Magnolia Gardens Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Granada Hills, California.
- Location
- 17922 San Fernando Mission Rd, Granada Hills, California 91344
- CMS Provider Number
- 055142
- Inspections on file
- 54
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Magnolia Gardens Convalescent Hospital during CMS and state inspections, most recent first.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents.
A resident with ESRD and documented dislikes for pasta and rice was served rice at lunch, despite clear documentation of these preferences in their records and meal ticket. The RD confirmed that dietary preferences should have been honored and an appropriate substitute offered, in accordance with facility policy.
A dietary aide was observed with her personal cell phone in the food preparation area and was seen reaching for it during food service. The staff member acknowledged the phone should not have been there, and the RD confirmed that personal items must be kept away from food prep areas to prevent cross-contamination. Facility policy requires personal belongings to be stored separately from food service areas.
A resident with multiple diagnoses and moderate cognitive impairment was transferred to the hospital after a change in condition. The RN responsible for the transfer documented two sets of vital signs but recorded the same time for both, leading to a discrepancy. Additionally, the Resident Transfer Record was left incomplete, missing key information such as insurance details, symptom onset, diet order, mental status, and possessions. Both the RN and DON confirmed the documentation errors and omissions.
A resident was discharged without a complete Discharge Summary or Post Discharge Plan of Care, as required. The documentation lacked a recapitulation of the resident's stay, essential contact information, and details about the resident's status and care preferences. Discharge planning was also not included in the comprehensive care plan, as confirmed by the ADON during interviews and record reviews.
A resident with a history of cancer, dementia, and a recent prolonged fall was admitted without a required trauma care evaluation, despite facility policy mandating universal trauma screening. The Social Services Director confirmed the assessment was missed, and record review showed no trauma care evaluation was completed.
The facility did not ensure that care plans for two residents with pressure ulcers included specific low air loss mattress (LALM) settings and modes as required by physician orders, and failed to implement a fall prevention intervention (floor mat) for another resident with a history of falls. Staff interviews and record reviews confirmed that care plans were not comprehensive or individualized, and required interventions were not consistently implemented or documented.
A resident with diabetes experienced a critically low blood sugar level, and although an LVN intervened by administering orange juice and the blood sugar normalized, the physician was not notified as required by facility policy. The lack of documentation and notification was confirmed during interviews and record review, despite protocols mandating immediate provider notification for hypoglycemic events.
Two residents requiring low air loss mattresses for wound care or pressure ulcer prevention were found with incorrect mattress settings—one with the mattress in static mode instead of alternating, and another with the weight setting much higher than recommended. Nursing staff had not checked or adjusted the settings as required, and physician orders lacked specific instructions for mattress modes or levels. Facility policy and equipment manuals indicated that settings should be individualized based on resident weight and clinical needs.
A resident with cognitive impairment and multiple medical conditions was found in bed with the call light placed underneath her legs, making it inaccessible. Both a CNA and the ADON confirmed that the call light should have been within the resident's reach to allow her to request assistance, and that its inaccessibility could delay care. Facility policy requires call lights to be accessible to residents, but this was not followed in this instance.
Staff failed to knock before entering the rooms of four residents, including individuals with dementia, intellectual disabilities, and other medical conditions. The Infection Preventionist entered without requesting permission, which did not align with facility policy requiring staff to promote resident dignity and respect.
Two residents with severe cognitive impairment and high fall risk were observed using bed pad alarms, but neither had a care plan addressing the use of these alarms. Nursing staff confirmed the alarms were in use due to fall risk, and review of records showed the absence of required care plans with interventions or measurable objectives, contrary to facility policy.
A resident was found with medications and supplements stored at bedside despite not being assessed as safe for self-administration, making them accessible to others. Additionally, two residents at high risk for falls had bed pad alarms in use, but staff did not check or document the alarms' functionality as required by facility policy. These actions resulted in a failure to maintain a safe environment and adequate supervision.
Surveyors found an expired first aid kit stored in the medication room and a medication cart left unlocked and unattended in a hallway. Staff confirmed that expired items should be removed immediately and that medication carts must be locked when unattended, in accordance with facility policy.
Staff failed to follow infection control protocols, including not removing isolation gowns before leaving a resident's room on enhanced barrier precautions, not providing a trashcan for PPE disposal in a room under droplet isolation, allowing oxygen tubing to touch the floor, not labeling urinals for two residents, and not wearing full PPE when entering a room on transmission-based precautions for COVID-19 exposure.
Two residents with significant cognitive and physical impairments were found unable to access their call lights, despite care plans and facility policy requiring call lights to be within reach. Staff confirmed that the call lights were not accessible, which could result in delayed care for these residents.
A resident with an indwelling catheter and multiple diagnoses, including diabetes and obstructive uropathy, was admitted and required substantial assistance with daily activities. The baseline care plan created within 48 hours of admission failed to include necessary nursing interventions for catheter care, despite physician orders specifying daily care. Staff interviews and record reviews confirmed the omission, which did not meet facility policy for immediate care planning.
A resident receiving daily subcutaneous anticoagulant injections did not have injection sites rotated as required by professional standards and manufacturer instructions. Documentation in the MAR indicated repeated use of the abdomen without specifying or alternating the exact site, and nursing staff confirmed the lack of site rotation, which is necessary to prevent tissue damage and discomfort.
A resident with severely impaired cognition and limited English proficiency was not provided with a communication board, despite requiring substantial assistance with daily activities and having a care plan noting communication difficulties. Staff were unaware of the resident's primary language, and no communication board was found at the bedside, contrary to facility policy and expectations stated by the DON.
Two residents did not receive continuous oxygen therapy as ordered by their physicians, and two residents had oxygen tubing that was not dated or changed according to facility policy. Staff confirmed that physician orders and facility protocols for oxygen administration and equipment maintenance were not followed, as observed during surveyor visits and interviews.
A resident with end stage renal disease and on hemodialysis had a physician's order for fluid restriction, specifically requiring no water pitcher at the bedside. Despite this, surveyors observed a full pitcher and glasses of water at the bedside. Both an LVN and the DON confirmed that the physician's order was not followed, and facility policy required adherence to such orders.
A resident with multiple diagnoses and moderate cognitive impairment received nine prescribed medications significantly later than the scheduled administration time, resulting in a medication error rate of 32.14%. The nurse responsible cited being busy as the reason for the delay, and facility policy requires medications to be given within one hour of the prescribed time.
Two residents had leftover food brought by family or visitors that was not labeled with a resident identifier or use by date, nor properly refrigerated, as required by facility policy. Staff confirmed that these actions did not follow established procedures for food safety and storage.
The facility did not provide the required minimum of 80 square feet per resident in 26 multiple-resident rooms, with room sizes ranging from 72 to 79 square feet per resident. Despite this, residents and staff reported adequate space for care and mobility, and rooms were equipped with privacy features and necessary furnishings.
The facility failed to conduct psychosocial assessments upon admission for two residents and did not make follow-up calls to three residents after discharge. This oversight involved residents with severe cognitive impairments and physical disabilities, highlighting a lapse in ensuring safe transitions and adequate support post-discharge.
A resident with a cardiac pacemaker and atrial fibrillation had an apical pulse exceeding 100 bpm on multiple occasions. An LVN failed to document notifying the physician, as required by the facility's policy. This lack of documentation risked the resident's care due to incomplete medical records.
A resident was administered ivermectin for a body rash without a scabies diagnosis. Despite having conditions like atrial fibrillation and type 2 diabetes, there was no documented evidence of scabies, which ivermectin is used to treat. The Infection Preventionist confirmed the medication was given without proper diagnosis, highlighting unnecessary use and potential adverse effects.
The facility failed to ensure proper reconciliation of controlled medications for Medication Cart A, as licensed nurses did not consistently sign the Controlled Drugs Accountability Sheet (CDAS) for several shifts. This lapse in protocol, confirmed by both an LVN and the DON, could lead to inaccurate reconciliation and risk of drug diversion. The facility's policy requires both outgoing and incoming nurses to count and sign for controlled substances together, with discrepancies reported immediately.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairments, as observed during staff interviews. Both residents required total assistance, and their care plans specified that call lights should be accessible. Staff found the call lights out of reach and repositioned them, acknowledging the oversight.
A resident with a stage IV pressure ulcer was found with four layers of linen between their skin and a low air loss mattress (LALM), contrary to facility policy and physician orders. Staff, including LVNs and a CNA, misunderstood the correct number of linen layers, compromising the LALM's effectiveness in promoting wound healing. The ADON confirmed that excess linen layers would negate the LALM's benefits.
A facility failed to maintain infection control practices by allowing a resident's urinary catheter tubing to touch the floor, risking infection. The resident, with severe cognitive impairment and multiple medical conditions, required total assistance. Despite orders to secure the tubing, a CNA admitted to neglecting proper placement, leading to the deficiency.
A resident with cognitive impairments and self-care deficits was not provided with necessary assistance for nail trimming, resulting in long fingernails that posed a risk of self-injury. Despite a care plan and facility policy requiring regular nail care, staff did not adequately address the resident's needs, as confirmed by observations and interviews with facility personnel.
The facility failed to ensure complete H&P documentation for two residents, omitting mental status assessments. One resident with severe cognitive impairment and another with intact cognition had incomplete H&Ps, confirmed by the DON. Facility policies require comprehensive medical information, including mental status, within 72 hours of admission.
A facility failed to document the administration of Tylenol for a resident, as required by their medication administration policy. The resident, who had multiple fractures and impaired cognition, received Tylenol, but this was not recorded in the MAR. The DON confirmed the omission, which could lead to medication errors and confusion in care delivery.
A CNA failed to wear gloves and a gown when entering a contact isolation room for a resident with MRSA, despite signage indicating the need for contact precautions. The CNA admitted to uncertainty and habit as reasons for not donning the required PPE. The Infection Preventionist confirmed the necessity of PPE to prevent infection spread, aligning with the facility's infection control policies.
The facility failed to report two suspected and one confirmed case of scabies among residents, violating infection control policies. A resident with impaired cognition was prescribed Elimite cream as a prophylactic measure, while another resident with intact cognition was noted with a rash and prescribed permethrin cream. A third resident was confirmed to have scabies and was prescribed ivermectin and permethrin cream. The Infection Prevention Nurse acknowledged the failure to report these cases to the ACDC, as required by the facility's policy.
A facility failed to document a resident's skin condition in the discharge summary, despite a dermatology consultation noting dermatitis and scaly erythema. Both an LVN and an RN confirmed the omission, which violated the facility's policy requiring comprehensive documentation for discharge.
The facility failed to rotate injection sites for a resident with diabetes and did not correctly perform orthostatic blood pressure measurements for a resident on Duloxetine. These actions were against the facility's policies and put the residents at risk for complications.
The facility failed to ensure proper food handling and storage practices by not dating and maintaining food in the residents' refrigerator according to policy. This was observed for four residents, with undated food items including fried chicken, jasmine rice, mayonnaise, and lentil soup. The DON and ADON confirmed that food should be labeled with the date it was brought in or opened to prevent the risk of residents consuming spoiled food.
A facility failed to maintain accurate medical records for a resident with end-stage renal disease requiring dialysis. LVNs documented blood pressure readings on the resident's left arm, where an AV shunt was placed, despite professional standards contraindicating this practice. The errors were attributed to mistakes, typos, and confusion with other residents.
The facility failed to observe proper infection control measures, including an LVN not wearing PPE during a respiratory treatment for a resident on ESP, a resident's nasal cannula oxygen tubing being on the floor, and two residents' oxygen tubing not being labeled with a date.
A resident with multiple health issues and a high risk for falls was found with their call light under the bed, out of reach. This was confirmed by a CNA and acknowledged by the DON, who emphasized the importance of call light accessibility for safety and prompt assistance.
The facility failed to provide a homelike environment for a resident, as evidenced by peeling and missing paint in the resident's bedroom ceiling. Despite the resident's intact cognition and dependency on assistance, the maintenance department did not address the issue for about four months. Both the Maintenance Director and the Director of Nursing acknowledged the oversight and the need for the ceiling to be in good repair.
A facility failed to develop a comprehensive care plan for a resident with end stage renal disease requiring dialysis, despite having physician's orders to monitor the resident's AV shunt. This oversight was confirmed by the MDS Nurse and the Director of Nursing, highlighting a lapse in following the facility's policy for timely care plan development.
A resident with chronic obstructive pulmonary disease and difficulty walking was observed smoking in a non-designated area surrounded by flammable substances, despite multiple 'NO SMOKING' signs. Staff confirmed that the designated smoking area was the west side patio, which had appropriate safety measures in place.
A resident with end-stage renal disease had a POLST indicating no resuscitation, but it was invalid due to the physician's failure to sign it. This oversight could lead to actions contrary to the resident's wishes in an emergency.
A facility failed to ensure an LVN administered the correct dosage of aspirin to a resident as ordered by the physician. The LVN gave 81 mg instead of the prescribed 325 mg, which was confirmed during a medication pass observation. The resident had multiple diagnoses, including cerebral infarction and chronic kidney disease. The DON highlighted the importance of following physician orders to avoid harm.
The facility failed to monitor a resident's targeted behavior for the use of quetiapine, an antipsychotic medication, as required by their policy. The resident had schizoaffective disorder and severely impaired cognition, and there was no documentation of behavioral monitoring in the medical records.
The facility failed to store a resident's insulin within the proper temperature range and did not label an opened hydromorphone solution bottle with an opened date for another resident. These deficiencies were identified through observations, interviews, and record reviews, potentially affecting the effectiveness of the medications.
The facility failed to meet the required room size of 80 square feet per resident for 26 of 40 multiple resident rooms. Despite residents not expressing concerns and the rooms being equipped for accessibility and privacy, the rooms did not meet the regulatory square footage requirements.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD) and documented dislikes for both pasta and rice was served rice during lunch. The resident's admission record, Minimum Data Set (MDS), and Nutrition/Dietary Note all indicated these food preferences, and the resident's meal ticket for the day in question also reflected the dislike for rice. Despite this documentation, the resident was observed being served rice, and the resident confirmed that rice is regularly served despite staff being aware of the preference. The Registered Dietitian (RD) reviewed the resident's dietary documentation and confirmed that the facility should have honored the resident's preferences and provided an appropriate substitute. The facility's policy requires that food preferences be assessed upon admission and communicated to the interdisciplinary team, with modifications made only with the resident's consent. The failure to follow these documented preferences led to the resident being served an unwanted food item.
Personal Cell Phone Found in Food Preparation Area by Dietary Staff
Penalty
Summary
During an observation in the facility's kitchen, a dietary aide (DA) was found to have her personal cell phone placed in the food preparation area. The DA was seen reaching for her cell phone, which was located on a surface used for food preparation. Upon interview, the DA acknowledged that the cell phone belonged to her and admitted it should not have been in the food preparation area. The Registered Dietician (RD) confirmed during an interview that personal items, including cell phones, must be kept away from food preparation areas to prevent cross-contamination. A review of the facility's policy and procedure on Sanitation and Infection Control indicated that all employee personal belongings, such as clothing, food, and cell phones, should be stored in a separate area away from food or items used in food service. The failure to follow this policy was observed with the DA's cell phone being present in the food preparation area, which did not comply with the facility's infection control and sanitation standards.
Incomplete and Inaccurate Resident Transfer Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting the correct time on the Resident Transfer Record and by leaving several required sections incomplete. The resident, who had a history of Parkinson's disease, anxiety disorder, and spinal stenosis, was admitted with moderate cognitive impairment and required partial to moderate assistance with daily activities. On the day of the incident, the resident experienced lower abdominal pain, prompting a physician's order for hospital transfer. During the transfer process, the responsible RN documented two sets of vital signs: one at 10:45 a.m. on the SBAR form and another set, taken around 11:45 a.m., on the Resident Transfer Record. However, the RN mistakenly recorded the time as 10:45 a.m. on both documents, resulting in a discrepancy between the actual time the vital signs were taken and the time documented. Additionally, the Resident Transfer Record was found to have several blank sections, including the resident's Social Security Number, insurance information, date and time symptoms were first noted, current diet order, baseline mental status, and possessions transferred. Both the RN and the DON acknowledged the errors and omissions during interviews, confirming that the Resident Transfer Record was incomplete and contained inaccurate information regarding the timing of vital signs. The facility's policy requires that all health records be accurate, timely, specific, and complete, but these standards were not met in this instance.
Failure to Complete Discharge Documentation and Planning
Penalty
Summary
The facility failed to ensure proper discharge planning and documentation for one resident. Specifically, the Discharge Summary did not include a recapitulation of the resident's stay, omitting details about the course of treatment while in the facility. The Post Discharge Plan of Care was incomplete, missing critical information such as the address and phone number of the discharge location, contact information for the discharge and continuing care physicians, the reason for admission and discharge, the resident's mental and psychosocial status, and care preferences. These omissions were confirmed by the Assistant Director of Nursing (ADON) during interviews and record reviews. Additionally, there was no evidence that discharge planning was incorporated into the resident's comprehensive care plan. The ADON acknowledged that a care plan for discharge planning should have been developed to establish goals for the resident's discharge and to involve the interdisciplinary team in supporting those goals. Facility policies reviewed indicated that a complete recapitulation and a comprehensive discharge summary and plan are required to ensure continuity of care and proper adjustment to a new living environment.
Failure to Complete Trauma Care Evaluation for Resident
Penalty
Summary
The facility failed to conduct a trauma care evaluation for one of four sampled residents, despite facility policy requiring universal screening for trauma-informed care. The resident in question was admitted with diagnoses including rhabdomyolysis, dementia, and a history of malignant neoplasm of the breast. Upon admission, the resident had experienced a significant traumatic event, having fallen at home and remained on the floor for approximately five days before being found. The resident's Minimum Data Set indicated intact cognition and dependence on staff for several activities of daily living. During a review of the resident's records, it was found that no trauma care evaluation had been completed. The Social Services Director confirmed that a trauma care evaluation should have been performed for all residents and acknowledged missing this assessment for the resident. The facility's policy on trauma-informed and culturally competent care specifies that universal screening is required to identify the need for further assessment and care, but this was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, specifically regarding the use of low air loss mattresses (LALM) and fall prevention interventions. For two residents with significant pressure ulcers and related risk factors, the care plans did not specify the required LALM setting levels and modes, despite physician orders indicating the need for these specialized mattresses for wound and skin management. Staff interviews confirmed that the care plans lacked individualized details, and the responsible nurse was unable to clarify the appropriate settings, acknowledging the care plans were not comprehensive or person-centered. Additionally, for a resident with a history of falls and multiple neurological and musculoskeletal diagnoses, the care plan included the use of a floor mat (landing mat) as a fall prevention measure. However, during observation, the floor mat was not in place, and the assigned CNA reported not having seen or placed the mat that day. Documentation did not confirm the mat's use, and the DON confirmed that the intervention should have been implemented and monitored by nursing staff, but there was no evidence this occurred. The facility's own policies and procedures require comprehensive, individualized care plans with measurable objectives and timetables, as well as the implementation of physician-ordered interventions. The deficiencies identified were based on direct record review, staff interviews, and observations, demonstrating a failure to ensure that care plans were both comprehensive and implemented as written for residents with complex care needs.
Failure to Notify Physician of Critically Low Blood Sugar Event
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced a critically low blood sugar level of 45 mg/dl. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, atrial fibrillation, and an above-knee amputation, was admitted with intact cognition and required varying levels of assistance with daily activities. On the date of the incident, a Licensed Vocational Nurse (LVN) administered orange juice as an intervention for the low blood sugar and rechecked the resident's blood sugar 15 minutes later, which had increased to 74 mg/dl. However, the LVN did not document physician notification, and during interviews, it was confirmed that physician notification and documentation were not completed as required. Facility policy required prompt notification of the physician and resident representative for changes in a resident's condition, including hypoglycemic events. The Assistant Director of Nursing (ADON) confirmed that the physician should have been notified and a Change of Condition form completed, regardless of the resident's blood sugar returning to normal after intervention. The facility's policy on diabetes care also specified immediate provider notification for hypoglycemia, which was not followed in this instance.
Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALM) were set to the correct settings for two residents, both of whom required specialized support surfaces for wound care or prevention of pressure ulcers. For one resident with a history of diabetes and bilateral above-knee amputations, who was severely cognitively impaired and required total assistance, the LALM was observed to be set to static mode rather than the alternating mode as recommended for wound management. Nursing staff had not checked the mattress setting that morning, and the physician's order did not specify the required mode. The treatment nurse confirmed that the alternating mode was necessary to prevent constant pressure on the skin, which could increase the risk of pressure ulcers. For another resident with diabetes and a right femur fracture, who was at risk for pressure ulcers and required maximal assistance, the LALM was found to be set at a weight setting of 280 lbs instead of the recommended 120 lbs based on the resident's body weight. The certified nursing assistant had not checked the setting at the start of her shift and only adjusted it after being prompted. The physician's order for this resident also lacked clarification on the specific setting level or mode, but the treatment nurse confirmed the correct setting should match the resident's weight as posted on the pump unit. Facility policy and the user manuals for the LALM systems indicated that mattress settings should be adjusted according to the resident's weight and clinical needs, and that alternating mode is used to minimize pressure on the skin. The Director of Nursing stated that settings should be individualized for each resident to promote wound healing or prevent skin breakdown, and that failure to follow recommended settings could place residents at risk for further pressure ulcers.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was cognitively impaired and dependent on staff for transfer, toileting, dressing, and bathing, was observed lying in bed with the call light placed underneath her legs, making it inaccessible. The resident had a medical history including seizures, hypothyroidism, and osteoporosis, and required assistance for most activities of daily living. During the observation, a CNA confirmed that the call light should have been within the resident's reach to allow her to call for assistance, and acknowledged that its inaccessibility could delay care. Further interview with the Assistant Director of Nursing corroborated that the call light was not within reach, which could result in delayed response to the resident's needs. Review of the facility's policy indicated that call lights are to be accessible to residents when in bed or in a wheelchair, and the observed situation did not comply with this policy. The deficiency was based on direct observation, staff interviews, and review of facility policy and resident records.
Failure to Knock Before Entering Resident Rooms Compromises Dignity
Penalty
Summary
Facility staff failed to maintain resident dignity and respect by not knocking before entering the rooms of four residents. During an observation, the Infection Preventionist (IP) entered the rooms of these residents without knocking or requesting permission, contrary to facility policy. The IP acknowledged during an interview that she did not knock and recognized the importance of this action in showing respect to residents. The facility's policy on dignity, revised in February 2022, requires staff to knock and request permission before entering a resident's room to promote well-being and self-worth. The residents involved had varying cognitive and physical needs. Two residents had severely impaired cognitive skills and required significant assistance with daily activities, while the other two had intact cognitive skills but still required some assistance with personal hygiene and toileting. The failure to knock before entering affected residents with diagnoses including dementia, intellectual disabilities, epilepsy, cerebral palsy, anxiety, and atrial fibrillation. This practice had the potential to impact the residents' self-esteem and sense of self-worth.
Failure to Develop and Implement Care Plans for Bed Pad Alarm Use in High Fall Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were both identified as high fall risks and were observed using bed pad alarms. Both residents had severe cognitive impairment and required substantial to maximal assistance with activities of daily living, as documented in their Minimum Data Set assessments. Despite their high risk for falls, as indicated in their respective Fall Risk Assessments, there was no care plan in place addressing the use of bed pad alarms for either resident. Observations confirmed that both residents were using bed sensor pads connected to alarm monitors, and interviews with nursing staff verified that the alarms were in use due to the residents' high fall risk. However, review of the care plans by the Infection Preventionist revealed that neither resident had a care plan that included interventions or measurable objectives related to the use of bed pad alarms. This lack of care planning was contrary to the facility's own policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Secure Medications and Ensure Functionality of Bed Pad Alarms
Penalty
Summary
A deficiency was identified when a resident was found to have multiple bottles of supplements and medications stored at their bedside, accessible to other residents. The resident's care plan noted that the family requested supplements be kept at the bedside, but the resident's assessment indicated they were not safe to self-administer medications and required staff assistance for all medication administration. Despite this, the medications were left in a plastic bag at the bedside, and both the Director of Social Service and the DON confirmed the presence of these medications. Facility policy required that medications be stored securely and only accessible to authorized personnel, which was not followed in this instance. Additionally, the facility failed to ensure daily checks and documentation of the functionality of bed pad alarms for two residents identified as high fall risks. Both residents had severe cognitive impairment and required substantial assistance with daily activities. Observations confirmed that both residents were using bed pad alarms, but staff were unable to demonstrate or document that the alarms were checked for proper functioning as required by facility policy. Interviews with nursing staff and the DON revealed a lack of clarity on where or how the checks were to be documented, and in one case, a nurse stated the alarm was not functioning. The facility's policies required that personal alarms be checked daily for proper functioning and that nursing staff monitor and document their status. However, record reviews for both residents did not show any evidence that these checks were performed or documented. This lack of adherence to policy and procedure resulted in a failure to provide an environment free from accident hazards and adequate supervision to prevent accidents for the residents involved.
Expired First Aid Kit and Unattended Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure proper storage and timely removal of expired drugs and biologicals, as evidenced by the presence of an expired first aid kit in the medication storage room. During an inspection, a registered nurse confirmed that the first aid kit had expired and acknowledged that licensed staff are required to immediately remove expired items from the medication storage area. The Director of Nursing also confirmed that nurses are expected to inspect the medication storage room every shift and remove expired medications and supplies, but an expired kit was still present during the survey. Additionally, a medication cart was observed left unlocked and unattended in a hallway, with staff walking by the unsecured cart. The licensed vocational nurse responsible for the cart admitted to leaving it unlocked while retrieving a binder, despite facility policy requiring medication carts to be locked when unattended. The Assistant Director of Nursing confirmed that medication carts should always be locked when not attended by authorized personnel. Facility policy states that medications and biologicals must be stored securely and only accessible to authorized staff.
Multiple Lapses in Infection Control and PPE Use
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in several instances. In one case, a treatment nurse provided wound care to a resident on enhanced barrier precautions due to a sacrococcyx pressure sore and exited the resident's room while still wearing an isolation gown. Both the infection preventionist and the director of nursing confirmed that the gown should have been removed before leaving the room, as per facility policy and standard infection control practices. In another instance, a resident on droplet isolation for COVID-19 exposure did not have a trashcan inside the room, making it impossible for staff or visitors to properly doff and dispose of personal protective equipment (PPE) before exiting. The director of social services, infection preventionist, and director of nursing all acknowledged that a trashcan is required inside such rooms to prevent the spread of infection. Additionally, a resident's nasal cannula oxygen tubing was observed lying on the floor, which was recognized by staff as a contamination risk, and the tubing was immediately discarded. Further deficiencies included two residents whose urinals were not labeled with their identifiers, creating a risk of cross-contamination if the urinals were accidentally switched. Staff confirmed that urinals should be labeled with the resident's initials, room, and bed number. Lastly, a certified nurse assistant entered a room under respiratory precautions for COVID-19 exposure without wearing a gown, contrary to posted signage and facility policy, which required full PPE for anyone entering the room.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents who required assistance with activities of daily living. For one resident with end stage renal disease, heart failure, and bipolar disorder, the care plan specifically indicated that the call light should be within easy reach due to the resident's moderate cognitive impairment and need for moderate to maximal staff assistance. However, during an observation, the call light was found hanging under the bed and not accessible to the resident. A CNA confirmed that the resident could not reach the call light, which could result in delayed care. Similarly, another resident with hypertensive chronic kidney disease, major depression, and essential hypertension, who also had severely impaired cognition and required maximal assistance, was observed lying in bed with the call light located on the wall and out of reach. The resident stated she could not reach the call light, and the CNA acknowledged the risk of delayed care if the resident was unable to call for assistance. The facility's policy required that a means to call staff for assistance be provided, but this was not followed in these cases.
Incomplete Baseline Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review of the resident's admission records, assessments, and physician orders, it was found that although the baseline care plan noted the presence of an indwelling catheter, it did not include any nursing interventions or instructions for the care and monitoring of the catheter. The resident had diagnoses including type 2 diabetes mellitus, obstructive uropathy, and reflux uropathy, and required substantial to maximal assistance with activities of daily living. Physician orders specifically indicated the need for daily catheter care, but this was not reflected in the baseline care plan. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not address the required interventions for the resident's catheter. The facility's policy requires that a baseline care plan be developed within 48 hours of admission to address immediate health and safety needs, including all necessary services and treatments. The omission of catheter care interventions in the baseline care plan constituted a failure to meet this requirement for the resident.
Failure to Rotate Subcutaneous Injection Sites for Anticoagulant Administration
Penalty
Summary
The facility failed to ensure that subcutaneous injection sites were rotated for a resident receiving anticoagulant therapy, specifically Enoxaparin Sodium (Lovenox), as required by professional standards of practice. Review of the resident's Medication Administration Record (MAR) for March and April showed that injections were consistently documented as being administered in the abdomen, without specifying the exact area or indicating rotation of sites. This practice was confirmed during an interview with a registered nurse, who acknowledged that proper documentation and rotation of injection sites are necessary to prevent tissue damage and discomfort. The resident involved had a history of muscle weakness, COPD, and hypertension, and required staff assistance with activities of daily living. The resident's cognitive skills for daily decision-making were intact. Physician orders directed daily subcutaneous administration of Lovenox for deep vein thrombosis prophylaxis. Manufacturer instructions provided by the facility also specified alternating injection sites between the left and right sides of the abdomen. Despite these guidelines, the facility's documentation and practice did not reflect adherence to site rotation protocols.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A deficiency was identified when a resident whose primary language was Arabic and who had severely impaired cognitive skills was not provided with a communication board to assist with communication. The resident required substantial to maximal assistance with activities of daily living, including eating, oral hygiene, toileting hygiene, and personal hygiene. The resident's care plan noted a risk for unmet needs due to communication difficulties and specified that the resident's main language was Arabic. However, during observation and interviews, staff were unable to locate a communication board at the resident's bedside, and a nurse was not aware of the resident's primary language. The Director of Nursing confirmed that staff should use a communication board to facilitate communication with the resident, especially given the language barrier. The facility's policy required meaningful access to information and services for individuals with limited English proficiency. Despite this, the lack of a communication board at the bedside prevented staff from effectively communicating with the resident, which could have delayed the resident's care and treatment.
Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to ensure that residents received continuous oxygen therapy as ordered by their physicians for two of five sampled residents. One resident with a history of acute respiratory failure, hypoxia, and COVID-19 was observed without an oxygen machine at bedside, despite a physician's order for continuous oxygen at three liters per minute via nasal cannula. The resident confirmed not using oxygen recently, and staff interviews revealed that the physician's order was not followed, with no documented reason for discontinuation or physician notification. Another resident with acute respiratory failure and COPD was also found not wearing the prescribed nasal cannula during observation, despite an active order for oxygen therapy. Additionally, the facility did not ensure that oxygen tubing was dated and changed according to facility policy and physician orders for two residents. One resident's oxygen tubing and bag were observed to be undated, and staff confirmed that the tubing should have been dated and replaced weekly. Another resident's oxygen tubing and bag were found to be dated beyond the required seven-day change interval, indicating the tubing had not been replaced as scheduled. Staff interviews confirmed that central supply was responsible for changing and dating the tubing, and that the failure to do so was not in accordance with facility policy. Record reviews and staff interviews consistently indicated that the facility's policies required oxygen to be administered as ordered by the physician and for oxygen equipment to be dated and changed at specified intervals. Observations and documentation showed that these requirements were not met for multiple residents, with staff acknowledging the lapses in following physician orders and facility protocols for respiratory care and infection prevention.
Failure to Implement Fluid Restriction Order for Dialysis Resident
Penalty
Summary
The facility failed to implement a physician's order for fluid restriction for a resident with end stage renal disease who was dependent on hemodialysis. The physician's order, dated 1/28/2025, specified that the resident should be on fluid restriction and that no water pitcher should be placed at the bedside. Despite this, during an observation on 4/27/2025, a full pitcher of water, a full glass of water, and another half-full glass of water were found on the resident's side table. The resident confirmed awareness of the fluid restriction and stated that water was only consumed with morning medications. Staff interviews confirmed knowledge of the physician's order and acknowledged that the order was not followed, as water was present at the bedside. The Director of Nursing also confirmed that staff are required to implement physician orders for fluid restriction, particularly for residents undergoing hemodialysis. Review of facility policy indicated that fluid restriction orders limiting water at the bedside should be followed as directed by the attending physician.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a medication error rate of 32.14 percent. This was identified during observation, interview, and record review, where nine medication errors were found out of 28 opportunities, all involving a single resident. The errors consisted of administering nine different medications at times different from those ordered by the physician. The resident involved had a history of difficulty walking, depression, dysphagia, and falls, and was assessed as having moderately impaired cognitive skills, requiring partial to moderate staff assistance for daily activities. The resident was prescribed multiple medications, including anastrazole, bupropion, carvedilol, furosemide, sertraline, vitamin C, thiamine, a multivitamin with minerals, and magnesium oxide, all scheduled for administration at specific times, primarily at 9:00 a.m. and 5:00 p.m. On the day of the observed deficiency, a nurse prepared and administered the resident's morning medications at 11:24 a.m., well past the scheduled 9:00 a.m. administration time and outside the facility's one-hour window policy. The nurse acknowledged being late due to being busy with other residents and confirmed that administering medications outside the prescribed time frame is considered a medication error. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified.
Failure to Label and Store Leftover Food Brought by Visitors
Penalty
Summary
The facility failed to ensure that leftover food brought in by family or visitors for two residents was properly labeled with the resident's identifier and a use by date, as required by facility policy. In the case of one resident with chronic kidney disease and hypertension, who was cognitively intact and independent in activities of daily living, two containers of food brought by a family member were found on the overbed table without any labeling. The resident confirmed the food was brought the previous day. A registered nurse acknowledged that the food should have been labeled and refrigerated according to policy, but this was not done. Similarly, another resident with chronic kidney disease and hypertension, who required assistance with activities of daily living but was cognitively intact, had a box of pizza left on the overbed table, also brought by a visitor the previous day. This food was not labeled or refrigerated as required. The registered nurse confirmed that the leftover pizza should have been labeled with the resident's name and use by date and refrigerated to prevent spoilage, in accordance with the facility's policy. Both instances were observed and confirmed through interviews and record reviews.
Failure to Meet Minimum Room Size Requirements for Multiple-Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 26 out of 40 multiple-resident rooms, as required by federal and state regulations. During a recertification survey, it was found that several rooms, including those with two to four beds, did not meet the minimum square footage per resident. The room sizes ranged from 72 to 79 square feet per resident, which is below the required 80 square feet for multiple-resident rooms. The deficiency was identified through observation, interviews, and record review, including a review of the facility's room variance waiver application and supporting documentation. Despite the deficiency in room size, observations and resident interviews indicated that residents had sufficient space to move freely, and staff were able to provide care and maintain privacy. Residents reported no issues with mobility or receiving care in their rooms, and each room was equipped with privacy curtains, call lights, and adequate storage. The facility's policy stated that bedrooms should meet the required square footage, but the actual measurements in the identified rooms did not comply with these standards.
Failure to Conduct Psychosocial Assessments and Follow-Up Calls
Penalty
Summary
The facility failed to ensure that the social services department conducted psychosocial assessments upon admission for two residents and did not make follow-up calls to three residents after they were discharged home. This deficiency was identified during interviews and record reviews, revealing that the facility did not adhere to its policy of providing medically related social services to help each resident achieve the highest possible quality of life. Resident 1 was admitted with a non-displaced fracture of the right femur, a history of falling, and difficulty walking. The resident's cognition was severely impaired, requiring assistance with daily activities. Despite being discharged home with a 24-hour caregiver, there was no documented evidence of a follow-up call to ensure the resident's safe transition home. The Social Services Director (SSD) acknowledged the oversight and the absence of discharge documentation. Similarly, Resident 2, admitted with metabolic encephalopathy and other conditions, did not receive a psychosocial assessment upon admission, and no follow-up call was made after discharge. Resident 3, admitted with fractures and muscle weakness, also lacked a psychosocial assessment and follow-up call post-discharge. The SSD admitted to these deficiencies, recognizing the importance of such assessments and follow-up calls for resident safety and adjustment post-discharge.
Failure to Document Physician Notification for Elevated Apical Pulse
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of atrial fibrillation, a cardiac pacemaker, and type 2 diabetes. The resident was readmitted to the facility with a physician's order to monitor the apical pulse daily and notify the physician if the pulse was less than 60 or greater than 100 beats per minute (bpm). On multiple occasions, the resident's apical pulse exceeded 100 bpm, but the facility did not document efforts to notify the physician as required. Licensed Vocational Nurse 1 (LVN 1) was responsible for monitoring the resident's apical pulse and acknowledged that the pulse exceeded 100 bpm on several dates. Although LVN 1 stated that she called the physician, she failed to document these calls in the resident's medical record. The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and changes in the resident's condition be documented to facilitate communication among the interdisciplinary team. The lack of documentation placed the resident at risk of not receiving appropriate care due to incomplete medical records.
Unnecessary Administration of Ivermectin
Penalty
Summary
The facility failed to ensure there was an adequate indication for the use of ivermectin for a resident who was not diagnosed with scabies. The resident, who was readmitted to the facility with diagnoses including atrial fibrillation, presence of a cardiac pacemaker, and type 2 diabetes, was administered ivermectin for a body rash. However, there was no documented evidence that the resident had scabies, which is a condition that ivermectin is typically used to treat. The medication was administered on two consecutive days, despite the absence of a scabies diagnosis. During a review of the resident's medical records and a concurrent interview with the Infection Preventionist, it was confirmed that ivermectin was administered without a proper diagnosis of scabies. The Infection Preventionist acknowledged that the medication should not have been given, as the resident did not have scabies. The report highlights that the use of ivermectin in this case was unnecessary and could potentially lead to adverse side effects.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that licensed nurse staff completed the reconciliation of controlled medications for one of four medication carts, specifically Medication Cart A. This process is crucial for validating that the amount of controlled substances, which have a high potential for abuse, at the end of a shift matches the expected amount. During an interview and record review, it was found that there were gaps in the Controlled Drugs Accountability Sheet (CDAS) for November and December 2024, where two licensed nurses did not sign off on the reconciliation process on multiple dates. Licensed Vocational Nurse 2 (LVN 2) acknowledged these gaps and stated that while they always counted the medications with another nurse, they could not confirm if the medications were counted but not signed for, or if they were not counted at all. The Director of Nursing (DON) confirmed that the facility's protocol requires both the outgoing and incoming licensed nurses to count the controlled medications together and sign the CDAS form. Any discrepancies should be reported immediately to the DON for further investigation. The facility's policy and procedure on controlled substances, last reviewed in April 2024, mandates compliance with all relevant laws and regulations, including the reconciliation of controlled substances at the end of each shift. The failure to adhere to these protocols had the potential to result in inaccurate reconciliation and placed the facility at risk for drug diversion and loss of controlled medications.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical aspect of accommodating the needs and preferences of residents. Resident 1, who was admitted with severe cognitive impairment and required total assistance for daily activities, was found with a call light that was stuck on the left side of the bed frame, making it inaccessible. This was observed during an interview with an LVN, who acknowledged the issue and repositioned the call light within reach. The resident's care plan had specified that the call light should be attached to the bed within the resident's access, but this was not adhered to. Similarly, Resident 2, who also had severe cognitive impairment and required maximum assistance, was observed sitting in a geriatric chair with the call light tangled and out of reach. This was confirmed by a CNA and later by an LVN, who untangled and repositioned the call light. The resident's care plan also indicated that the call light should be within reach, and the facility's policy required that residents be provided with a means to call for assistance. The Assistant Director of Nursing confirmed that staff should ensure call lights are accessible when leaving residents' rooms.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress (LALM) for a resident with a stage IV pressure ulcer, which is a severe form of skin and tissue injury. The resident, who had been admitted with multiple health issues including the absence of both legs above the knee and a stage IV pressure ulcer in the sacral region, was observed with four layers of linen between their skin and the LALM. This was contrary to the physician's orders and the facility's policy, which specified that no more than two layers of linen should be used to ensure the effectiveness of the LALM in promoting wound healing. During observations and interviews, it was noted that the nursing staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, were not adhering to the guidelines. They mistakenly believed that the cloth incontinence pad and folded bed sheet constituted fewer layers than they actually did. The Assistant Director of Nursing confirmed that using multiple layers of linen would negate the benefits of the LALM, as it would not effectively aid in the healing process of the pressure ulcer. The facility's policy clearly outlined the importance of limiting linen layers to ensure pressure redistribution and moisture control, which are critical for preventing further skin breakdown.
Failure to Maintain Infection Control with Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring that a resident's indwelling urinary catheter tubing was kept off the floor. This deficiency was observed during a concurrent observation and interview with two Licensed Vocational Nurses (LVNs), where it was noted that the catheter tubing was touching the floor. The LVNs acknowledged that the tubing should be monitored to prevent it from touching the floor, as this could lead to germs entering the resident's body and causing a urinary tract infection. The resident involved had a history of significant medical conditions, including the absence of both legs above the knee, a stage IV pressure ulcer in the sacral region, obstructive uropathy, and reflux uropathy. The resident's cognitive skills were severely impaired, requiring total assistance from staff for daily activities. Despite physician orders to secure the catheter tubing daily, a Certified Nursing Assistant (CNA) admitted to forgetting to place the urine collection bag and tubing inside a basin, which resulted in the tubing touching the floor. The facility's policy on infection prevention and catheter care clearly stated that catheter tubing and drainage bags should be kept off the floor to prevent infections.
Failure to Assist Resident with Nail Trimming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for a resident who required help with nail trimming. The resident, admitted with diagnoses including a urinary tract infection and adult failure to thrive, was found to have severely impaired cognition and was dependent on staff for personal hygiene tasks. Despite a care plan indicating the need for assistance with grooming and nail trimming, the resident's fingernails were observed to be long, posing a risk of self-injury. Interviews with facility staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, confirmed the resident's long fingernails and the associated risk of self-injury. The staff acknowledged the difficulty in trimming the resident's nails due to the resident's reluctance to open their hands, but no attempts were made to address this challenge with additional staff support. The Director of Nursing also confirmed the need for nail care, aligning with the facility's policy that emphasizes regular cleaning and trimming to prevent infections and skin problems.
Incomplete H&P Documentation for Mental Status
Penalty
Summary
The facility failed to ensure that the History and Physical (H&P) examinations for two residents were completed in their entirety by the attending physician, specifically omitting the assessment of mental status. For one resident, admitted with diagnoses including urinary tract infection and adult failure to thrive, the H&P did not document the resident's mental status, despite the Minimum Data Set (MDS) indicating severe cognitive impairment. This omission was confirmed during an interview with the Director of Nursing (DON), who acknowledged the importance of mental status as a baseline assessment for care planning. Similarly, another resident admitted with hemiplegia and hemiparesis following a cerebral infarction had an H&P that lacked documentation of mental status, even though the MDS indicated intact cognition. The DON confirmed the incompleteness of this H&P as well. The facility's policies require physicians to provide comprehensive medical information, including mental status assessments, within 72 hours of admission if not completed prior. The failure to adhere to these policies resulted in incomplete H&P documentation, potentially affecting care coordination and timely service delivery.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that a licensed nurse documented the administration of Tylenol on the Medication Administration Record (MAR) for a resident on a specific date. This oversight was identified during an interview and record review, where it was found that the resident received Tylenol 500 mg by mouth, but this administration was not recorded in the MAR. The Director of Nursing (DON) confirmed that the MAR did not reflect the administration of Tylenol, which is a requirement according to the facility's medication administration policy. The resident involved had been admitted with multiple fractures and had moderately impaired cognition, requiring assistance with daily activities. The facility's policy mandates that the individual administering medication must document the administration details, including the date, time, dosage, route, and the signature of the person administering the drug. The failure to document the administration of Tylenol as per the policy had the potential to result in medication errors and confusion in the delivery of care and services.
Failure to Use PPE in Contact Isolation Room
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) donned appropriate personal protective equipment (PPE) before entering a contact isolation room for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident, who was admitted with diagnoses including unspecified atrial fibrillation and MRSA, had an order for contact precautions due to MRSA of the left foot. Despite signage indicating contact precautions outside the resident's room, the CNA entered without wearing gloves and a gown, which are required for contact isolation. During an interview, the CNA acknowledged the requirement to wear a mask, gown, and gloves when entering the isolation room but admitted to not wearing gloves and a gown due to uncertainty and habit. The Infection Preventionist confirmed that PPE must be worn based on the type of precautions to decrease the risk of infection. The facility's policy on infection prevention and control, as well as the policy on PPE, both emphasize the importance of wearing appropriate PPE to prevent the transmission of infections.
Failure to Report Scabies Cases
Penalty
Summary
The facility failed to report two suspected cases and one confirmed case of scabies among residents, which is a deficiency in their infection prevention and control program. Resident 1 was admitted with diagnoses including acute cholecystitis and COPD, and had severely impaired cognition, requiring maximum assistance for personal care. A physician ordered Elimite cream for Resident 1 as a prophylactic measure against scabies. Resident 4, who had intact cognition and required supervision for personal hygiene, was noted with a rash and was prescribed permethrin cream for dermatitis prophylaxis. Resident 2, with a diagnosis of COPD and intact cognition, was confirmed to have scabies and was prescribed ivermectin and permethrin cream. The Infection Prevention Nurse admitted that the facility did not report the suspected scabies cases of Residents 1 and 4, nor the confirmed case of Resident 2, to the Acute Communicable Disease Center (ACDC) as required. The facility's policy, last reviewed in April 2024, mandates reporting of both confirmed and suspected cases of communicable diseases, including scabies, to the ACDC. The failure to report these cases was a breach of the facility's infection control policy and had the potential to result in the spread of scabies among staff and other residents.
Failure to Document Skin Condition in Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary report for a resident that included information about the resident's current skin condition upon discharge. The resident, who was admitted with acute cholecystitis and chronic obstructive pulmonary disease, had a dermatology consultation that noted a skin condition involving papulosquamous non-bullous scaly erythema and dermatitis. However, the discharge summary report did not document the resident's skin condition, leaving the section blank. During interviews and record reviews, both a Licensed Vocational Nurse and a Registered Nurse confirmed that the skin condition was not documented in the Post Discharge Plan of Care. The facility's policy on transfer or discharge requires documentation of all necessary information to meet the resident's needs, which was not adhered to in this case. This oversight had the potential to result in unsafe discharge and incomplete communication regarding the resident's stay in the facility.
Failure to Rotate Injection Sites and Incorrect Blood Pressure Measurement
Penalty
Summary
The facility failed to meet professional standards of practice by not rotating injection sites when administering insulin to a resident with type 2 diabetes mellitus. The resident's Medication Administration Record (MAR) showed repeated use of the same injection sites over several days, which was confirmed by a Licensed Vocational Nurse (LVN). The Director of Nursing (DON) acknowledged that not rotating injection sites could lead to the development of scar tissue, which can inhibit the absorption of medication. The facility's policy on medication administration was not followed, as it required proper rotation of injection sites to prevent such issues. Additionally, the facility did not correctly perform orthostatic blood pressure measurements for a resident taking Duloxetine, an antidepressant medication that can cause postural hypotension. The Licensed Vocational Nurse (LVN) responsible for taking the resident's blood pressure admitted to placing the resident in a semi-Fowler position instead of lying flat, and waiting 20 to 30 minutes before taking the next reading. This method was not in accordance with the facility's policy, which required immediate position changes to accurately detect orthostatic hypotension. The DON confirmed the importance of correct procedures to prevent fainting and falls. The deficiencies were identified through observation, interview, and record review, highlighting the facility's failure to adhere to its own policies and procedures. These practices put the residents at risk for complications such as lipodystrophy, amyloidosis, dizziness, lightheadedness, and fainting. The facility's policies on medication administration and blood pressure measurement were not properly implemented, leading to these deficiencies.
Failure to Ensure Proper Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure proper food handling and storage practices by not dating and maintaining food in the refrigerator designated for residents' foods according to the facility's policy. This was observed for four of seven sampled residents. Specifically, Resident 7 had an undated box with fried chicken, biscuit, and coleslaw; Resident 61 had three undated food containers and an undated container of jasmine rice; Resident 8 had an undated opened mayonnaise; and Resident 29 had undated lentil soup. The Director of Nursing (DON) confirmed that foods should have a date written on them when opened and should be stored in the refrigerator for no more than three days. The Assistant Director of Nursing (ADON) also stated that food should be labeled with the date it was brought into the facility by families to prevent the risk of residents consuming spoiled food. A review of the facility's policies indicated that food brought by family/visitors should be labeled and stored in a manner that distinguishes it from facility-prepared food. Perishable foods should be stored in re-sealable containers with tightly fitting lids in a refrigerator and labeled with the resident's name, the item, and the use-by date. The policy also stated that leftover food or unused portions of packaged foods should be discarded and no food should be stored beyond 72 hours from receipt. All items should be properly covered, dated, and labeled with appropriate dates, including the delivery date and the open date for potentially hazardous food (PHF).
Inaccurate Medical Records for Resident with AV Shunt
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 45, who was admitted with end-stage renal disease requiring dialysis. Licensed vocational nurses (LVNs) documented blood pressure readings on the resident's left arm, where an arteriovenous (AV) shunt was placed, despite professional standards contraindicating this practice. The incorrect documentation occurred multiple times over several months, as evidenced by the Blood Pressure Summary report and interviews with the involved LVNs. Resident 45, who had intact cognition and the capacity to understand and make decisions, stated that staff usually took his blood pressure on the right arm and was aware that the left arm should not be used due to the AV shunt. Interviews with LVNs revealed that the incorrect documentation was attributed to mistakes, typos, and confusion with other residents. Each LVN acknowledged the error and emphasized the risks associated with taking blood pressure on the same side as the AV shunt. The Director of Nursing (DON) confirmed that LVNs are expected to document accurately and that the facility did not have specific signs in Resident 45's room to indicate no blood pressures on the left arm. The facility's policies on charting and documentation, as well as care for residents receiving renal dialysis, were reviewed and indicated the need for accurate and complete documentation and the prohibition of blood pressure measurements in or around the shunt area.
Infection Control Deficiencies
Penalty
Summary
The facility failed to observe proper infection control measures in several instances. One incident involved a Licensed Vocational Nurse (LVN) who did not wear a gown and gloves while administering a respiratory treatment to a resident on Enhanced Standard Precautions (ESP). The resident had been readmitted with diagnoses including diastolic heart failure and Parkinson's disease. Despite the ESP sign being present initially, it was later found missing, and the LVN was unaware of the need for ESP, which could lead to the spread of infections. The Infection Preventionist and Treatment Nurse confirmed the necessity of ESP for the resident due to their vulnerability and open wounds. Another deficiency was observed with a resident's nasal cannula oxygen tubing being on the floor. The resident had severe cognitive impairment and required oxygen at 2 liters per minute. The tubing was found on the floor, which was confirmed by a Certified Nursing Assistant (CNA) and acknowledged by the Director of Nursing (DON) as a potential source of respiratory infection due to contamination. Additionally, two residents' nasal cannula oxygen tubing was not labeled with a date, contrary to the facility's policy. Both residents had conditions requiring oxygen therapy, and the lack of labeling was confirmed by an LVN and the DON. The facility's policy mandates that oxygen equipment should be dated when initially used and when changed, but this was not followed, increasing the risk of infection due to potentially outdated equipment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which had the potential to cause a delay in care and unmet needs. Resident 188, who was admitted with diagnoses including acute respiratory failure with hypoxia, difficulty in walking, generalized muscle weakness, and repeated falls, was observed with their call light under the bed. The resident's Minimum Data Set indicated moderately impaired cognition and a need for maximum assistance with toileting hygiene. The resident's care plan included an intervention to keep the call light within easy reach to reduce the risk of falls and injury. During an observation, the call light was found on the floor under the resident's bed, which was confirmed by a Certified Nursing Assistant (CNA 1). The Director of Nursing (DON) stated that call lights should be within reach for safety and customer service, as residents might try to get up by themselves and fall if they cannot call for help. The facility's policy on call lights, last reviewed on 4/9/2024, indicated that call lights should be within the resident's reach to ensure prompt assistance.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 8, as evidenced by peeling and missing paint in three areas of the resident's bedroom ceiling. Resident 8, who was admitted with diagnoses including heart failure, depression, and osteoarthritis, had intact cognition and was dependent on assistance for transferring. During an observation, Resident 8 reported that the maintenance department had not returned to fix the peeling paint, which had been an issue for about four months. The Maintenance Director confirmed the condition of the ceiling and acknowledged that it should not be in such a state, attributing the oversight to being busy and not keeping records of work orders for room repairs. The Director of Nursing also confirmed that the ceiling should be free from chipping and cracks, and acknowledged that the condition of Resident 8's ceiling should have been a priority. The facility's policies on maintenance and providing a homelike environment were reviewed, indicating that the building should be maintained in good repair and free from hazards. Despite these policies, the facility failed to address the peeling paint in Resident 8's room, violating the resident's right to a comfortable, homelike environment.
Failure to Develop Comprehensive Care Plan for Dialysis Patient
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with end stage renal disease requiring dialysis. Despite having physician's orders to monitor the resident's left forearm arteriovenous shunt for various symptoms and to remove the pressure dressing on specific days, the facility did not create a care plan to address these needs. This oversight was identified during a review of the resident's records and confirmed by the MDS Nurse, who acknowledged the importance of having a care plan to monitor the dialysis site and manage potential risks such as bleeding and infection. The Director of Nursing also confirmed that care plans are essential for delivering appropriate care and should be documented immediately upon admission. The facility's policy mandates that a comprehensive care plan be developed within seven days of the required MDS assessment and no more than 21 days after admission. However, in this case, the care plan for the resident's AV shunt was not developed, putting the resident at risk of not receiving the necessary care and monitoring for their condition.
Resident Smoking in Non-Designated Area Near Flammable Substances
Penalty
Summary
The facility failed to ensure that a resident smoked in the designated smoking area, leading to a potential safety hazard. Resident 61, who has chronic obstructive pulmonary disease and difficulty walking, was observed smoking in the outdoor activity area, which is not a designated smoking area. This area was surrounded by flammable substances, including trees, grass, plants, and a generator with diesel fuel. Despite multiple 'NO SMOKING' signs and the presence of a fire extinguisher, the resident was found smoking alone without any fire-resistant apron, blanket, or self-extinguishing ashtrays. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed that the west side patio was the only designated smoking area equipped with safety measures such as self-extinguishing ashtrays, fire blankets, and fire protective aprons. The Maintenance Director also stated that the outdoor activity area was not safe for smoking due to the risk of fire from surrounding leaves and debris. The facility's policy indicated that residents have the right to smoke but must comply with safety regulations, which was not adhered to in this case.
Physician's Failure to Sign POLST
Penalty
Summary
The facility failed to ensure that the physician signed the Physician Order for Life-Sustaining Treatment (POLST) for Resident 45, who was admitted with end-stage renal disease requiring dialysis. The POLST, dated 8/20/2023, indicated that Resident 45 did not want resuscitation if found without a pulse and not breathing. However, the POLST lacked the required physician's signature, rendering it invalid. This oversight was confirmed during an interview and record review with Registered Nurse 1, who acknowledged that without the physician's signature, the POLST was not valid, and the facility would be forced to treat the resident as a full code. Resident 45's medical records indicated that they had the capacity to understand and make decisions regarding their care. The facility's policy, dated 4/2024, stated that the physician is responsible for guiding staff and documenting decisions regarding life-sustaining treatments. Despite this policy, the physician did not sign the POLST, which could lead to actions contrary to the resident's wishes in an emergency. This deficiency highlights a failure in adhering to the facility's procedures for validating POLST forms.
Incorrect Dosage of Aspirin Administered
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) administered the correct dosage of aspirin to a resident as ordered by the physician. Specifically, LVN 7 administered 81 mg of aspirin instead of the prescribed 325 mg to Resident 190. This discrepancy was observed during a medication pass, where LVN 7 was seen giving the resident several medications, including the incorrect dosage of aspirin. Upon review of the resident's physician orders, it was confirmed that the correct dosage should have been 325 mg for cerebrovascular accident prevention. LVN 7 acknowledged the error during the observation. Resident 190 had been admitted to the facility with multiple diagnoses, including cerebral infarction, hemiplegia, stage three chronic kidney disease, and gastrostomy status. The resident's history and physical assessment indicated the capacity to understand and make decisions. The Director of Nursing (DON) emphasized the importance of following physician orders to avoid serious bodily harm. The facility's medication pass policy, last reviewed on 4/9/2024, mandates that medications be administered according to the right resident, right medication, right dose, right route/method, and right time.
Failure to Monitor Targeted Behavior for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure licensed nurses monitored a resident's targeted behavior for the use of quetiapine, an antipsychotic medication, for one of the sampled residents. The resident, who had diagnoses including schizoaffective disorder and severely impaired cognition, was admitted and readmitted to the facility with a physician's order for quetiapine to manage paranoid feelings causing fear. However, there was no documentation indicating that the nurses were monitoring the resident's targeted behavior as required by the facility's policy and procedure for psychotropic medication use. During interviews and record reviews, it was confirmed that there was no evidence of behavioral monitoring in the resident's Medication Administration Record or other areas of the medical record. The Director of Nursing acknowledged that monitoring the target behavior is essential to determine the medication's effectiveness and to avoid adverse side effects. The facility's policy indicated that psychotropic medication management should include adequate monitoring for efficacy and adverse consequences, which was not followed in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that a resident's insulin was stored within the proper temperature range. Resident 63, who was admitted with diabetes and metabolic encephalopathy, had insulin stored in a refrigerator that was consistently out of the required temperature range of 36-46 degrees Fahrenheit. Despite multiple observations and reports by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), the refrigerator temperature remained above the acceptable range, potentially affecting the effectiveness of the insulin medication. The facility's policy indicated that medications should be stored under proper temperature controls, which was not adhered to in this case. Additionally, the facility did not label an opened medication bottle of hydromorphone solution with an opened date for Resident 187, who was admitted with diagnoses including palliative care, atrial fibrillation, and heart failure. The hydromorphone solution was administered on two occasions without the bottle being labeled with an opened date. The Director of Nursing confirmed that the medication should have been labeled when opened, as per the facility's policy, to ensure its efficacy. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors. The failure to store insulin at the correct temperature and to label the hydromorphone solution properly had the potential to diminish the effectiveness of these medications, which could adversely affect the residents' health outcomes.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to meet the required room size of 80 square feet per resident for 26 of 40 multiple resident rooms. During the recertification survey, it was observed that the rooms with an application for variance had sufficient space for residents to move freely and for the operation and use of wheelchairs, walkers, and canes. However, the room sizes did not meet the minimum requirements, with some rooms being as small as 72 square feet per resident. Despite the residents not expressing concerns about their room space during the Resident Council meeting, the deficiency was noted based on the square footage measurements provided in the Client Accommodation Analysis and the room waiver request submitted by the Administrator. The rooms in question included Rooms 102, 103, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, 120, 123, 126, 133, 136, 137, 138, 139, 140, and 141. The facility's waiver request indicated that the rooms were in accordance with the special needs of the residents and did not adversely affect their health and safety. Each room was equipped with adequate space for personal items, privacy curtains, call lights, and accessibility for both ambulatory and non-ambulatory patients. Despite these provisions, the rooms did not meet the regulatory requirements for square footage per resident, leading to the noted deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
