Los Angeles Comm Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4081 East Olympic Blvd, Los Angeles, California 90023
- CMS Provider Number
- 555638
- Inspections on file
- 18
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Los Angeles Comm Hospital during CMS and state inspections, most recent first.
Two residents in a persistent vegetative state had peripheral line dressings that were not changed according to the facility's policy, increasing their risk of infection. Additionally, a medication cart was not cleaned after a liquid medication spill, posing a risk of cross-contamination.
The facility did not post the results of complaint investigations by the CDPH from the past three years in accessible areas, as required by federal regulations. The DON confirmed that only the last recertification survey was available, omitting recent complaint investigation results. The ACON highlighted the importance of posting these results for transparency and compliance with resident rights.
A facility failed to accurately complete the MDS assessment for a resident by not encoding a psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The MDS Nurse admitted the error, and the ACON stressed the importance of MDS accuracy for proper care. The facility's policy requires assessments to be certified for accuracy.
A facility failed to update the PASRR Level I screening for a resident with a new diagnosis of psychosis, who was prescribed Quetiapine for symptoms manifested by pulling out tubes. The DON acknowledged the oversight, as the initial screening indicated no serious mental illness, and a re-evaluation was required to determine the need for specialized services.
A resident with severe cognitive impairment and respiratory failure was using non-behavioral restraints to prevent tube removal. The care plan required releasing and repositioning the restraints every two hours, but the restraint flow sheet lacked these instructions. This discrepancy was confirmed by staff and could lead to increased discomfort for the resident.
A resident with severe medical conditions and dependent on staff for all ADLs had their hair care neglected, resulting in matted hair with dandruff. Observations and staff interviews confirmed that hair care was not provided as scheduled, despite facility policy requiring shampooing as part of the bathing program.
A facility failed to label the oxygen tubing for a resident with chronic respiratory failure, which is necessary for infection control. The tubing was not dated, making it unclear when it was last changed, posing a potential risk for respiratory infection. Interviews with the DON and ACNO confirmed that labeling is a facility policy, and the lack of adherence to this policy was noted.
A facility failed to act on a pharmacy consultant's recommendation to review and justify the use of Quetiapine for a resident with chronic respiratory failure and a tracheostomy. The resident was receiving the medication for psychosis, but there was no documentation supporting this diagnosis. The Director of Nursing did not follow through with the recommendation, risking unnecessary medication administration.
A facility failed to implement non-pharmacological interventions before administering Quetiapine to a resident without a documented diagnosis of psychosis. The resident, with chronic respiratory failure and a gastrostomy tube, was prescribed the medication for pulling out tubes, but there was no evidence of attempted behavioral interventions or a pattern of behavior justifying its use. Interviews revealed that the behavior was not indicative of psychosis, and the medication was deemed unnecessary, contrary to facility policy requiring alternative interventions before psychoactive medication use.
The facility failed to maintain a medication error rate below 5%, as observed when two residents did not receive their scheduled nebulizer medications on time. LVNs noted the delays, and the DRT confirmed the late administration, which was not documented promptly as per facility policy.
A facility failed to refrigerate an intravenous medication, Amikacin, as required by its labeling. During an observation, an RN found the medication stored in an IV cart instead of a refrigerator, despite being scheduled for administration later that day. The RN acknowledged the error, noting that improper storage could render the medication ineffective or expired. Facility policy requires proper storage conditions, including temperature control.
A facility failed to meet the required square footage for a resident room, which was intended for two residents. The room measured 155 square feet, below the required 160 square feet. The facility had submitted a waiver request for this deficiency, and the DON stated that the room was unoccupied and posed no harm to resident safety or well-being.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely changing of peripheral line dressings for two residents, placing them at risk for infection. Resident 19 had a peripheral line dressing on the right forearm that was not changed for seven days, despite the facility's policy requiring a change every 72 hours. Similarly, Resident 17's peripheral line dressing on the right hand was not changed for six days. Both residents were in a persistent vegetative state, dependent on ventilators, and required assistance with personal care, increasing their vulnerability to infections. Additionally, the facility did not maintain proper sanitation of a medication cart, as a sticky liquid medication spill was observed on the cart, potentially leading to cross-contamination. The facility's policy mandates that medication carts be kept free of spills to prevent contamination and ensure the effectiveness of medications. The failure to clean the medication cart after the spill was noted during an observation with an LVN, who acknowledged the risk of cross-contamination due to the soiled cart.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to post the results of complaint investigations conducted by the California Department of Public Health (CDPH) over the past three years in areas that are prominent and accessible to residents, visitors, family members, or resident representatives. During an observation and interview with the Director of Nursing (DON), it was revealed that the survey binder available at the nursing station hallway only included the last recertification survey conducted by the CDPH. The DON acknowledged that the facility had been visited by the CDPH for complaint investigations in the past two years, but the results of these investigations were not included in the survey binder. The DON admitted that all survey results should be posted and accessible to ensure transparency and compliance with resident rights. Further interviews with the Associate Chief of Nursing (ACON) confirmed that posting survey and complaint investigation results is a federal requirement. The ACON emphasized the importance of making these results available so that residents, their representatives, and facility staff can review the facility's plan of action to prevent recurrence of the identified deficiencies. A review of the facility's admission packet, specifically the section on resident rights, indicated that residents have the right to examine the results of the most recent surveys and any plans of correction. The facility's failure to post these results constitutes a violation of this right, potentially leaving residents and their families uninformed about the facility's compliance status and past performance history.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 8, by not correctly encoding the diagnosis of a psychotic disorder under Section I (Active Diagnoses). This error was discovered during a review of Resident 8's MDS, which indicated that the resident's cognitive skills for daily decision-making were severely impaired and that the resident was dependent on staff for various hygiene tasks. The MDS Nurse acknowledged that the MDS assessment was completed inaccurately, as there was a missing check mark for the psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The deficiency was further highlighted during an interview with the Associate Chief Nursing Officer (ACON), who emphasized the importance of MDS accuracy for reflecting the care provided by the facility. The facility's policy and procedure on Assessment and Care Planning require the assessment to be certified for accuracy by the individuals completing any portion of it. The incorrect data transmitted to the Center for Medicare and Medicaid Services (CMS) had the potential to negatively affect Resident 8's plan of care.
Failure to Update PASRR Screening for Resident with New Psychosis Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASRR) Level I screening for a resident who had a new diagnosis of psychosis. This oversight involved a resident who was admitted with chronic respiratory failure and required a tracheostomy and gastrostomy tube. The resident was later prescribed Quetiapine for psychosis, which was manifested by pulling out tubes. Despite this new diagnosis and medication, the PASRR Level I screening was not updated to reflect the change in the resident's mental health status. During an interview and record review, the Director of Nursing (DON) acknowledged the failure to submit a new PASRR Level I screening after the resident's diagnosis of psychosis. The initial PASRR Level I screening indicated no serious mental illness and did not require a Level II evaluation. However, the resident's condition changed, necessitating a re-evaluation to determine if specialized services were needed. The PASRR reference manual requires facilities to notify the state mental health authority of significant changes in a resident's condition, which was not done in this case.
Deficiency in Care Plan for Resident Using Restraints
Penalty
Summary
The facility failed to ensure that a revised care plan was in place for a resident using non-behavioral restraints. The resident, identified as Resident 25, was admitted with a diagnosis of respiratory failure and had additional diagnoses of seizures and pneumonia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for daily activities. The care plan for the resident included the use of bilateral restraints to prevent the removal of medical tubes, with specific instructions to release the restraints for 15 minutes every two hours and to reposition them under supervision. However, the Non-Behavioral Restraint Order and Flow Sheet, which should have reflected the care plan's interventions, lacked specific instructions on the duration and frequency of restraint release and repositioning. This discrepancy was noted during a review of the resident's records and confirmed by both the MDS Nurse and a Licensed Vocational Nurse (LVN). The absence of detailed instructions on the flow sheet had the potential to result in the restraints being left on longer than necessary, which could increase the resident's discomfort. The facility's policy and procedure documents emphasized the importance of care planning and documentation, including the use of protective restraints and monitoring. Despite these guidelines, the care plan for Resident 25 was not adequately updated to reflect the necessary interventions, leading to a deficiency in the resident's care. The lack of alignment between the care plan and the restraint flow sheet was identified as a significant issue during the survey.
Failure to Provide Adequate Hair Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident's hair was shampooed twice a week as required, leading to the resident's hair becoming matted and having an abundance of dandruff. The resident, who was admitted with chronic respiratory failure, sepsis, a tracheostomy, and encephalopathy, was in a persistent vegetative state and dependent on staff for all activities of daily living (ADLs), including personal hygiene. Observations on a specific date revealed the resident's hair condition, and interviews with staff confirmed that hair care was supposed to be provided on shower days, which occurred twice a week. The Certified Nursing Assistant (CNA) acknowledged that the resident's hair looked dirty and emphasized the importance of washing and combing the hair to prevent dryness, dandruff, and tangling. The Associate Chief Nursing Officer (ACNO) confirmed that hair care was part of the resident's ADLs and should have been performed on shower days to maintain hygiene and prevent scalp infection. The facility's policy on hair and scalp care indicated that shampooing should be part of the bathing program, and the condition of the hair and scalp should be observed, with cream rinse used if the hair is tangled.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
The facility failed to ensure that the corrugated oxygen tubing for a resident was labeled with a date of change, which is a critical step for infection control. This deficiency was identified during an observation and interview with a respiratory therapist who noted that the tubing was not dated, making it unclear when it was last changed. The resident in question, who was admitted with chronic respiratory failure and had a tracheostomy, was dependent on staff for all activities of daily living and was receiving oxygen therapy continuously. The lack of labeling on the oxygen tubing posed a potential risk for respiratory infection. Interviews with the Director of Nursing and the Associate Chief Nursing Officer confirmed that it is the facility's policy to label all respiratory equipment with a date of change. The Director of Nursing highlighted that a clogged oxygen tubing could result in inadequate oxygen delivery, potentially causing shortness of breath. The facility's policy and procedure document indicated that all equipment should be changed as needed or when visibly dirty and dated, but this was not adhered to in the case of the resident's oxygen tubing.
Failure to Address Pharmacy Consultant's Recommendation for Medication Review
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's recommendation regarding a resident's medication regimen was acknowledged and acted upon. Specifically, the pharmacy consultant recommended a review and justification for the restarting of Quetiapine, a psychotropic drug, for a resident. This recommendation was not followed through by the Director of Nursing (DON), who was responsible for addressing such recommendations with the resident's physician. The facility's policy required that the attending physician address the consultant pharmacist's recommendation by their next scheduled visit, but this was not done. The resident involved had a history of chronic respiratory failure with a tracheostomy and a gastrostomy tube. The resident was receiving Quetiapine for psychosis manifested by pulling out tubes, but there was no documentation in the psychiatric progress notes to support the diagnosis of psychosis or the use of Quetiapine. The failure to address the pharmacy consultant's recommendation placed the resident at risk for unnecessary medication administration, as there was no documented justification for the medication's use.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure consistent indication and identification of behavior, as well as the implementation of non-pharmacological interventions, before administering Quetiapine, a psychotropic drug, to a resident. The resident, who was admitted with chronic respiratory failure and a gastrostomy tube, was prescribed Quetiapine for psychosis manifested by pulling out tubes. However, the Director of Nursing (DON) confirmed that there was no documentation of the resident's behavior or attempted behavioral interventions prior to the initiation of Quetiapine. Furthermore, the resident's psychiatric progress notes did not indicate a diagnosis of psychosis, and the facility lacked evidence of a pattern of behavior that would justify the use of the medication. Interviews with the Director of Staff Development (DSD) and the Associate Chief Nursing Officer (ACON) revealed that pulling out tubes was not considered a specific behavior of a resident with psychotic features. The DSD acknowledged that the use of Quetiapine was unnecessary and could lead to adverse effects, including chemical imbalance and cardiac complications. The ACON stated that the facility should have employed less restrictive measures, such as hand mittens or one-on-one monitoring, before resorting to psychotropic medication. The facility's policy required that alternative interventions be attempted and documented before administering psychoactive medications, which was not adhered to in this case.
Medication Administration Errors Due to Delayed Dosing
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5%, resulting in medication errors. During an observation of 27 medication administration opportunities, two routine medications were not administered at their scheduled times. Licensed Vocational Nurse 1 (LVN 1) observed that a nebulizer medication, levalbuterol, was not administered to a resident at the scheduled time of 7:00 a.m. as per the Medication Administration Record (MAR). LVN 1 acknowledged that not administering routine medications at the scheduled time could lead to medication errors. Similarly, Licensed Vocational Nurse 2 (LVN 2) observed that another nebulizer medication, albuterol/ipratropium, was not administered to a different resident at the scheduled time of 7:00 a.m. The Director of Respiratory Therapy (DRT) confirmed that both medications were administered after their scheduled times, as indicated by a red box on the MAR. The DRT acknowledged that this delay could result in medication errors, overmedicating residents, and a lack of communication between staff. The facility's policy on medication administration requires that medications be charted immediately after administration, which was not adhered to in these instances.
Improper Storage of Intravenous Medication
Penalty
Summary
The facility failed to ensure that an intravenous medication, Amikacin, was refrigerated as required by its labeling. During an observation and interview, a registered nurse identified that the medication, which was scheduled to be administered at 9:00 p.m., was improperly stored in the intravenous medication cart instead of being refrigerated. The nurse acknowledged that the medication should have been refrigerated and noted that improper storage could lead to the medication being ineffective or expired. The facility's policy on medication storage mandates that drugs be stored under proper conditions, including temperature control.
Room Size Deficiency Identified in Facility
Penalty
Summary
The facility failed to meet the minimum square footage requirement for a resident room, specifically room [ROOM NUMBER], which was intended to accommodate two residents. The required size for such a room is 160 square feet, but the room was measured to be only 155 square feet. This discrepancy was identified during an observation conducted by the Director of Nursing (DON) and the Maintenance Supervisor (MS). The facility had previously submitted a room waiver request to address this issue, indicating that the room was slightly below the required size. During the survey, the DON confirmed that the room was unoccupied and did not have ventilator or tracheostomy access. The facility had been submitting annual waiver requests for this room due to its size deficiency. Despite the room's size not meeting the regulatory requirements, the DON stated that there was no harm to resident safety or well-being. Observations made over the course of the survey indicated that the room sizes did not adversely affect the health or safety of residents.
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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