Montecito Heights Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4585 N. Figueroa St., Los Angeles, California 90065
- CMS Provider Number
- 055163
- Inspections on file
- 25
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Montecito Heights Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Two residents receiving opioid pain medications did not have their pain levels or vital signs assessed and documented as required by physician orders and facility policy. Pain reassessment after medication administration was not completed within the required timeframe, and pre-administration assessments were inconsistently performed, resulting in inadequate monitoring and documentation of pain management.
Surveyors found that boxed food items were stored directly on the floor and a dispensing scoop was left inside a salt container, contrary to facility policy requiring food to be stored at least six inches off the floor and scoops to be stored separately for infection control.
A resident with multiple chronic conditions and cognitive intactness was not provided with a Notice of Medicare Non-Coverage (NOMNC) when the facility initiated discharge from Medicare Part A skilled services. Staff interviews and record review confirmed the NOMNC was not given, despite facility policy and CMS guidelines requiring notification prior to the end of covered services.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as using trunk restraints despite staff and observation confirming no restraints, and another was inaccurately assessed as frequently incontinent and not on a bowel/bladder program, despite being generally continent and expressing a need for scheduled toileting assistance. These discrepancies between MDS documentation and actual resident status were confirmed by staff and had the potential to impact care.
A resident admitted with ESRD, hypertension, and a left femoral permcath for dialysis did not have their dialysis access site addressed in the baseline care plan, despite physician orders to monitor the site and facility policy requiring comprehensive care planning within 48 hours. Both nursing staff and the DON acknowledged the omission of this critical information from the care plan.
Two residents did not have individualized, person-centered care plans developed to address their specific needs. One resident with severe cognitive impairment and frequent incontinence had a care plan that only included medication administration, lacking other necessary interventions. Another resident with dementia and an order for oxygen therapy did not have a care plan addressing oxygen use. Staff confirmed that these care plans were insufficient and did not meet facility policy requirements.
A resident with impaired mobility and multiple risk factors for pressure injuries was not provided with bilateral heel protectors as ordered by the physician and outlined in the care plan. Instead, the resident's heels were placed on a pillow while in bed. Both an LVN and the DON confirmed the omission, which was not in accordance with facility policy for pressure injury prevention.
A resident with a seizure disorder, paraplegia, and other medical conditions was not provided with bilateral padded side rails as ordered by the physician for seizure precautions. Despite care plans and facility policy requiring this intervention, observations and staff interviews confirmed the absence of padding on the bedrails, placing the resident at risk for injury.
Two residents did not receive appropriate urinary and bowel care services, including failure to maintain continence support for a resident with a history of UTIs and improper catheter management for another resident, resulting in a dependent loop and urine backflow. These deficiencies were inconsistent with facility policies aimed at preventing UTIs and skin breakdown.
Two residents receiving oxygen therapy did not receive care according to facility protocols: one resident's oxygen humidifier bottle was allowed to run empty despite continuous use and a stated need for humidification, while another resident's nasal cannula was not labeled with the date of last change as required. Staff interviews and observations confirmed these lapses, which were not in line with the facility's policies for respiratory care.
A resident with ESRD and a left femoral permcath for hemodialysis did not receive proper assessment and monitoring of the dialysis access site, as required by facility policy. Admission documentation was inaccurate regarding the resident's dialysis status and access site, and pre and post dialysis assessments were incomplete on multiple occasions, failing to include necessary evaluations of the access site.
Two rooms were found to exceed the regulatory limit of four residents per room, with one room housing seven beds and another five beds. Observations and interviews with a resident and a CNA indicated that there was adequate space for care and movement, and all residents had privacy curtains, call-lights, dressers, and bedside tables.
A facility failed to monitor the placement and functionality of bed and wheelchair alarms for a resident with dementia and mobility issues. Although physician orders were given to apply these alarms for safety, monitoring did not begin until several months later. Staff interviews confirmed the delay, and the facility's policy required regular checks and documentation of these devices.
A resident with a history of CHF and hypertension was found with an altered level of consciousness and low oxygen saturation. The facility failed to provide adequate oxygen therapy, initially administering only 4L via nasal cannula instead of a non-rebreather mask. Paramedics later corrected this, improving the resident's condition. Documentation of the oxygen therapy was lacking, contrary to facility policy.
Two residents signed Assisted Living Waiver forms in a language they did not understand, resulting in them and their families being unaware of the contents. Despite being cognitively intact and preferring communication in their own language, the facility provided the documents in English without proper interpretation. Interviews revealed that neither the residents nor their families received copies of the signed documents, contrary to the facility's policies on resident rights and translation services.
A resident scheduled for discharge to a lower level of care did not receive the required Notice of Proposed Transfer and Discharge. Despite being cognitively intact and needing assistance with daily activities, the resident was not informed in writing about the discharge date and reasons. The DON confirmed the oversight, which was against the facility's policy requiring notice 30 days prior or as soon as practicable.
The facility did not post the actual daily hours worked by staff for four days in June 2024, displaying only projected hours instead. This was confirmed by the DSD, who stated that actual hours were kept in a separate binder. The facility's policy requires posting actual nursing hours to ensure patient safety and adequate staffing.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with hemiplegia had the call light on the floor, while another with muscle weakness had it hanging far away. Staff confirmed the inaccessibility, contradicting the facility's policy requiring call lights to be within reach.
The facility failed to update care plans for two residents after discontinuing treatments. One resident's care plan was not revised to reflect the end of antibiotic therapy, while another's was not updated after the removal of an indwelling catheter. This oversight was confirmed through record reviews and staff interviews, highlighting a deficiency in care planning.
A resident with Type 1 diabetes did not receive insulin injections in accordance with professional standards, as the facility failed to rotate the injection sites as ordered by the physician. The resident received Basaglar injections in the same site on the right arm for four consecutive days, contrary to the physician's instructions and facility policy, which required site rotation to prevent skin complications.
A resident continued to receive Enoxaparin, a blood thinner, without a physician's order due to a failure in communication and follow-through by the DON. Despite a pharmacist's recommendation to discontinue the medication, it was administered daily, placing the resident at risk for adverse effects. The oversight was discovered during a surveyor interview, highlighting a lapse in following the facility's medication administration policies.
A resident with dementia and dysphagia was served coffee with a thin consistency instead of the prescribed nectar thick liquid, contrary to the Physician's Order. The error was acknowledged by a CNA, and both the RD and DON confirmed the importance of following the therapeutic diet to prevent choking and aspiration risks.
A resident with hemiplegia and other conditions was not provided with a dycem, a non-slip mat, during meals as required by their care plan. Despite having a divided plate, the dycem was missing, which was confirmed by the resident and observed by surveyors. Facility staff acknowledged the importance of the equipment, but records showed it was not consistently provided.
A resident with a history of UTI, Type II diabetes, and paralysis was observed with an indwelling catheter bag touching the floor while seated in a wheelchair. A CNA acknowledged the infection control issue, and the DON confirmed the CNA's responsibility to prevent such occurrences, as per facility policy.
The facility exceeded the room capacity regulation by accommodating more than four residents in two rooms, with one room housing seven and another five residents. Despite this, observations showed adequate space for care, privacy curtains, and safe egress. Interviews with residents and CNAs revealed no concerns about space or care provision. A room waiver request was submitted, aligning with residents' special needs, and the Department recommended its continuation.
Failure to Follow Pain Assessment and Monitoring Protocols for Residents Receiving Opioid Pain Medications
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not adhering to physician orders and facility policies regarding pain assessment and monitoring. For one resident with a history of lumbar spinal fusion, low back pain, and end-stage renal disease, the care plan required administration of oxycodone as needed, with pain reassessment within one hour after administration. However, medication administration records showed that pain was not reassessed within the required timeframe, with follow-up assessments occurring more than one to five hours after medication was given. Both the registered nurse and the director of nursing confirmed that the facility's protocol and policy required pain reassessment within one hour, and acknowledged that this was not done as required. For another resident with multiple fractures, respiratory failure, and a history of falls, physician orders and the care plan required pain assessment and documentation every shift, as well as assessment of respiratory rate prior to administering hydromorphone. Medication administration records indicated that pain levels and respiratory rates were not consistently assessed or documented prior to medication administration on several occasions. Interviews with nursing staff and the director of nursing confirmed that these assessments were necessary and should have been documented each time pain medication was administered. The facility's policies on pain management and medication administration required licensed nurses to complete pain assessments for residents identified as having pain, administer pain medication as ordered, and re-evaluate and document the resident's pain level within one hour after medication. The failure to follow these protocols resulted in inadequate monitoring and documentation of pain management for both residents.
Improper Food Storage and Unsanitary Food Preparation Practices
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices in the kitchen. Specifically, boxed food items, including rice, non-dairy creamer packets, parsley, mayonnaise, and salt, were found stored directly on the floor in the dry storage room. Additionally, a dispensing scoop was stored inside a clear storage container of salt. These practices were observed during a concurrent interview and observation with a kitchen staff member, who confirmed that the items should have been stored at least six inches off the floor and that the scoop should not be kept inside the salt container due to sanitation concerns. Further interviews with the dietary supervisor revealed that the food items were left on the floor after cleaning other portions of the dry storage area. The dietary supervisor also acknowledged that facility policy requires food to be stored six inches off the floor and that scoops should not be left inside food containers for infection control purposes. A review of the facility's policy and procedure on food storage and handling confirmed these requirements.
Failure to Provide Required Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted with multiple diagnoses including type 2 diabetes, schizoaffective disorder, major depressive disorder, hypertension, and anxiety disorder, was cognitively intact and required assistance with several activities of daily living. According to the resident's records, the last covered day for Medicare Part A services was identified, and the discharge from Medicare services was initiated by the facility before benefit days were exhausted. However, the NOMNC was not provided to the resident because she left the facility to go home. Interviews with the Business Office Manager and the Director of Nursing confirmed that the resident should have received the NOMNC, as the discharge was planned and initiated by the facility. Both staff members acknowledged that the NOMNC is necessary to inform residents of their last covered day and their right to appeal the discharge. Review of facility policy and CMS guidelines further supported the requirement to provide the NOMNC at least two days before the end of covered services, which was not done in this case.
Inaccurate MDS Assessments for Restraint Use and Bowel/Bladder Status
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to restraint use and bowel/bladder documentation. For one resident with dementia, difficulty walking, and muscle weakness, the MDS inaccurately indicated the use of trunk restraints. Observations and interviews with staff confirmed that the resident did not have restraints, and both the MDS Coordinator and Director of Nursing acknowledged the inaccuracy in the MDS documentation regarding restraint use. For another resident admitted with a history of antimicrobial resistance, urinary tract infection, acute kidney failure, and difficulty walking, the MDS assessment inaccurately documented the resident as frequently incontinent of bowel and bladder, and not on a bowel and bladder program. However, the care plan indicated the resident was continent, and interviews with the resident and staff confirmed the resident was generally able to control bowel and bladder function, with rare episodes of incontinence. The resident expressed a desire for scheduled reminders and assistance to the restroom, which was not reflected in the MDS or care plan alignment. Facility policy and procedure reviews confirmed the requirement for accurate resident assessments and the use of the Resident Assessment Instrument (RAI) process to ensure proper care planning. The discrepancies between the MDS assessments and actual resident status had the potential to result in inadequate care, as acknowledged by facility staff during interviews.
Incomplete Baseline Care Plan for Dialysis Access Site
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident admitted with end stage renal disease, hypertension, and an acquired absence of the left leg below the knee. Upon admission, the resident had a left femoral permcath in place for dialysis access, as well as arteriovenous fistulas in both upper arms. Physician orders required monitoring of the left femoral permcath site for signs of infection or complications during every shift. The resident's cognitive skills were intact, and they required partial to moderate assistance with daily activities. Despite these needs and orders, the baseline care plan created within 48 hours of admission did not include any information regarding the resident's left femoral dialysis access site. Both the registered nurse and the director of nursing confirmed that the baseline care plan was incomplete and did not address the dialysis access site, which was necessary for the resident's immediate care. Facility policy required that baseline care plans include all essential health information to ensure proper care upon admission, but this was not followed in this instance.
Failure to Develop Individualized Care Plans for Incontinence and Oxygen Use
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with specific clinical needs. For one resident with hemiplegia, hemiparesis, severe cognitive impairment, and frequent incontinence of bowel and urine, the care plan only included an intervention to administer medications as ordered and document their effectiveness. There were no additional interventions listed to address the resident's incontinence, such as assistance with toileting or changing soiled briefs. Both the MDS Coordinator and the Director of Nursing acknowledged during interviews that the care plan was insufficient and did not adequately address the resident's needs for incontinence care. For another resident with diagnoses including cough, dementia, and type 2 diabetes mellitus, and who had a physician order for oxygen administration via nasal cannula as needed to maintain oxygen saturation above 92%, the facility did not develop a comprehensive care plan to address oxygen use. The resident's Minimum Data Set indicated severe cognitive impairment and a need for substantial to maximal assistance with activities of daily living. Despite these needs and the physician's order, the care plans reviewed did not include interventions or monitoring related to oxygen therapy. The facility's policy required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes to meet each resident's identified needs. The lack of appropriate care planning for both residents was confirmed by staff interviews and record reviews, indicating that the facility did not follow its own policy and failed to ensure that care plans described the services necessary to maintain the residents' highest practicable well-being.
Failure to Provide Ordered Heel Protectors for At-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for a resident at risk for pressure injuries. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was identified as being at moderate risk for pressure ulcer development due to impaired mobility, incontinence, and poor nutrition. The care plan and physician orders specified the use of bilateral heel protectors while the resident was in bed to prevent pressure injuries. However, during observation, the resident was found in bed without the required heel protectors, with their heels instead placed on a pillow. Interviews with both an LVN and the DON confirmed that the resident should have been wearing bilateral heel protectors as per the physician's order and care plan. The facility's policy on pressure injury prevention also required staff to implement such interventions. The failure to provide the ordered heel protectors constituted a lapse in following prescribed care for a resident at risk for pressure injuries.
Failure to Provide Ordered Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to follow physician orders for a resident with a seizure disorder by not providing bilateral padded side rails as required for seizure precautions. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was admitted and readmitted with a care plan that included interventions to protect the resident from injury during seizures. Physician orders specifically directed the use of bilateral padded side rails, and the facility's policy also listed side rail padding as a seizure precaution. Despite these orders and policies, observations on multiple occasions revealed that the resident's bedrails did not have any padding. Interviews with nursing staff and the Director of Nursing confirmed that the resident had an order for padded side rails, and that the padding was necessary to protect the resident from injury during a seizure. The facility's failure to implement these precautions constituted a deficiency in providing a safe environment and adequate supervision for the resident.
Deficient Urinary and Bowel Care Services for Two Residents
Penalty
Summary
The facility failed to provide appropriate urinary and bowel care services for two residents. For one resident, who was admitted with a history of resistance to multiple antimicrobial drugs, urinary tract infection (UTI), acute kidney failure, and difficulty walking, the care plan indicated the resident was continent of bowel and bladder with a goal to keep the resident dry, clean, and comfortable. However, the Minimum Data Set (MDS) assessment reflected frequent incontinence and did not offer a bowel and bladder program. The resident reported awareness of the need to urinate and have bowel movements, rarely soiled herself, and expressed embarrassment after an incident of incontinence, stating that scheduled reminders and assistance would be helpful. Staff interviews confirmed that the care plan and MDS were inconsistent and that the resident should have been started on a bowel and bladder program to prevent UTIs and skin breakdown, as outlined in facility policy. For the second resident, who was admitted with diagnoses including a displaced avulsion fracture, difficulty walking, muscle weakness, and obstructive and reflux uropathy, the care plan required that the indwelling catheter bag and tubing be positioned below the level of the bladder. During observation, the resident's catheter tubing was found to have a large dependent loop containing yellow liquid with sediment, which had backflowed to the urine drainage port. A registered nurse confirmed that the tubing was improperly looped and that urine was not draining correctly, which could lead to infection. The DON stated that catheter tubing should always remain straight to prevent UTIs, especially for residents with a history of obstruction. Facility policies reviewed indicated the importance of providing appropriate treatment and services to minimize UTIs, restore bowel and bladder function, and prevent skin breakdown. The policies also specified that catheter collection bags should be kept below the level of the bladder to prevent backflow. The observed failures in care for both residents were inconsistent with these policies and resulted in deficiencies in providing necessary urinary and bowel care services.
Failure to Follow Oxygen Therapy Protocols for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care services for two residents by not following established protocols for oxygen therapy. For one resident with COPD and heart failure, the physician ordered oxygen at four liters per minute as needed, and the care plan required humidification to prevent symptoms of poor oxygen absorption. Observations revealed that the resident's oxygen humidifier bottle was nearly empty on one occasion and completely empty on another, despite the resident using oxygen continuously and stating a need for humidification. A nurse confirmed the humidifier bottle was empty and acknowledged that lack of humidification could lead to nasal dryness and bleeding. The Director of Nursing stated that humidifier bottles should be checked daily and changed before running out, in line with facility policy. For another resident with respiratory failure and a history of fractures, the physician ordered continuous oxygen therapy via nasal cannula. The facility's policy required that nasal cannulas be changed every seven days and labeled with the date of change to prevent infection. During an observation, the resident's nasal cannula was not labeled with the date it was last changed. A nurse confirmed the cannula should be labeled and changed weekly, and the DON reiterated the importance of labeling to prevent bacterial growth and respiratory infections. The facility's own policies and procedures for oxygen therapy were not followed in both cases. The humidifier bottle for one resident was allowed to run empty, and the nasal cannula for another resident was not labeled as required. These lapses were confirmed by staff interviews and direct observation, and were contrary to the facility's written protocols for respiratory care.
Failure to Ensure Accurate Assessment and Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a history of ESRD, hypertension, and a left leg amputation, and had a left femoral artery permcath as the current dialysis access site. However, the clinical admission form did not indicate that the resident underwent dialysis, and the admission progress note incorrectly documented the dialysis access site as a right upper arm AVF instead of the left femoral permcath. This resulted in inaccurate documentation of the resident's dialysis needs and access site. Further review revealed that the facility did not complete thorough pre and post dialysis assessments for the resident on multiple occasions. Specifically, assessment forms for several dialysis dates were incomplete and did not include required evaluations of the dialysis access site after treatment. Both the RN and DON confirmed that licensed staff were required to assess the dialysis access site before and after each dialysis session, but this was not done as required. The facility's own policy mandated daily assessment and documentation of the vascular access site, as well as completion of pre and post dialysis evaluations by a licensed nurse. Observations and interviews confirmed that the resident was aware of her dialysis schedule and access site, but facility documentation and assessments did not accurately reflect her current treatment or provide the necessary monitoring. The lack of accurate admission documentation and incomplete pre and post dialysis assessments led to a failure in ensuring safe and appropriate dialysis care for the resident.
Non-Compliance with Resident Room Occupancy Limits
Penalty
Summary
The facility failed to ensure that two rooms did not accommodate more than four residents, as required by regulations. Review of the facility's room waiver request letter indicated that these rooms exceeded the four-bed limit, with one room containing seven beds and another containing five beds. The waiver letter stated that the rooms had adequate space for each resident and that the arrangement would not adversely affect residents' health and safety. Observations confirmed that each resident had privacy curtains, working call-lights, a dresser, and a bedside table. During multiple observations, nursing staff were seen providing care with adequate space in the affected rooms. Interviews with a resident and a CNA revealed that neither had concerns about the available space, and both felt there was sufficient room for movement and care activities. Despite these observations, the rooms did not comply with the regulation limiting occupancy to four residents per room.
Failure to Monitor Assistive Signaling Devices
Penalty
Summary
The facility failed to ensure the proper monitoring of assistive signaling devices, specifically bed and wheelchair alarms, for a resident with dementia and mobility issues. The resident was admitted with diagnoses including dementia, difficulty walking, and generalized muscle weakness, and had a history of falls. Physician orders were given to apply a bed alarm on December 23, 2024, and a wheelchair alarm on January 3, 2025, for the resident's safety. However, the facility did not begin monitoring the placement and functionality of these alarms until March 18, 2025, which was a significant delay from when the alarms were initially applied. Interviews with facility staff, including licensed vocational nurses and the director of nursing, confirmed that the monitoring of these alarms only started on March 18, 2025. The facility's policy required that the placement and functionality of signaling devices be verified every shift and documented in the resident's medical record. The lack of monitoring had the potential for the alarms to malfunction without the facility's knowledge, increasing the risk of the resident leaving the bed or wheelchair unnoticed, which could lead to accidents.
Failure to Administer Adequate Oxygen Therapy
Penalty
Summary
The facility failed to administer adequate supplemental oxygen to a resident in accordance with professional standards of practice. The resident, who had a history of congestive heart failure and hypertension, was found with an altered level of consciousness and an oxygen saturation of 64%, which is significantly below the normal range. Despite the critical condition, the resident was initially given only four liters of oxygen via a nasal cannula, which was insufficient for the resident's needs. The paramedics later found the resident cyanotic and cold to the touch, with an oxygen saturation of 70% after receiving the nasal cannula oxygen. The paramedics promptly placed the resident on a non-rebreather mask at 15 liters per minute, which increased the resident's oxygen saturation to 87%. Interviews with the nursing staff revealed a lack of documentation regarding the amount of oxygen administered and the device used, which was acknowledged by the Director of Nursing as a critical oversight. The facility's policy and procedures require that progress notes reflect changes in the resident's condition and that oxygen therapy be administered safely to meet resident needs, which was not adhered to in this case.
Failure to Provide Documents in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that two residents and their families were fully informed and understood the documents they signed, specifically the Assisted Living Waiver (ALW) forms and consents. Both residents, who were cognitively intact, required assistance with various activities of daily living and preferred communication in their own language. Despite this, the ALW forms and consents were provided in English, a language the residents did not understand, and no interpreter was used at the time of signing. This resulted in the residents and their families being unaware of the contents of the documents they signed. Interviews with the residents and their family members revealed that they did not remember what they signed and were not provided copies of the documents. The facility's administrator, who spoke the residents' language, claimed to have interpreted the documents during the signing process. However, the facility's policies on resident rights and translation services were not adhered to, as the residents were not informed in a language they could understand, nor were they provided with competent translation services as required by the facility's procedures.
Failure to Provide Timely Notice of Discharge
Penalty
Summary
The facility failed to provide a Notice of Proposed Transfer and Discharge to a resident who was scheduled for a planned discharge to a lower level of care. The resident, who was cognitively intact and required supervision and assistance with various activities of daily living, was originally admitted in 2017 and readmitted with diagnoses including diabetes, reduced mobility, and difficulty in walking. The interdisciplinary team met with the resident and a family member to discuss the discharge plan, but the required notice was not given. The Director of Nursing acknowledged during an interview that the notice should have been provided to the resident as soon as the discharge date was known. The facility's policy requires that such notice be given 30 days prior to discharge or as soon as practicable, and a copy should be kept in the medical record. However, this procedure was not followed, resulting in the deficiency.
Failure to Post Actual Staff Hours
Penalty
Summary
The facility failed to comply with federal requirements by not posting the actual daily hours worked by staff in an area accessible to the public for four out of six days in June 2024. Observations made on June 3rd, 4th, 5th, and 6th revealed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) displayed in the facility lobby only reflected the projected working hours of staff rather than the actual hours worked. This discrepancy was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that the actual hours were kept in a separate binder and not posted as required. The facility's policy, titled 'Nursing Department - NHPPD Staffing Audit Guidelines,' dated March 14, 2024, mandates the posting of actual nursing hours performed by direct caregivers per patient day. The DSD emphasized the importance of posting actual nursing hours to ensure patient safety and adequate staffing for the current patient census. The failure to provide residents, family, or visitors with the actual number of staff could lead to feelings of unease among them, as they would not have access to accurate staffing information.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care and services. Resident 10, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with the call light on the floor, out of reach. The resident's care plan emphasized the importance of having the call light within reach due to the risk of falls and dependency on staff for activities of daily living. During an observation, a Licensed Vocational Nurse confirmed that the call light was not accessible to Resident 10, acknowledging that it should be within reach to allow the resident to call for help. Similarly, Resident 113, admitted with diagnoses including alcohol and stimulant abuse and muscle weakness, was observed with the call light hanging from the wall, far from reach. The resident was unaware of the call light's location, and a Certified Nursing Assistant confirmed its inaccessibility. The facility's Director of Nursing stated that call lights are required to be accessible at all times, and the facility's policy mandates that call cords be placed within residents' reach. These observations highlight the facility's failure to adhere to its policy, potentially impacting residents' ability to request assistance.
Failure to Revise Care Plans for Discontinued Treatments
Penalty
Summary
The facility failed to revise care plans for two residents, leading to a deficiency in care planning. Resident 20's care plan was not updated to reflect the discontinuation of antibiotic therapy. The resident was initially prescribed Ceftriaxone Sodium Injection for a urinary tract infection and later switched to Keflex. Despite the completion of these antibiotic courses, the care plan continued to indicate that the resident was on antibiotic therapy. This oversight was confirmed during a review of the resident's medical records and interviews with the Minimum Data Set Coordinator and the Director of Nursing. Similarly, the care plan for Resident 47 was not revised following the removal of an indwelling catheter. The resident was admitted with a urinary tract infection and had an indwelling catheter in place. The physician ordered the removal of the catheter, but the care plan was not updated to reflect this change. Observations and interviews confirmed that the catheter had been removed, yet the care plan still indicated its presence. The Director of Nursing acknowledged that the care plan should have been revised to accurately reflect the resident's current status. The facility's policy on comprehensive person-centered care planning requires that care plans be reviewed and revised after each assessment and upon changes in a resident's condition. The failure to update the care plans for these residents placed them at risk for inconsistent care, as the plans did not accurately reflect their current medical needs and treatments.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not rotating the site for administration of a subcutaneous injection of Basaglar, a long-acting insulin. This deficiency was identified for one of the three sampled residents, who was diagnosed with Type 1 diabetes and required insulin administration. The physician's order specifically indicated that the injection sites should be rotated to prevent complications, but this was not adhered to. The resident, who had intact cognition and required moderate assistance with daily activities, received the Basaglar injection in the same site on the right arm for four consecutive days. This practice was confirmed during a review of the resident's medical record with the MDS Coordinator, who acknowledged the need for site rotation to prevent skin complications. The Director of Nursing also confirmed that the licensed nurses were required to rotate the injection sites as per the physician's order and the facility's policy on subcutaneous injections.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication by not following the physician's order to discontinue Enoxaparin, a blood thinner, on a specified date. The resident continued to receive the medication for several days without a physician's order, which placed the resident at risk for adverse effects such as internal bleeding. The Director of Nursing (DON) acknowledged the oversight, stating that she forgot to follow through on the pharmacy's recommendation to discontinue the medication. The resident, who was initially admitted with a fracture of the left femur and other mobility issues, had intact cognition and required assistance with certain activities. The resident's care plan included administering Enoxaparin as ordered and monitoring for adverse reactions. Despite a pharmacist's note recommending the discontinuation of Enoxaparin, the medication was administered daily until the oversight was discovered during a surveyor interview. The facility's policy indicated that changes in medication orders should be documented and carried out promptly, which did not occur in this case.
Failure to Serve Therapeutic Diet as Prescribed
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served according to the Physician's Order for a resident diagnosed with dementia, muscle weakness, and requiring assistance with personal care. The Physician's Order specified a no added salt diet, mechanical soft texture, and nectar thick consistency liquids due to mild signs of dysphagia. Despite these orders, the resident was observed consuming coffee with a thin consistency, which was not in compliance with the prescribed nectar thick liquid requirement. During observations and interviews, it was revealed that the staff served the resident coffee with a thin consistency instead of the required nectar thick consistency. The Certified Nursing Assistant (CNA) acknowledged the error but was unaware of which staff member served the coffee. Both the Registered Dietician and the Director of Nursing confirmed the necessity of following the Physician's Order for nectar thick liquids to prevent risks such as choking and aspiration. The facility's policy on therapeutic diets emphasized the importance of adhering to physician orders, which was not followed in this instance.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a dycem, a non-slip mat, to a resident who required it for eating, as part of their adaptive equipment needs. This deficiency was identified for a resident with hemiplegia, hemiparesis, diabetes Type II, and muscle weakness, who was admitted on 8/8/2023. The resident's care plan, revised on 8/9/2023, specified the need for a divided plate and dycem at each meal to assist with self-feeding. Despite this, observations on 6/5/2024 revealed that the resident was not provided with a dycem during lunch, although a divided plate was present. The resident confirmed that the blue mat, previously used to prevent the food tray from slipping, was missing and had not been replaced. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed the importance of providing adaptive equipment to the resident to support independent eating. The facility's policy, reviewed on 3/14/2024, indicated that adaptive equipment should be provided by the occupational therapist to the dietary department for daily meal services. However, a review of the Medical Administration Record for May 2024 showed no documentation of the adaptive equipment being provided at each meal, indicating a lapse in following the prescribed care plan and physician's orders.
Catheter Bag Touching Floor in LTC Facility
Penalty
Summary
The facility failed to ensure that an indwelling catheter bag was not touching the floor for one of the residents, which could potentially lead to a urinary tract infection. The resident, who was admitted with diagnoses including a urinary tract infection, Type II diabetes mellitus, and paralysis on the right side of the body, required assistance with daily activities. During an observation, the resident was seen sitting in a wheelchair with the catheter bag hanging and touching the floor. A Certified Nursing Assistant acknowledged that the catheter bag should not be touching the floor due to infection control concerns. The Director of Nursing confirmed that the CNA should have ensured the catheter bag was not in contact with the floor, as per the facility's policy and procedure on catheter care.
Room Capacity Exceeded in Two Resident Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as two rooms were found to accommodate more than the allowed number of residents. Specifically, one room housed seven residents, and another housed five, exceeding the regulatory limit. Despite this, observations indicated that nursing staff had adequate space to provide care, and privacy curtains were available for residents. Additionally, the rooms had two modes of egress, ensuring safety. Interviews with residents and CNAs revealed no concerns regarding space adequacy or care provision. A room waiver request was submitted, indicating that the room arrangements were in line with the residents' special needs and did not adversely affect their health or safety. The Department recommended the continuation of the Room Waiver Request.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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