cognitive and physical impairments, who was at risk for pressure ulcers, did not have a care plan updated to specify the use of a low air loss (LAL) mattress. The care plan only referenced general pressure-relieving devices without identifying the LAL mattress, and staff confirmed the omission during review.
A resident with malnutrition, diabetes, and heart failure experienced significant weight loss and had a physician's order for weekly weights, but staff failed to complete and document these weights as required. This resulted in inadequate monitoring of the resident's weight loss, despite care plan interventions and facility policy requiring such monitoring.
A resident with bilateral lower extremity edema and a physician's order for daily compression stockings did not receive them for two weeks due to ill-fitting old stockings and a delay in obtaining new ones. The resident, who was cognitively intact, reported the issue to staff, and both the treatment nurse and DON confirmed the lapse in care, acknowledging that the physician's order was not followed.
A resident with a history of cellulitis, hypertension, and muscle weakness, who was cognitively intact and required supervision for hygiene, did not receive a timely referral to podiatry for onychomycosis despite a wound consultant's recommendation and the resident's request. Staff interviews revealed that the need for podiatry care was known but not acted upon due to oversight, resulting in the resident having long, thick, discolored toenails.
A resident who was cognitively intact and able to participate in toileting with assistance was not provided with a scheduled toileting plan or bladder training, despite assessment findings and facility policy indicating these interventions were appropriate. Staff only provided a diaper and did not offer a bedpan or bedside commode, and no toileting program was attempted.
A resident with COPD was found receiving continuous oxygen therapy through tubing that was not labeled with the date of last change and appeared visibly soiled. Facility protocols and physician orders required regular changing and labeling of oxygen tubing, but these were not followed, resulting in the use of unclean equipment.
A resident with cognitive impairment and total dependence on staff was found with all four bed rails up, despite not using them for mobility or repositioning and being unable to remove them. Staff interviews and record review confirmed that alternatives to bed rails were not attempted prior to their use, and physician orders did not match the resident's abilities. Facility policy required alternatives to be tried before bed rails were used, but no documentation supported this was done.
A resident admitted with cellulitis, hypertension, and muscle weakness was not evaluated by a physician at least once every 30 days for the first 90 days after admission, as required. After the initial physician visit, only a PA conducted subsequent visits, and there was no documentation of physician visits for several months, despite the resident's desire to discuss ongoing health concerns.
A resident with severe cognitive impairment and multiple medical conditions did not have the prescribed Refresh Tears eye drops available in the medication cart. Instead, a nurse found only Polyvinyl Alcohol eye drops, which were not ordered for the resident. The nurse confirmed the correct medication had not been delivered and held the administration, in accordance with facility policy requiring verification of medication orders.
A resident with multiple diagnoses was prescribed Olanzapine for psychosis, and the consultant pharmacist recommended clarifying the behavioral indications for its use. Despite this, there was no documented follow-up by nursing staff with the physician to address or update the order, contrary to facility policy requiring action and documentation of pharmacist recommendations.
Surveyors found that two residents' medications were not managed according to policy: insulin pens for a resident with diabetes and other conditions were not discarded after use, and a bottle of valproic acid for another resident had an illegible label in the medication cart. An LPN confirmed these lapses, which were inconsistent with the facility's medication storage and labeling procedures.
A staff member failed to perform hand hygiene and change gloves between wound care treatments for a resident with multiple medical conditions, including diabetes and chronic respiratory failure. The staff member acknowledged not following proper procedures, which were outlined in the facility's infection control policies.
The facility did not make its most recent survey results easily accessible to residents and the public, as required. During an interview, the Administrator could not locate the survey binder and acknowledged it should be available for review. Facility policy confirms residents' right to examine survey results.
Multiple rooms were found to have less than the required 80 square feet of living space per resident, with three residents occupying rooms measuring between 210 and 214 square feet. Facility documentation and staff interviews confirmed the deficiency, and it was acknowledged that the limited space could impact care delivery and storage of personal and medical items.
A resident with a history of partial amputation and diabetes experienced verbal abuse from a CNA during a disagreement over a wheelchair's placement. The CNA raised her voice and yelled at the resident, causing distress. Staff confirmed the incident as verbal abuse, violating the facility's policy on resident rights.
A facility failed to provide a written discharge notice to a resident and did not notify the Ombudsman, as required by policy. The resident, with conditions including morbid obesity and schizophrenia, was not informed about their transfer to a lower level of care facility or their appeal rights. Interviews revealed that the Notice of Proposed Transfer/Discharge was not completed, resulting in the resident's lack of awareness about the discharge and the Ombudsman not being informed.
A facility failed to follow its policy for inventorying and securing a resident's personal property during their absence. The resident, who required substantial assistance and was cognitively intact, had their belongings left unaccounted for, as the inventory list was unsigned. Staff interviews confirmed the expectation to inventory belongings, but the process was not completed, leading to a deficiency.
The facility failed to document and discuss advance directives with residents, leading to incomplete or missing acknowledgments for several residents. This deficiency involved residents with varying decision-making capacities and risked unwanted medical interventions. Interviews revealed that the facility did not consistently follow its policy to inform residents about their rights and options for end-of-life care.
The facility failed to document a change of condition for two residents, leading to a deficiency in care. One resident, who was severely cognitively impaired, had a large red excoriated area and redness on the left calf, but no Change of Condition (COC) form was completed. Another resident with multiple diagnoses was also not properly assessed. The lack of documentation could result in neglecting treatment and not informing the physician or family, potentially affecting the provision of necessary care.
The facility failed to arrange necessary ophthalmology appointments for two residents, both with significant vision impairments and diabetes. One resident, anxious about losing sight, was not referred for surgery evaluation despite recommendations. Another resident's referral was not made due to insurance denial, and the staff was unaware of the need. The facility acknowledged its responsibility to schedule appointments, regardless of insurance issues.
The facility failed to provide prescribed restorative care for three residents, leading to potential worsening of contractures. A resident with severe cognitive impairment did not receive hand rolls and splints as ordered. Another resident with cognitive deficits missed bilateral hand roll applications on several days, and a third resident with a hand contracture did not receive the prescribed hand roll. Lack of RNA coverage contributed to these deficiencies, as confirmed by staff interviews.
The facility failed to properly document the destruction of controlled medications, including narcotics, as required by their policy. The DON admitted to not signing the destruction form alongside the RPH Consultant, leaving the process incomplete and increasing the risk of medication diversion. The facility's policy mandates two signatures for the destruction of controlled substances, which was not adhered to.
A facility failed to obtain informed consent from a resident's representative for the use of lorazepam, a psychotropic drug prescribed for anxiety and agitation. The resident, who lacked decision-making capacity and was dependent on others for personal care, had no documentation indicating informed consent was obtained. The facility's policy requires informed consent before administering such drugs, but staff did not verify if the physician had obtained it, leading to a potential lack of knowledge for the representative about the medication's risks and benefits.
A resident with multiple health conditions was found to be sleeping on a malfunctioning low loss air mattress, which had been sunken in the middle for several weeks. Despite staff attempts to fix it, the issue was not resolved or reported to higher management, leading to discomfort and potential harm. Observations and interviews with staff confirmed the deficiency, highlighting a failure to adhere to the facility's policy on accommodating resident needs.
The facility failed to resubmit a PASRR for a resident with severe cognitive impairment and multiple diagnoses, including paranoid schizophrenia, after the resident was placed in isolation. The oversight was acknowledged by both the MDS Coordinator and the DON, who stated that PASRRs should be completed by the hospital or the facility if not done. The failure to resubmit the PASRR was due to the resident's isolation status, risking the provision of necessary care and services.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizoaffective and anxiety disorders, resulting in the omission of a necessary Level 2 evaluation. The resident, who was on antipsychotic medication, was not identified as having a serious mental illness in the screening, contrary to the facility's policy requiring further evaluation for such conditions.
A resident at high risk for pressure ulcers was found on a low air loss mattress (LALM) set incorrectly at 340 lbs, despite weighing only 103 lbs. The facility's policy required mattress settings to be based on the resident's weight to prevent skin breakdown, but this was not adhered to, risking delayed wound healing or worsening of ulcers.
A resident was found with a cigarette lighter in violation of the facility's policy, which prohibits residents from keeping lighters to prevent fire hazards. Despite being alert and oriented, the resident was not educated about this policy, leading to a potential safety risk.
A facility failed to remove an expired diltiazem solution from storage, risking ineffective treatment for a resident with hypertension. The expired medication was discovered during an observation, and staff acknowledged it should have been discarded. The resident had a history of hypertension, cerebral infarction, and atrial fibrillation, and was prescribed diltiazem to manage their condition. The facility's policy requires outdated drugs to be returned or destroyed.
A cook in the facility's kitchen was observed without a beard restraint while handling food, despite having a two-inch beard. The cook admitted the oversight, acknowledging the risk of hair contamination. The dietary manager confirmed the requirement for a beard restraint or face mask to prevent cross-contamination, as per the facility's policy on preventing foodborne illness.
Staff Personal Belongings Stored in EBP Room in Violation of Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of staff personal belongings in the room of a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with cirrhosis of the liver, pleural effusion, and muscle weakness, and had an EBP care plan initiated with interventions that included cleaning and disinfecting equipment and high-touch surfaces, performing hand hygiene during direct contact, and posting EBP signage. The resident’s MDS indicated clear speech, ability to express needs and wants, and understanding, with substantial/maximal assistance required for toileting, bathing, and personal hygiene. During an observation and concurrent interview with the Infection Preventionist Nurse in the resident’s room, surveyors observed a black purse, black bag, vitamin water bottle, beige purse, and a clear water container with lemon slices stored on top of the closet. The resident denied ownership of these items and could not recall who placed them there. The Infection Preventionist Nurse stated that staff should not store their personal belongings in a resident room on EBP, as this increased the risk of spreading germs and causing cross contamination among other residents and staff. Review of the facility’s Enhanced Barrier Precautions and Infection Control policies showed that EBP are used to reduce the spread of multidrug-resistant organisms and that infection control policies are intended to prevent and manage transmission of diseases and infections and apply to all personnel.
Failure to Keep Smoking Patio Door Closed Allows Smoke Into Facility
Penalty
Summary
The facility failed to ensure that the door to the smoking patio was kept closed, resulting in cigarette smoke entering the building. During an observation, the patio door was found open despite a sign instructing that it should remain closed, and cigarette smoke was detected in the hallway near several resident rooms. A CNA was observed entering from the patio and leaving the door open, acknowledging that the door should be closed to prevent smoke from entering and affecting residents. The Infection Prevention Nurse also confirmed that cigarette smoke in the building can be an annoyance and cause difficulty breathing for residents. Review of the facility's policy indicated that a homelike environment should include pleasant neutral scents, which was not maintained in this instance.
Failure to Provide Ordered Splint Application for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with a physician's order for bilateral knee splint application received the prescribed restorative care. The order specified that the Restorative Nurse Assistant (RNA) was to apply splints to both knees for one hour, five times a week. Review of the resident's medical record and RNA task documentation over a 30-day period revealed that there was no documentation indicating the splints were applied as ordered. The RNA confirmed during interview and record review that there was no record of the splints being applied, and acknowledged the importance of the splints in maintaining form and preventing contractures. The resident involved had diagnoses including muscle weakness, an artificial hip joint, and a contracture of the left lower leg. The resident was dependent on staff for toileting, bathing, and dressing the lower body, and had intact cognition and decision-making capacity. The care plan reflected the physician's order for splint application to maintain function. The facility's policy required restorative nursing care to promote optimal safety and independence, but the lack of documentation and apparent failure to provide the ordered care constituted a deficiency.
Failure to Administer Medications as Ordered and Document Pain Assessments
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for four sampled residents. For one resident with severe cognitive impairment and multiple diagnoses, including diabetes and hypertension, gabapentin was ordered to be administered three times daily at specific times. However, medication administration records showed that doses were given significantly late on multiple occasions, outside the facility's policy of administering medications within one hour of the scheduled time. Another resident with diabetes and a recent knee replacement did not receive metformin as scheduled, with one morning dose administered over an hour late and a nighttime dose reportedly missed due to unavailability from the pharmacy. This resident also experienced unmanaged pain, as pain assessments were not documented in the medication administration record, and pain medication was not provided according to the physician's orders. Interviews with staff confirmed that pain levels were not consistently assessed or documented, and that medication administration was delayed or omitted when medications were not available. Additional residents with chronic conditions such as diabetes, hypertension, and epilepsy also experienced late administration of scheduled medications, including metformin, gabapentin, and hydrochlorothiazide. Medication administration records and staff interviews confirmed that medications were not given within the required timeframes, and documentation was not completed as per facility policy. Facility policies reviewed indicated that medications should be administered within one hour of the scheduled time and that pain assessments and documentation are required, but these protocols were not followed for the residents involved.
Insulin Not Relabeled After Physician Order Change
Penalty
Summary
The facility failed to ensure that insulin medication for a resident with diabetes was properly labeled and stored according to current physician orders. Specifically, after a physician changed the resident's Novolin insulin order, the medication cart still contained insulin labeled with the previous dosing instructions. The label on the insulin pen reflected an outdated order, and the medication was not discarded or relabeled to match the new prescription. The nurse did not notify the pharmacy of the new order immediately, nor was a change of order label placed on the medication as required by facility policy. The resident involved had a history of diabetes and hypertension and was able to understand and make decisions. The resident required some assistance with daily activities but was generally able to communicate needs. The discrepancy was identified during an observation and interview with a nurse, who acknowledged that the medication should have been discarded or relabeled to prevent administration errors. The facility's policies required that only the pharmacy modify prescription labels and that outdated medications be removed and replaced when orders change, but these procedures were not followed in this instance.
Failure to Ensure Call Light Accessibility and Provide Oral Care
Penalty
Summary
Surveyors identified that staff failed to ensure call lights were placed within reach for two residents and failed to provide oral care for one resident. For one resident with muscle weakness and hypertension, documentation showed the resident required significant assistance with activities of daily living (ADLs), including being dependent for toileting, lower body dressing, and transfers. The care plan specified that the call light should be placed within reach. During observation and interview, the resident reported being unable to see or reach the call light, expressing frustration at not being able to contact staff when needed. A CNA confirmed the call light was not accessible due to the resident's contracture and position in bed, acknowledging that this was not in accordance with the care plan and facility policy. The same resident also reported not having received oral care and lacking a toothbrush or toothpaste. The CNA stated that oral care had not been provided that day, despite the resident having already eaten two meals, and acknowledged that oral care should be performed after each meal. The CNA attributed the missed care to the resident's recent room transfer. A second resident, with hemiplegia and hypertension, was also found to have the call light out of reach, as it was hanging off the bed. This resident was dependent on staff for all ADLs and unable to use the call light unless it was placed next to them. An LVN confirmed the call light was not accessible and stated it should always be within reach. Facility policies reviewed by surveyors required staff to ensure call lights are within reach to provide prompt assistance and to support residents with ADLs, including personal and oral hygiene.
Failure to Ensure Nurse Competency in Admission Assessment and Medication Management
Penalty
Summary
The facility failed to ensure that a registered nurse possessed the necessary competencies and skills to properly assess a newly admitted resident, resulting in the resident receiving unnecessary medication and experiencing a delay in wound treatment. Upon admission, the nurse transcribed an order for Seroquel at a higher dose than what was indicated in the hospital discharge records and entered a diagnosis of bipolar disorder that was not present in the resident's medical history. The medical doctor later confirmed that the resident did not have bipolar disorder and that the higher dose of Seroquel was not appropriate, as the original hospital order was for a lower dose and for a different indication. Additionally, the admitting nurse did not identify or document a sacrococcygeal pressure ulcer during the initial assessment, despite later findings of a significant unstageable pressure ulcer measuring 21.1 cm. The wound was not assessed by the wound care nurse until several days after admission, and treatment was not initiated until three days post-admission. The delay in assessment and treatment was corroborated by interviews with the treatment nurse and assistant director of nursing, who acknowledged that the skin assessment should have been completed immediately upon admission to prevent further injury. Family members expressed concern about the resident's increased sleepiness and lack of progress in therapy, which they attributed to overmedication. The facility's policies and procedures require registered nurses to accurately assess new admissions, follow physician orders, and document the general condition of residents upon admission, including skin condition. These requirements were not met in this case, leading to unnecessary medication administration and delayed wound care for the resident.
Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of Seroquel, an antipsychotic medication. The clinical records did not contain a documented assessment to support the diagnosis of bipolar disorder, which was listed as the indication for Seroquel use. Review of the resident’s hospital and facility records showed that the original order for Seroquel was for acute agitation/delirium, but upon admission to the facility, the medication was continued for bipolar disorder without supporting documentation or evidence of such a diagnosis. The facility’s Minimum Data Set and psychiatric evaluation did not indicate the presence of behaviors or symptoms consistent with bipolar disorder or psychosis during the relevant period. Further review of the resident’s Medication Administration Record and behavior monitoring logs revealed that there were no documented episodes of the behaviors that would warrant the use of Seroquel for bipolar disorder. Interviews with therapy staff and the Director of Rehabilitation indicated that the resident initially was able to follow commands and participate in therapy, but later became lethargic and confused, which interfered with rehabilitation. Family members and staff expressed concerns that the resident was overmedicated, leading to increased sleepiness and decreased participation in therapy. The medical doctor confirmed that there was no diagnosis of bipolar disorder in the resident’s records and stated that he continued the Seroquel order from the hospital without verifying the indication. The facility’s policy required that psychotropic medications be used only with a clear clinical indication and after ruling out other causes for behaviors, but this was not followed in the resident’s case. The lack of proper assessment, documentation, and monitoring led to the resident receiving an antipsychotic medication without adequate justification.
Failure to Provide and Properly Set Pressure-Relieving Mattresses for At-Risk Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for several residents as ordered by their physicians and as outlined in facility policy. Specifically, three residents who were at risk for pressure ulcers due to immobility or other medical conditions were not provided with low air loss (LAL) mattresses as ordered. Observations and interviews confirmed that these residents were lying on regular mattresses despite having physician orders and care plans indicating the need for LAL mattresses to prevent pressure injuries. Staff interviews revealed a lack of awareness or follow-through regarding the implementation of these orders. Additionally, two residents who were provided with LAL mattresses did not have the mattresses set to the correct weight settings as required. In both cases, the mattress settings were significantly higher than the residents' actual weights, which staff acknowledged was not in accordance with manufacturer instructions or facility policy. Staff interviews confirmed that the incorrect settings could compromise the effectiveness of the mattresses in preventing pressure ulcers. The facility's own policies and procedures, as well as the manufacturer's operational manual, require that appropriate support surfaces be selected and maintained based on individual resident risk factors and that LAL mattresses be set according to the resident's weight. Despite these requirements, the facility did not ensure that the necessary equipment was provided or properly set for residents at risk for pressure ulcers, as evidenced by direct observation, record review, and staff interviews.
Failure to Provide Ordered Restorative Nursing Services Seven Days a Week
Penalty
Summary
The facility failed to ensure that two residents received Restorative Nurse Assistant (RNA) services as ordered by their physicians, specifically the application of bilateral elbow splints seven days a week. Both residents had physician orders and care plans indicating the need for daily application of elbow splints to prevent contractures and maintain range of motion. However, a review of RNA task forms revealed that the splints were not applied every day as required, with several days missed for each resident during the review periods. One resident, with diagnoses including hypertension, dysphagia, and respiratory failure, was dependent on staff for activities of daily living and had a care plan and physician order for daily bilateral elbow splint application. The RNA task form showed that the splints were not applied on a daily basis as ordered. Interviews with staff confirmed that the services were not provided every day, and staff acknowledged the importance of consistent splint application to prevent contractures. The second resident, diagnosed with traumatic brain injury, dysphagia, and respiratory failure, was also dependent on staff and had similar orders and care plan requirements for daily splint application. The RNA task form for this resident also indicated missed days. Staff interviews confirmed the inconsistency in providing the ordered restorative care. Facility policies and job descriptions reviewed during the survey supported the expectation that restorative nursing care should be provided as ordered and in accordance with residents' care plans.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident, who had multiple diagnoses including multiple sclerosis, COPD, acute kidney failure, and a seizure disorder, was observed to have two vape devices with cannabis symbols on her bedside table on multiple occasions. The resident reported using the vapes weekly in her room and keeping them on her bedside table. Facility staff, including an LVN and the Staff Development Assistant, acknowledged that they had not noticed the vapes during their daily rounds and recognized the potential risks, including negative exposure to other residents, possible contraindications with medications, and the risk of burns or injury to the resident herself. The facility's policy indicated that vape devices, while not considered smoking devices for ignition risk, still posed health and safety risks, including the potential for explosion or fire due to the battery. Another resident, with diagnoses including seizures, encephalopathy, and dysarthria, was found to have a left bed rail pad that was hanging off the bed rail during multiple observations. This resident was dependent on staff for most activities of daily living and was at risk for pressure ulcers and had a seizure disorder. Physician orders specified that the resident should have a low bed with padded bilateral upper half side rails and a floor mat to decrease potential injury. Both an LVN and the Assistant Director of Nursing confirmed that the left bed rail was not fully padded as required, and facility policy emphasized the importance of padding side rails for residents with seizure disorders to prevent injury during seizure activity. A third resident, with diagnoses including COPD, hypertension, type 2 diabetes, and muscle weakness, was found to have a personal lighter at his bedside, despite being a supervised smoker. The resident stated he was able to keep his lighter in his room, and an LVN confirmed that supervised smokers were not allowed to have lighters in their rooms due to the risk of burns or fire. Facility policy specified that residents without independent smoking privileges may not keep any smoking items, including lighters, except under direct supervision.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide timely and complete laboratory services as ordered for two residents. For one resident with diagnoses including malnutrition, schizophrenia, and bipolar disorder, the physician ordered a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Ammonia level. Review of the resident's records and interview with a Licensed Vocational Nurse revealed that these lab tests were not completed, and there were no results available. The nurse confirmed that the labs were ordered to monitor the resident due to her medications, but the required tests were not performed. For another resident with encephalopathy, generalized edema, and dependent on staff for all functional abilities, there was a physician's order for weekly pre-albumin blood draws to monitor protein levels. Record review and interview with a Registered Nurse showed that the weekly pre-albumin labs were not performed as ordered, with only sporadic draws documented over several months. The facility's policy stated that clinical laboratory services are to be provided to meet residents' needs, but these orders were not consistently carried out.
Deficient Food Storage Labeling and Ice Machine Cleaning Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. During an observation in the dry storage room, an opened box of whole wheat spaghetti pasta was found without a label indicating the date it was opened. The Dietary Service Supervisor (DSS) confirmed that all opened food items in dry storage should be labeled with the date they were opened, in accordance with the facility's policy. The DSS acknowledged that not labeling food items with an open date could result in residents consuming expired food. Additionally, during an observation in the kitchen area, the outside compartment of the ice machine was found to be dirty with a thick hard water deposit. The DSS stated that dietary staff were responsible for cleaning the outside compartment of the ice machine once a week, but there was no log maintained to document this cleaning. The facility's policy required dietary staff to clean and sanitize the outside of the ice machine daily and as needed. The DSS recognized the importance of cleaning the ice machine for infection control purposes.
Failure to Offer and Document Influenza Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza vaccine for the 2024-2025 flu season, as required by facility policy and procedure. Interviews with the Infection Prevention Nurse (IPN) revealed that there was no documentation in the residents' medical records indicating that the flu vaccine was either offered, administered, or declined for these residents. Both the electronic health records and the California Immunization Registry were reviewed, and neither resident had evidence of receiving or declining the vaccine for the specified season. Resident 152 had a history of respiratory failure, ventilator dependence, and pneumonia, and was assessed as unable to make decisions or participate in a mental status interview. Resident 441 had diagnoses including respiratory failure and COPD, was also ventilator dependent, and similarly assessed as unable to make decisions. Both residents were dependent on staff for all functional abilities, and their care plans indicated a high risk for infection with interventions to offer and administer vaccines as needed. However, there was no documentation in their care plans, interdisciplinary team meetings, or other records to show that the flu vaccine was offered or declined. Facility policies required that all residents be offered vaccines unless medically contraindicated or already immunized, and that refusals be documented in the medical record. Despite these requirements, the facility was unable to provide documentation that the two residents were offered the flu vaccine or that any declination was recorded, constituting a failure to follow established vaccination protocols.
Failure to Assess and Document Bed Rail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a comprehensive and accurate assessment was completed for a resident regarding the use of four bed rails. The resident, who had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, was admitted and readmitted to the facility and was documented as lacking the capacity to understand and make decisions. The Minimum Data Set (MDS) indicated the resident was dependent on staff for activities of daily living such as showering, toileting hygiene, and dressing. Observations on two separate days showed all four bed rails were up while the resident was in bed, and the resident was not using the bed rails for mobility or repositioning, nor was the resident able to remove the bed rails independently. Interviews with facility staff revealed that the need for all four bed rails had not been properly assessed, and alternatives to bed rails, as required by facility policy, had not been attempted or documented prior to their use. The facility's policy specified that alternatives such as roll guards, foam bumpers, lowering the bed, and concave mattresses should be considered before installing bed rails. Record review confirmed there was no documentation of attempted alternatives or a comprehensive assessment regarding the use of bed rails for this resident.
Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately for one resident by not coding the resident's diagnosis of depression under MDS section I5800 (Active Diagnoses). The resident's admission record and history and physical indicated a diagnosis of depression, and the resident was prescribed Sertraline HCL, an antidepressant, for symptoms including crying, yelling, and self-biting. Despite this, the MDS assessment did not reflect the depression diagnosis, as confirmed by the MDS nurse during a review and interview. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for several activities of daily living. The facility's policy required staff completing any portion of the MDS to certify its accuracy, but this was not followed in this instance. As a result, incorrect data was transmitted to CMS, and the omission had the potential to affect the resident's plan of care and delivery of services.
Failure to Resubmit PASARR Screening for Resident with Mental Illness Diagnoses
Penalty
Summary
The facility failed to complete and resubmit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident who had diagnoses of bipolar disorder and major depressive disorder (MDD). The initial PASARR Level I screening, completed by another facility, indicated that the resident had no serious mental illness diagnoses and that the case was closed, with no Level II evaluation required. However, upon admission, the resident's diagnoses of bipolar disorder and MDD were documented in the admission record and history and physical, indicating the presence of mental illness. Despite this information, the facility did not conduct a new PASARR Level I screening to reflect the resident's current diagnoses, which would have triggered a Level II evaluation and referral to the state mental health authority. The facility's policy and the PASRR reference manual both require that a new screening and referral be made if a significant change in mental condition is identified. The failure to resubmit the PASARR Level I screening and refer the resident for further evaluation resulted in the resident not being assessed for appropriate mental health services.
Failure to Revise Care Plan for Use of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to specifically address the use of a low air loss (LAL) mattress, which is a specialized device used to prevent and treat pressure ulcers. The resident in question had significant medical conditions, including metabolic encephalopathy, hemiplegia, and cerebral infarction, and was assessed as being at risk for developing pressure ulcers. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. The care plan in place addressed the risk for skin breakdown and included general interventions such as assessing risk and using pressure-relieving devices as needed, but did not specify the type of device to be used. During a review of the care plan and interviews with facility staff, it was confirmed that the care plan had not been updated to reflect the use of the LAL mattress for this resident. The Assistant Director of Nursing acknowledged that the care plan lacked specificity regarding the pressure-relieving device, which was necessary for consistent and individualized care. Facility policy required that care plans be revised as residents' conditions changed, but this was not done in this case.
Failure to Complete Ordered Weekly Weights for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses of malnutrition, diabetes mellitus, and congestive heart failure was readmitted to the facility and had a physician's order for weekly weights for four weeks due to an eight-pound weight loss in one month. The resident's care plan and change of condition documentation both reflected the need for weekly weights and ongoing monitoring, as well as the requirement to report significant changes to the physician. Despite these orders and care plan interventions, the last recorded weight for the resident was documented prior to the initiation of the weekly weight order, and no subsequent weekly weights were completed as required. During an interview and record review, a Licensed Vocational Nurse confirmed that the weekly weights were not performed according to the physician's order. The facility's policy on weight assessment and intervention also required monitoring of resident weights for undesirable or unintended weight loss or gain. The failure to obtain and document weekly weights as ordered resulted in inadequate monitoring of the resident's weight loss.
Failure to Provide Compression Stockings per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral lower extremity edema, cellulitis, hypertension, and generalized muscle weakness did not receive compression stockings as ordered by the physician. The resident was cognitively intact and able to make decisions, and the physician's order specified daily application of compression stockings to both lower extremities. During an observation, the resident was found without compression stockings and reported not having them for two weeks, stating that the previous stockings were too long and wide. The resident also indicated that nursing staff were aware of the lack of appropriate stockings during this period and expressed concern about ongoing swelling. Interviews with the treatment nurse and DON confirmed that the resident had not received the prescribed compression stockings for two weeks due to the old stockings being ill-fitting and new ones not being delivered. The treatment nurse acknowledged that the physician's order for daily application was not followed and that untreated edema could result in hospitalization. Facility policy indicated that incorrectly sized stockings could cause harm, but the resident was left without any compression stockings for an extended period, contrary to the physician's order.
Failure to Provide Timely Podiatry Referral for Foot Care
Penalty
Summary
A resident with a history of cellulitis in both lower limbs, hypertension, and generalized muscle weakness was admitted to the facility and was cognitively able to make decisions. The resident required supervision for personal hygiene and dressing. Documentation showed that a wound consultant recommended a referral to podiatry for onychomycosis, a fungal infection causing thickened, discolored toenails. Despite this recommendation and the resident's own request to see a foot doctor for the condition, the referral was not made. Observation confirmed the resident had long, thick, brownish-yellow toenails on both feet. Interviews with staff revealed that the treatment nurse was aware of the need for podiatry care and had informed the ADON, but the ADON did not follow through with the referral, citing oversight. The DON confirmed that podiatry care is a service provided by the facility and acknowledged the need for prompt assessment and treatment. The facility's policy indicated that residents should receive foot care in accordance with professional standards, but this was not followed in this case.
Failure to Implement Scheduled Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a scheduled toileting plan or bladder training for one resident, despite assessment findings indicating the resident was a good candidate for such interventions. The resident was cognitively intact, aware of the need to toilet, and able to participate in toileting activities with one-person assistance. Documentation showed that the resident required substantial assistance with toileting hygiene and lower body dressing, but no trial of a toileting program had been attempted. The resident expressed willingness to use a bedpan or bedside commode to avoid urinary infections, but reported that staff only provided a diaper and did not offer these alternatives. Interviews with staff confirmed that the resident was not offered a bedpan or bedside commode, and the facility's own assessment tool indicated the resident would benefit from scheduled toileting or bladder retraining. The facility's policy required staff to provide appropriate services and interventions, such as scheduled toileting, based on assessment results. However, no such program was implemented for the resident, contrary to both the assessment findings and facility policy.
Failure to Label and Change Oxygen Tubing as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) was observed receiving continuous oxygen therapy through tubing that was not labeled with the date it was last changed. The oxygen tubing appeared cloudy and contained clear, thick fluid near the nasal area. According to a licensed vocational nurse, oxygen tubing should be changed daily and labeled accordingly, while the physician's order specified that the nasal cannula or mask should be changed every seven days or as needed when soiled. The resident's care plan also indicated that oxygen tubing should be changed weekly or as needed. Despite these protocols, the tubing in use was not labeled and showed visible signs of soiling.
Failure to Attempt Alternatives Before Installing All Four Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted before installing all four bed rails for one resident. The resident in question had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, and was assessed as lacking capacity to make decisions. Observations on two separate days showed the resident lying in bed with all four bed rails up, despite not using the rails for mobility or repositioning and being unable to remove them easily. The resident was dependent on staff for activities of daily living and was not receiving ADL assistance at the time of observation. A review of the physician's orders indicated that all four bed rails were to be up and locked for ADL changes, mobility, positioning, and as an enabler, and this was considered a non-restraint. However, staff interviews revealed that the resident was not able to use the bed rails for mobility and that the physician's orders did not match the resident's abilities. Documentation was not found to show that alternatives to bed rails were attempted prior to their use. Facility policy required that alternatives such as roll guards, foam bumpers, or lowering the bed be tried before bed rails were used, but there was no evidence this was done for the resident.
Failure to Ensure Timely Physician Visits After Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was evaluated by a physician at least once every 30 days for the first 90 days following admission, as required. The resident, who was admitted with diagnoses including cellulitis of both lower limbs, hypertension, and generalized muscle weakness, was only seen by her physician once since admission. Clinical records confirmed that after the initial physician visit, subsequent visits were conducted by a Physician Assistant rather than the physician, and there was no documentation of physician visits for the required months. During interviews, the resident expressed concern about not seeing her physician and wanted to discuss her ongoing high blood pressure. Facility leadership, including the ADON and DON, acknowledged that the physician had not complied with the required visit schedule and that documentation of physician visits was missing for several months. The facility's policy also specified that the attending physician must visit patients at least once every 30 days for the first 90 days after admission, which was not followed in this case.
Failure to Provide Prescribed Eye Drops as Ordered
Penalty
Summary
The facility failed to ensure that the correct prescribed eye drops were available in the Sub-Acute Medication Cart according to the physician's orders for a resident. The resident, who had a history of respiratory failure, aphasia, dysphagia, and brain damage, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The physician had ordered Refresh Tears Ophthalmic Solution 0.5% for the resident. During a medication administration observation, a nurse was found to be removing Polyvinyl Alcohol 1.4% eye drops from the medication cart, which did not match the physician's order and was not prescribed for the resident. The nurse stated that the correct eye drops had not been delivered by the pharmacy and acknowledged that the Polyvinyl Alcohol drops required physician clarification, as there was no order for them. The resident's eye drops were held, and the nurse indicated that the situation could result in a medication error. Facility policy requires that medication labels and orders be checked for accuracy prior to administration.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act in a timely manner on the consultant pharmacist's recommendation regarding a resident's medication regimen. Specifically, a resident with diagnoses including psychosis, bipolar disorder, and diabetes mellitus was started on Olanzapine for psychosis manifested by constant worrying about a medical condition. The consultant pharmacist reviewed the medication regimen and recommended that the physician clarify and update the order for Olanzapine with appropriate behavioral indications. However, there was no documentation that the nursing staff followed up with the physician to address this recommendation or to clarify the behavioral manifestations justifying the use of the psychotropic medication. The resident's clinical records did not show any action taken by the licensed nursing staff to discuss or implement the pharmacist's recommendation, despite the psychiatrist evaluating the resident shortly after the recommendation was made. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented by staff or the prescriber, but this was not done. As a result, the resident was at risk for receiving unnecessary medication due to the lack of timely follow-up and documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified that insulin pens belonging to a resident with diagnoses including hemiplegia, type 2 diabetes, COPD, and epilepsy were found opened and not discarded in the medication storage room. The resident required maximal assistance with activities of daily living and had moderately impaired cognitive skills. During observation, a licensed vocational nurse confirmed that the insulin pens should have been discarded and acknowledged that failure to do so could result in an infection control issue. Additionally, a bottle of valproic acid prescribed to another resident with epilepsy, type 2 diabetes, schizophrenia, and aphonia was found in the medication cart with an illegible label. This resident had severely impaired cognitive skills and required moderate assistance with daily activities. The same nurse confirmed that all medications should have legible labels and that an illegible label could lead to medication errors and uncertainty about medication ownership. The facility's policy required medications and biologicals to be stored safely, securely, and properly, in accordance with manufacturer or supplier recommendations.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
Licensed staff failed to perform proper hand hygiene during wound care for one resident. Specifically, a staff member removed the dressing from the resident's right great toe, cleaned the wound, and applied a new dressing without washing his hands between steps. The same staff member then proceeded to treat another wound, an abrasion on the left heel, without changing gloves or washing hands between the two wound care treatments. During an interview, the staff member acknowledged not removing gloves or washing hands after treating each wound and stated awareness of the correct procedure. The resident involved had multiple medical conditions, including chronic respiratory failure, transient ischemic attack, and diabetes mellitus, and was dependent on staff for all activities of daily living. The resident was also at risk for developing pressure ulcers. Facility policy and procedures reviewed indicated that hand hygiene is the primary means to prevent the spread of infections and that gloves do not replace hand washing. The observed actions were not in accordance with these policies.
Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to ensure that the results of its last recertification survey were placed in a location that was easily accessible and viewable by residents and the public. During an observation and interview in the main lobby, the Administrator was unable to locate the binder containing the most recent survey results and acknowledged that it should be available for anyone to review. A review of the facility's policy and procedure on Resident Rights confirmed that residents have the right to examine survey results.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that residents in rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 13 had at least 80 square feet of living space per resident, as required. Observations showed that these rooms each contained three occupied beds, and a review of the Client Accommodation Analysis confirmed that the floor space in these rooms ranged from 210 to 214 square feet, which is less than the required 240 square feet for three residents. A Room Variance Waiver request letter also acknowledged that these rooms did not meet the minimum space requirement. During an interview, the Administrator confirmed awareness of the room size issue and noted that, although there had been no complaints, the limited space could affect staff's ability to provide care and store necessary items.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a disagreement between the resident and CNA regarding the placement of a roommate's wheelchair, which was obstructing the resident's passage. The resident, who had a history of partial amputation, functional quadriplegia, and diabetes mellitus, expressed that the wheelchair was blocking his way out of the room. The CNA responded by raising her voice, which escalated into yelling, causing the resident to feel upset. The incident was documented in the resident's progress notes and change of condition report, indicating that the CNA's voice became progressively louder during the disagreement. Interviews with staff members, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that the CNA yelled at the resident, which was considered verbal abuse. The LVN noted that the CNA should have explained the situation calmly, while the RN stated that the CNA's behavior was verbally abusive and inappropriate. The facility's policy on abuse and mistreatment of residents emphasizes the right of residents to be free from verbal abuse. The policy defines verbal abuse as the use of language that includes disparaging and derogatory terms within hearing distance of residents. The incident was reported to the facility's administration, and the CNA was suspended and subsequently terminated for her conduct, which violated resident rights and the facility's code of conduct.
Failure to Provide Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident, as well as a copy of the notice to the Office of the State Long-Term Care Ombudsman. This deficiency involved a resident who was originally admitted to the facility and later readmitted, with diagnoses including morbid obesity and schizophrenia. The resident had the capacity to understand and make decisions, as confirmed by the History and Physical and Minimum Data Set assessments. Despite this, the resident was not informed in writing about the discharge to another facility for a lower level of care, nor were they made aware of their appeal rights. Interviews with the Ombudsman, the resident, the Assistant Director of Nursing, and the Social Services Director revealed that the Notice of Proposed Transfer/Discharge was not completed or provided. The facility's policy required that a copy of the notice be sent to the Ombudsman at the same time it was provided to the resident and their representative. The failure to follow this policy resulted in the resident being unaware of the facility they were being transferred to and their rights to appeal the discharge, while the Ombudsman was not informed of the discharge to another facility.
Failure to Inventory and Secure Resident's Personal Property
Penalty
Summary
The facility failed to implement its policy and procedure regarding the inventory and safekeeping of a resident's personal property during their absence. This deficiency was identified for one of the sampled residents, who was admitted with Type 2 Diabetes Mellitus and Bipolar Disorder. The resident required substantial assistance with activities of daily living and was cognitively intact. During the resident's absence, the facility did not properly inventory and secure the resident's belongings, as required by their policy. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that there was an expectation to inventory and secure resident belongings when a resident is transferred to the hospital. However, a review of the resident's belongings list showed it was not signed, indicating that the inventory was not checked. The Social Services Director confirmed that the inventory list should be signed to acknowledge that belongings have been checked, and leaving it unsigned means the inventory was not performed, which is against the facility's policy.
Failure to Document and Discuss Advance Directives
Penalty
Summary
The facility failed to ensure that medical records were updated to document discussions and provide written information about advance directives to residents and/or their responsible parties. This deficiency was identified for five of the 36 sampled residents, including those with varying capacities for decision-making. For instance, Resident 71, who had the capacity to make decisions, did not have their cognitive skills for daily decision-making completed in the Minimum Data Set (MDS). Similarly, Resident 31, who lacked decision-making capacity, also did not have the necessary documentation regarding advance directives. The report highlights that the facility's policy and procedure require informing residents of their health status, medical condition, and treatment options, including the right to formulate an advance directive. However, during interviews with the Director of Nursing (DON) and the Social Service Director (SSD), it was revealed that advance directive acknowledgments were either incomplete or missing for several residents. The SSD noted that advance directive acknowledgments should be completed within five days of admission, but this was not consistently done. The lack of documentation and discussion regarding advance directives had the potential to result in medical interventions that residents may not have wanted. The facility's failure to adhere to its policy and procedure for informing residents about their rights and options for end-of-life care contributed to this deficiency. The DON acknowledged the risk of providing unwanted medical interventions if advance directive information was not properly communicated and documented.
Failure to Document Change of Condition for Residents
Penalty
Summary
The facility failed to ensure a change of condition was documented for two residents, leading to a deficiency in care. Resident 117, who was severely cognitively impaired and required extensive assistance with activities of daily living, was observed with a large red excoriated area on the upper buttocks and redness on the left calf. Despite these observations, a Change of Condition (COC) form was not completed, and the redness on the left calf was not documented. Treatment Nurse 2 acknowledged the absence of a COC form for Resident 117's left leg redness, highlighting the risk of staff not being informed about the resident's condition. Similarly, Resident 7, who had multiple diagnoses including type 2 diabetes mellitus and major depression, was also not properly assessed for a change of condition. The facility's policy required detailed observations and documentation of any change in a resident's condition, but this was not adhered to. Licensed Vocational Nurse 4 and the Director of Nursing confirmed that the lack of documentation could result in neglecting a resident's treatment and not informing the resident's physician or family. This oversight in documenting changes in residents' conditions has the potential to negatively affect the provision of necessary care and services.
Failure to Arrange Ophthalmology Appointments for Residents
Penalty
Summary
The facility failed to provide necessary vision care services to two residents, Resident 119 and Resident 150, by not arranging ophthalmology appointments for surgery evaluations. Resident 150, who has a history of left eye visual loss and type 2 diabetes mellitus, expressed difficulty in reading and anxiety about losing his sight. Despite a care plan indicating impaired vision and a recommendation for an ophthalmology referral due to diabetic retinopathy, the Social Service Assistant did not schedule the necessary appointment. The Assistant Director of Nursing confirmed the lack of documentation for a referral to a retina specialist, which could lead to permanent blindness. Similarly, Resident 119, diagnosed with type 2 diabetes mellitus and blindness in one eye, was not referred for a glaucoma surgery evaluation as recommended. The Registered Nurse mentioned that the referral was not made due to insurance denial, and the Social Service Director was unaware of the referral requirement. The Director of Nursing acknowledged the facility's responsibility to schedule appointments regardless of insurance issues. These deficiencies potentially jeopardized the residents' vision and quality of life.
Failure to Provide Prescribed Restorative Care
Penalty
Summary
The facility failed to provide complete Restorative Nursing Assistant (RNA) treatments as per physician's orders for three residents, leading to a potential risk of worsening contractures. Resident 115, who was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs), did not receive hand rolls and splints seven days a week as ordered. RNA 2 confirmed that when they were not present, no one covered their residents, resulting in missed services. Resident 124, who had cognitive communication deficits and was dependent on staff for ADLs, also did not receive the prescribed bilateral hand rolls for 4-6 hours daily on multiple occasions. RNA 3 acknowledged the lack of documentation and coverage on days they were absent, which could lead to increased pain and tighter contractures. Similarly, Resident 145, who had a right-hand contracture and required maximal assistance, did not receive the right-hand roll as ordered on several days, as confirmed by RNA 3. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the lack of RNA coverage contributed to the failure to provide necessary restorative services. The DSD emphasized the importance of daily documentation and the potential impact on residents' function and contractures if devices were not applied as ordered. The DON acknowledged the staffing challenges and the potential for increased contractures if splints were not applied as prescribed.
Failure to Document Medication Destruction
Penalty
Summary
The facility failed to ensure the accurate destruction of medications, including narcotics, as per their policy and procedure. During an inspection of the controlled medication area, it was found that multiple medications were disposed of without the required signature of a licensed nurse witnessing the destruction. The medications included various controlled substances such as Lacosamide, Lorazepam, Zolpidem Tartrate, Hydrocodone-Acetaminophen, Hydromorphone, Morphine Sulfate, Doxycycline Hyclate, and Clonazepam. The Director of Nursing (DON) admitted that the destruction process was not properly documented, as he was the only licensed nurse responsible for the task and failed to sign the destruction form alongside the Registered Pharmacy (RPH) Consultant. The RPH Consultant confirmed that the facility did not adhere to the policy for narcotic destruction, which requires the signatures of at least two witnesses to validate the destruction and disposal of controlled substances. The DON acknowledged that the lack of proper documentation posed a risk for diversion and theft of medications. The facility's policy, revised in April 2019, clearly states the necessity of having two signatures for the destruction of unused, non-hazardous controlled substances, which was not followed in this instance.
Failure to Obtain Informed Consent for Psychotropic Drug Use
Penalty
Summary
The facility failed to obtain informed consent from the resident representative for the use of a psychotropic drug, lorazepam, prescribed to a resident. The resident, who was diagnosed with hypertensive heart disease, acute kidney failure, and anxiety disorder, was determined to lack the capacity to understand and make decisions. The resident was totally dependent on others for personal care activities. Despite these conditions, the facility did not have documentation indicating that informed consent was obtained from the resident's representative for the use of lorazepam, a medication prescribed for anxiety and agitation. During a review of the resident's clinical records, a registered nurse confirmed the absence of documentation for informed consent, and the Director of Nursing acknowledged the oversight. The facility's policy requires informed consent to be obtained by the physician before administering psychotropic drugs. However, the facility staff failed to verify whether the physician had obtained consent from the resident's representative, as required by their policy. This oversight had the potential to leave the resident representative uninformed about the risks and benefits of the medication.
Deficient Mattress Maintenance in Resident's Room
Penalty
Summary
The facility failed to ensure that a low loss air mattress was in functioning condition for a resident, leading to the resident sleeping in an uncomfortable and potentially harmful bed. The resident, who had diagnoses including type 2 diabetes mellitus, acute respiratory failure, and anxiety disorder, was observed to have a sunken mattress in the middle of the bed. The resident reported that the mattress had been in this condition for a few weeks, causing discomfort and back pain. Despite attempts by staff to fix the mattress, it remained unfixed, and the issue was not escalated to higher management. Observations and interviews with facility staff, including a CNA, LVN, and the DON, confirmed the mattress's condition and acknowledged the potential negative impact on the resident's comfort and well-being. The facility's policy on accommodating resident needs emphasized the importance of maintaining a safe and comfortable environment, which was not adhered to in this case. The DON admitted that the issue should have been reported and addressed promptly to prevent discomfort and potential harm to the resident.
Failure to Resubmit PASRR for Resident in Isolation
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) assessment was resubmitted for a resident, identified as Resident 38, to determine the facility's ability to provide special care and needs. Resident 38 was initially admitted and later readmitted with diagnoses including metabolic encephalopathy, heart failure, anxiety, and paranoid schizophrenia. The Minimum Data Set (MDS) indicated that Resident 38 was severely cognitively impaired and required extensive assistance with activities of daily living. The PASRR, a federal requirement, was not resubmitted after Resident 38 was placed in isolation, which was necessary to determine the appropriate care and services for the resident. During interviews, both the MDS Coordinator and the Director of Nursing (DON) acknowledged the oversight. The MDS Coordinator stated that PASRRs should be completed when a resident is in the hospital or by the facility if not done by the hospital. The DON confirmed that if a hospital did not complete a resident's PASRR, the facility was responsible for doing so, especially if a Level 1 PASRR was positive. The failure to resubmit the PASRR for Resident 38 was attributed to the resident being in isolation, and both staff members recognized the risk of not resubmitting the PASRR, which could result in the resident not receiving necessary services and resources for their mental illness.
Failure to Conduct Accurate PASRR Screening
Penalty
Summary
The facility failed to correctly complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident diagnosed with schizoaffective disorder and anxiety disorder. The resident, who was originally admitted and later readmitted to the facility, was prescribed quetiapine fumarate, an antipsychotic medication, for symptoms associated with schizoaffective disorder. Despite these diagnoses and the prescription, the PASRR Level 1 screening did not reflect the resident's mental health conditions or the use of antipsychotic medication. Consequently, the screening did not trigger a PASRR Level 2 evaluation, which is necessary for residents with serious mental illnesses to receive appropriate treatment recommendations. During an interview and record review, the Minimum Data Set (MDS) coordinator acknowledged that the PASRR Level 1 screening was completed inaccurately. The coordinator confirmed that the resident's case was closed without a Level 2 evaluation due to the incorrect indication of no serious mental illness. The facility's policy requires that if a Level 1 screening is positive for suspected mental illness, it should advance to a Level 2 evaluation. This oversight in the screening process potentially impacted the resident's access to necessary mental health evaluations and treatment recommendations.
Incorrect LALM Setting for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the low air loss mattress (LALM) for a resident was set and maintained at the correct setting, which is crucial for preventing and treating pressure ulcers. The resident, who was at high risk for developing pressure ulcers, was observed lying on a LALM set at 340 lbs, despite weighing only 103 lbs. This incorrect setting was identified during an observation and interview with the treatment nurse, who acknowledged that the setting should be based on the resident's actual weight. The resident had a history of dysphagia, cerebral infarction, and muscle weakness, and was totally dependent on staff for daily activities. The resident's skin condition included unstageable ulcers and a stage 1 ulcer, indicating a high risk for further skin breakdown. The facility's policy required that air mattresses be adjusted according to the patient's weight to minimize pressure on the skin, but this was not followed, placing the resident at risk for delayed wound healing or worsening of pressure ulcers.
Resident Possession of Lighter Against Facility Policy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 164, did not have a cigarette lighter in his possession, which could potentially lead to a fire hazard. During an observation and interview on the smoking patio, Resident 164 was found holding a lighter and stated that he keeps his own cigarettes and lighter. Later, another observation in Resident 164's room revealed a lighter on the nightstand, and the resident confirmed that staff were aware of his possession of the lighter but had not provided any education regarding the facility's policy on lighter possession. Interviews with facility staff, including an Activity Assistant (AA1) and another staff member (AD1), confirmed that the facility's policy prohibits residents from keeping lighters to prevent them from smoking in their rooms or potentially starting a fire. The policy allows residents who are alert and oriented to keep cigarettes but not lighters. Despite this policy, Resident 164, who has the capacity to understand and make decisions, was not informed or educated about the policy, leading to the deficiency. The resident's medical history includes diagnoses of congestive heart failure, hypertension, and a heart attack.
Expired Medication Not Removed from Storage
Penalty
Summary
The facility failed to remove an opened expired medication, diltiazem solution, from the subacute medication refrigerator room storage for a resident. This oversight was identified during an observation and interview with a registered nurse, who acknowledged the presence of the expired medication and confirmed that it should have been discarded immediately. The expired medication had a pharmacy fill date and an expiration date, indicating it was no longer suitable for use. The registered nurse expressed concern that administering the expired medication could affect the resident's blood pressure due to a loss of potency. The resident involved had a medical history that included hypertension, cerebral infarction, and atrial fibrillation, and was prescribed diltiazem to manage their condition. The Director of Nursing confirmed that expired medications should be placed in a designated box for destruction and acknowledged that expired medications might not function effectively, potentially impacting the resident's blood pressure management. The facility's policy on medication storage, which was reviewed, stated that discontinued, outdated, or deteriorated drugs should be returned to the pharmacy or destroyed.
Cook Failed to Wear Beard Restraint in Kitchen
Penalty
Summary
The facility failed to ensure that the cook was wearing a beard restraint while working in the kitchen, which had the potential to result in food contamination with hair. During an observation, the cook was seen standing at the steam table taking temperatures and stirring food without a beard restraint, despite having a beard approximately two inches long. In an interview, the cook acknowledged the requirement to wear a beard restraint and admitted that not wearing one could lead to hair in the food. The dietary manager confirmed that the cook should have been wearing a beard restraint or a regular face mask to prevent cross-contamination. The facility's policy and procedure on preventing foodborne illness, dated October 2017, indicated that beard restraints must be worn to prevent hair from contacting exposed food, clean equipment, utensils, and linens.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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