Monterey Park Conv Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Monterey Park, California.
- Location
- 416 N Garfield Ave, Monterey Park, California 91754
- CMS Provider Number
- 055162
- Inspections on file
- 27
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Monterey Park Conv Hosp during CMS and state inspections, most recent first.
Two residents, one with cognitive impairment and another lacking decision-making capacity, were admitted without the required advance directive acknowledgement being completed within 72 hours, as mandated by facility policy. Both the Social Services Director and DON confirmed the omission during record reviews and interviews.
A dietary aide with facial hair was observed in the kitchen and food storage areas without a beard mask, in violation of facility policy requiring hair restraints to prevent food contamination. Both the aide and the dietary service supervisor acknowledged the risk of hair falling into food and the importance of wearing a beard mask to prevent the spread of germs.
Staff failed to follow infection prevention and control practices, including not wearing required PPE when entering the room of a resident on contact isolation, transporting a resident on transmission-based precautions to communal areas, and not performing hand hygiene or changing gloves after providing peri-care or before administering medications to residents with indwelling devices.
The facility did not ensure the kitchen ceiling was free from water stains, bubbling, and peeling paint following a recent leak, and allowed a dumpster to overflow and remain uncovered, contrary to facility policy. These actions resulted in an unsanitary and unhomelike environment, with the potential for food contamination and pest intrusion as acknowledged by the Maintenance Director.
Six residents with severe cognitive impairments and high care needs were found with bed rails in the half-length position, contrary to physician orders specifying quarter-length rails. Staff interviews revealed confusion about bed rail types, and one resident was injured after becoming trapped on a bed rail. The facility did not follow its own policies or physician orders regarding bed rail use and monitoring, placing residents at risk for entrapment and injury.
A resident with cognitive impairment and multiple care needs was found with food particles on their chest and stomach after a meal, attempting to clean themselves. An RN confirmed the issue and stated a CNA should have provided assistance. The DON acknowledged this did not meet dignity standards, and facility policy requires staff to maintain resident cleanliness and respect.
A resident with multiple mental health diagnoses was prescribed Xanax for anxiety with a physician's order referencing repetitive movements, but there was no documentation of monitoring for these symptoms. Staff interviews revealed confusion about the resident's behaviors, and nursing staff could not specify or monitor the required symptoms, contrary to facility policy on psychotropic medication use.
A resident with acute respiratory failure and other serious conditions did not have an individualized care plan for oxygen therapy, despite physician orders and facility policy requiring one. The resident was observed without the nasal cannula in place and experiencing rapid breathing, and staff confirmed that a care plan for oxygen use was missing.
Two residents were not provided with appropriate safety interventions: one was transported in a wheelchair without footrests, risking injury, and another with a seizure disorder did not have padded bedside rails as required by their care plan and facility policy.
A resident with acute respiratory needs did not have the nasal cannula prongs properly placed in the nostrils while receiving oxygen, as observed by staff. The resident was noted to be hyperventilating, and staff confirmed that the nasal cannula should be correctly positioned to deliver oxygen as ordered.
A resident with end stage renal disease and a fluid restriction order was left with a full pitcher of water and a large bottle of juice at bedside, without proper signage indicating fluid limits or AV shunt precautions. Staff interviews revealed inconsistent monitoring of fluid intake and lack of awareness of the specific fluid restriction, resulting in failure to follow physician orders and facility policy for hemodialysis care.
The facility did not ensure that the Daily Staffing Report was complete and clearly posted in a visible location, as it was placed behind another form and lacked required direct care hours for RNs, LVNs, CNAs, and RNAs on multiple days. Staff interviews confirmed the report should be visible and complete, in accordance with facility policy.
A multiple occupancy room was found to house three residents in a space measuring 223 square feet, which is below the required 80 square feet per resident. Each resident had a bed, bedside table, nightstand, and wheelchair, and no complaints were reported by residents or staff regarding the room size.
A resident at high risk for falls experienced two falls due to inadequate supervision and a non-functional sensor alarm. Despite severe cognitive impairment and a need for assistance, the care plan was not updated to include necessary supervision. The resident suffered injuries from falls, highlighting deficiencies in the facility's care practices.
The facility failed to remove an expired Humulin R insulin vial and improperly stored five unopened Insulin Glargine Flex Pens at room temperature instead of in the refrigerator. The DON confirmed these deficiencies, acknowledging the potential ineffectiveness of the insulin due to expiration and improper storage.
The facility failed to follow proper food handling practices, as observed by surveyors. A broken rice container lid, an unsealed cookie container, a dirty and rusty can opener, and an overflowing trash can were noted. The Dietary Supervisor confirmed these issues, which contradict the facility's policies on maintaining cleanliness and preventing foodborne illnesses.
The facility failed to properly dispose of kitchen garbage, as two bags of trash were found on the ground outside the kitchen. The maintenance supervisor confirmed that the trash should have been in the dumpster to prevent vermin attraction, which is an infection control issue. The Dietary Supervisor noted that the trash company sometimes leaves the dumpster on the street, leading to improper disposal. The facility's policy requires garbage to be disposed of in the dumpster to prevent attracting insects and rodents.
A resident with impaired cognitive skills and total dependence on staff did not receive adequate privacy during a medication administration via G-tube. An LVN failed to close the door or pull the privacy curtain, compromising the resident's dignity. The facility's policy on resident rights, which mandates personal privacy during medical treatment, was not followed.
The facility failed to provide a clean and safe environment in three sampled rooms. In two rooms, a bathroom toilet was found with fecal matter, and in another room, a bathroom light had exposed wires and no cover. An LVN and the Maintenance Supervisor confirmed these issues, citing the facility's policy for a safe and homelike environment.
A resident admitted with end-stage renal disease and requiring hemodialysis did not have a baseline care plan developed within 48 hours of admission. The facility's policy mandates such a plan to ensure effective and person-centered care, including special needs like dialysis. The absence of this plan was confirmed by the MDSN and acknowledged by the DON, highlighting a deficiency in meeting the resident's immediate needs.
A resident with diabetes and cerebral infarction, who had intact cognitive skills, often refused timely medication administration. Despite this, the facility failed to develop a care plan to address the resident's non-compliance, as confirmed by an LVN, QAN, and DON. The facility's policy mandates comprehensive care plans for such issues, but this was not followed, potentially affecting the resident's health.
A resident with Alzheimer's and hyperlipidemia received eye drops without proper lacrimal duct pressure application by an LVN, risking systemic absorption. The LVN also failed to use separate tissues for each eye, potentially causing cross-contamination. The facility's policy required these steps, which were not followed.
A resident with a sacral pressure ulcer was found to be using a malfunctioning Low Air Loss (LAL) mattress, which was intended to prevent and treat pressure ulcers. Despite the facility's policy on pressure injury prevention, the mattress was observed to be soft and slightly deflated, and staff acknowledged its inconsistent functionality. The resident's care plan required a functioning LAL mattress, but the issue persisted, leaving the resident at risk of worsening their condition.
A resident receiving hemodialysis at an LTC facility was not provided with appropriate care and services due to incomplete and inaccurate documentation of the dialysis access site. The facility failed to assess the resident's right upper chest access site on several occasions, and the dialysis communication records lacked essential information. The errors were confirmed by nursing staff, highlighting the need for accurate documentation to ensure proper care.
A resident with Parkinson's disease and impaired cognitive skills did not receive their prescribed Calcitonin Solution nasal spray, a medication for bone loss, due to an LVN's oversight during medication administration. The omission was acknowledged by the LVN and confirmed by the DON, highlighting a failure to follow physician orders as per the facility's medication administration policy.
A resident with visual impairment and cognitive decline was not provided with the necessary assistance and adaptive feeding equipment during meals, as required by a physician's order. Despite having a plate guard on the meal tray, the resident was observed eating with her hands without using the provided utensil. Staff interviews revealed a lack of verbal cues and hand-over-hand assistance, and the absence of a care plan addressing the resident's needs. Facility policies on assistive devices and activities of daily living were not adequately followed.
A facility failed to ensure staff followed infection control policies for a resident on Enhanced Standard Precaution (ESP) due to a gastrostomy tube and a history of infections. A CNA was observed not wearing a gown during high-contact care, despite facility policies and staff interviews confirming the need for gowns and gloves to prevent infection spread.
A resident with Parkinson's disease in an LTC facility was found to have an inaccessible call light in their bathroom, as the call light switch was positioned three feet above ground without a pull string. This deficiency was confirmed by the Maintenance Supervisor and acknowledged by the DON, highlighting a failure to adhere to the facility's policy requiring accessible call systems.
The facility did not meet the minimum square footage requirement for Room E, which housed three residents in a space measuring 223 square feet, falling short of the 80 square feet per resident standard. Despite this, residents appeared comfortable, and no complaints were reported. A waiver request was submitted, and the Department recommended its approval.
Failure to Provide Advance Directive Information Upon Admission
Penalty
Summary
The facility failed to follow its policy regarding advance directives for two residents. For the first resident, who was admitted with immunodeficiency and schizoaffective disorder and was assessed as moderately impaired in cognitive skills, there was no documentation of advance directive acknowledgement in the medical chart or electronic health record. The Social Services Director confirmed that this acknowledgement should have been completed within 72 hours of admission but was not done. For the second resident, admitted with sepsis, acute respiratory failure, and immunodeficiency, and documented as lacking capacity to make decisions, there was also no advance directive acknowledgement in the chart or electronic record. The Social Services Director and the Director of Nursing both confirmed that the facility's policy requires this acknowledgement within 72 hours of admission, but it was not completed for this resident either.
Failure to Ensure Dietary Staff Wore Required Beard Restraint
Penalty
Summary
During an observation in the kitchen, a dietary aide was seen with a mustache and beard and was not wearing a beard mask while present in the kitchen and food storage areas. The dietary aide acknowledged forgetting to wear the beard mask that day. Both the dietary aide and the dietary service supervisor confirmed that hair could fall into food and cause contamination, and agreed on the importance of wearing a beard mask to prevent the spread of germs. Review of the facility's policy and procedures indicated that dietary staff are required to wear hair restraints, including beard restraints, to prevent hair from contacting food. This failure to follow policy had the potential to result in cross contamination and harmful bacterial growth for a large number of medically compromised residents who receive food from the kitchen.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for multiple residents, as observed and documented by surveyors. In one instance, a nurse entered the room of a resident on contact isolation for ESBL of the urine without donning an isolation gown, contrary to the facility's policy and the resident's care plan. Additionally, this resident, who was under transmission-based precautions, was transported to and left in the dining room area for activities, which was not permitted under the facility's policy for residents on such precautions. Another deficiency was observed with a nurse providing care to a resident on enhanced barrier precautions due to the presence of a gastrostomy tube. The nurse failed to change gloves and perform hand hygiene after touching multiple surfaces and before administering medications via the gastrostomy tube and an insulin injection. This was inconsistent with the facility's policy on enhanced barrier precautions, which requires glove and gown use and hand hygiene during high-contact care activities for residents with indwelling medical devices. Further observations revealed that staff did not remove gloves or perform hand hygiene after providing peri-care to three different residents, and subsequently touched the residents' bodies, bed sheets, or applied lotion without changing gloves. These actions were in direct violation of the facility's hand hygiene policy, which mandates hand hygiene after assisting with personal body functions and after glove removal. Interviews with staff confirmed awareness of the correct procedures, but these were not followed during the observed care activities.
Failure to Maintain Sanitary Kitchen Ceiling and Proper Dumpster Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by not ensuring that the kitchen ceiling was free from water leak stains, bubbling, and peeling paint, and by allowing one of four dumpsters to overflow and remain uncovered. During observation, the kitchen ceiling was found to have water stains, paint patches, bubbling, and peeling paint, which the Dietary Service Supervisor attributed to a rain event two weeks prior. The Maintenance Director confirmed that the water leak had been repaired but had not inspected the kitchen ceiling and was unaware of the water stain and peeling paint until recently. The Maintenance Director acknowledged that the peeling paint could fall into food being prepared, potentially leading to contamination. Additionally, one of the facility's dumpsters was observed overflowing with boxes and not completely closed, which the Maintenance Director stated could allow insects or animals to access the trash and potentially spread germs and disease within the facility. Review of facility policies indicated that dumpsters should have tightly fitting lids and be emptied according to contract, with schedules adjusted as needed based on volume. The policies also required preventative maintenance to maintain a safe environment, which was not followed in these instances.
Failure to Follow Physician Orders and Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use and adherence to physician's orders regarding bed rails for six residents. In multiple instances, residents were observed with bed rails in the half-length position when physician orders specified quarter-length rails. This discrepancy was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the bed rails in use did not match the orders. Additionally, some staff members demonstrated a lack of understanding regarding the differences between quarter, half, and full side rails, further contributing to the improper use of bed rails. Several residents involved had significant cognitive impairments and were dependent on staff for most activities of daily living, including transfers, hygiene, and dressing. The residents had diagnoses such as dementia, Alzheimer's disease, depression, schizophrenia, osteoporosis, hemiplegia, and sepsis. Care plans and physician orders for these residents consistently indicated the need for quarter-length side rails to assist with mobility and repositioning, with instructions to monitor for potential entrapment. However, observations revealed that half-length rails were used instead, and the required monitoring and risk assessments were not adequately performed or documented. As a result of these failures, one resident experienced an incident where they became trapped on the bed rail, resulting in a cut on the nose bridge and a precarious position with the upper body off the bed and head touching the floor. The facility's own policies required a person-centered approach, correct installation, and maintenance of bed rails, as well as adherence to physician orders. The lack of compliance with these policies and orders placed multiple residents at risk for entrapment and injury.
Failure to Maintain Resident Dignity and Cleanliness After Mealtime
Penalty
Summary
A deficiency was identified when a resident, who was moderately impaired in cognitive skills and required varying levels of assistance with activities of daily living, was observed with yellow and brown food particles on their bare chest and stomach after a meal. The resident was seen attempting to remove the food particles themselves and expressed a desire to be clean. A registered nurse confirmed the presence of food particles and stated that a CNA should have cleaned the resident after the meal. The Director of Nursing acknowledged that the resident should not have had food particles on their body, as this impacts the resident's dignity. Review of facility policies indicated that staff are required to treat residents with respect and dignity, and to assist them in maintaining their quality of life and well-being. The failure to clean the resident after the meal was not in accordance with these policies.
Failure to Ensure Appropriate Use and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Xanax, was appropriate to treat a specific and documented condition in accordance with facility policy. The resident, who had diagnoses including dementia, Alzheimer's disease, depression, schizophrenia, and anxiety, had a physician's order for Xanax to be administered daily for anxiety as manifested by constant restlessness and repetitive physical movement. However, there was no documented evidence in the Medication Administration Record or Treatment Administration Record that the resident was monitored for these symptoms as required for the use of Xanax. Observations showed the resident was frequently sleeping, and staff interviews revealed inconsistencies and lack of clarity regarding the presence or nature of the resident's repetitive movements. Some staff described the movement as scratching, while others stated there were no repetitive movements. Nursing staff, including LVNs and RNs, were unable to specify or monitor the symptoms as indicated in the medication order, and the DON acknowledged the need for clarification. The facility's policy required psychotropic medications to be used only for specific, diagnosed, and documented conditions, with monitoring and documentation of the resident's response, which was not followed in this case.
Failure to Develop Individualized Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address a resident's oxygen needs. The resident in question was admitted with diagnoses including sepsis, acute respiratory failure, and immunodeficiency, and was determined to lack the capacity to make decisions. Physician orders specified oxygen administration via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95% as needed. However, review of the resident's care plans revealed that no care plan addressing oxygen use had been developed, contrary to facility policy and professional standards. During observation, the resident was seen without the nasal cannula in place and was hyperventilating while moving around. A registered nurse had to adjust the nasal cannula to ensure proper oxygen delivery. Staff interviews confirmed that a care plan for oxygen use was missing and should have been in place to guide staff in providing appropriate care. Facility policies reviewed indicated that care plans should describe the services necessary to maintain the resident's highest practicable well-being and that oxygen administration should be consistent with the care plan and resident's needs.
Failure to Prevent Accidents and Implement Seizure Precautions
Penalty
Summary
The facility failed to implement necessary interventions to prevent injuries for two residents. In the first instance, a resident with a history of a displaced comminuted fracture of the left femur and severe cognitive impairment was observed being transported in a wheelchair without the use of footrests. The resident's feet were on the floor while being pushed by a CNA, despite facility policy and staff interviews confirming that footrests should be used during transport to prevent the resident's feet from dragging and potentially causing injury. In the second instance, a resident with epilepsy and a care plan indicating seizure precautions was found to have unpadded metal bedside rails. Observations and interviews with the resident and nursing staff confirmed that the bedside rails were not padded as required to protect the resident from injury during seizure activity. The facility's policy on seizure precautions specifies that residents should be protected from injury according to current standards of practice, including the use of padded rails.
Failure to Ensure Proper Placement of Nasal Cannula for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, acute respiratory failure, and immunodeficiency, who lacked decision-making capacity, did not receive oxygen therapy as ordered. The physician's orders specified oxygen via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95%. During an observation, the resident was found with the nasal cannula prongs not inserted in the nostrils while receiving oxygen, and was noted to be moving around and hyperventilating. A registered nurse was observed correcting the placement of the nasal cannula and confirmed that the prongs should be in the nostrils to deliver oxygen as ordered. The Director of Nursing also stated that the nasal cannula should be properly placed in the nostrils for effective oxygen administration. Review of the facility's policy confirmed that the equipment and placement depend on the delivery system ordered, such as a nasal cannula for oxygen through the nostrils.
Failure to Provide Safe Hemodialysis Care and Enforce Fluid Restriction
Penalty
Summary
Facility staff failed to provide safe and appropriate hemodialysis care for a resident with end stage renal disease who required strict fluid restriction and special precautions for an arteriovenous (AV) shunt. Observations revealed that a full pitcher of water and a large bottle of juice were left at the resident's bedside, despite a physician's order and care plan specifying a 1000 cc per day fluid restriction. There was no sign posted in the resident's room indicating the fluid restriction or specifying which arm had the AV shunt to prevent blood pressure readings, IV access, or laboratory sticks on that arm. Interviews with staff indicated a lack of knowledge regarding the exact fluid restriction amount and inconsistent monitoring of the resident's fluid intake. The resident, who had moderate cognitive impairment and required assistance with daily activities, reported that staff did not measure or limit fluid intake and was unaware of the fluid restriction. Multiple staff members confirmed that fluid intake was not being accurately monitored and that appropriate signage was not in place. The facility's policy required adherence to physician orders and care plans for residents receiving hemodialysis, including not using the AV shunt arm for certain procedures, but these protocols were not followed for this resident.
Incomplete and Improperly Posted Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Staffing Report was both complete and posted in a manner that was visible and accessible to residents, visitors, and staff on multiple consecutive days. On three separate days, the report was observed to be placed behind another facility form, making it not visible. Additionally, on two of those days, the report did not include the actual direct care hours for RNs, LVNs, CNAs, and RNAs for the day shift, as required by facility policy. Interviews with the Director of Staff Development and nursing staff confirmed that the Daily Staffing Report should be visible and complete, including the actual direct care hours for each category of nursing staff. Review of the facility's policy indicated that the report must be posted daily in a prominent place and include the total number and actual hours worked by licensed and unlicensed nursing staff per shift. The failure to post complete and visible staffing information was directly observed and acknowledged by facility staff.
Room Size Below Minimum Requirement for Multiple Occupancy
Penalty
Summary
The facility failed to ensure that one of its multiple resident rooms, Room A, met the minimum square footage requirement of 80 square feet per resident. During an observation, Room A was found to house three residents, each with their own bed, bedside table, nightstand, and wheelchair, but the total room size was only 223 square feet, which is less than the required 240 square feet for three residents. Interviews with residents and staff revealed no complaints about the room size, and all residents appeared comfortable at the time of observation. Documentation reviewed confirmed the room's measurements and current occupancy.
Failure to Provide Supervision and Functional Alarm Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and ensure the proper functioning of a sensor alarm for a resident at high risk for falls. Resident 34, who was admitted with diagnoses including muscle weakness, repeated falls, and lack of coordination, experienced two falls due to these deficiencies. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for partial moderate assistance with daily activities, including toileting and transfers. Despite these needs, the facility did not update the care plan to include necessary supervision, and the sensor alarm intended to alert staff when the resident got out of bed was not functioning. On two separate occasions, Resident 34 suffered falls that resulted in injuries. The first fall occurred on February 13, 2024, leading to a laceration on the forehead that required hospital transfer for possible suturing. The second fall happened on March 23, 2024, when the resident was found on the bathroom floor without supervision. Interviews with staff, including the Quality Assurance Nurse and the Director of Rehab, confirmed that the resident required supervision and assistance, which was not provided at the time of the incidents. The facility's policies and procedures emphasized the need for alarms and comprehensive care plans to ensure resident safety. However, the care plan for Resident 34 was not revised to reflect the resident's high fall risk and need for supervision. The failure to update the care plan and ensure the alarm's functionality contributed to the resident's falls and subsequent injuries, highlighting a significant oversight in the facility's care practices.
Improper Storage and Expiration of Insulin
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not removing an expired Humulin R insulin vial from the refrigerator. During an observation and interview with the Director of Nursing (DON), it was noted that the Humulin R insulin vial was labeled with an open date and a discard date, indicating it should have been discarded within 28 days of opening. The DON acknowledged that the insulin vial was expired and should have been removed, as expired insulin may be ineffective in controlling a resident's blood sugar, potentially leading to medical complications. Additionally, the facility did not store five unopened Insulin Glargine Flex Pens in the refrigerator as required. These pens were found at room temperature in a plastic bag on the countertop. The DON confirmed that the insulin pens should have been refrigerated according to product labeling. Since the storage duration at room temperature was unknown, the pens were considered expired and unsafe for administration. The improper storage of insulin could render it ineffective, posing a risk of medical complications for residents.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. A container of rice was found with a broken lid, compromising its integrity and potentially allowing contamination. Additionally, a container of cookies was not sealed properly, which could lead to exposure to pests and pathogens. The can opener in the kitchen was observed to be dirty, with dried food residue and rust, indicating a lack of proper cleaning and maintenance. Furthermore, the trash can was overflowing, which could attract pests and contribute to unsanitary conditions. During an interview, the Dietary Supervisor acknowledged these issues, confirming that the food containers should be tightly closed to prevent pest infestation and that the can opener should be cleaned after each use. The facility's policy and procedure documents, which were reviewed, emphasize the importance of maintaining cleanliness and sanitation in food service areas to prevent foodborne illnesses. These deficiencies in food handling and sanitation practices have the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Improper Disposal of Kitchen Garbage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse from the kitchen, as observed when two bags of kitchen trash were found on the ground outside the back of the facility kitchen. During an observation and interview with the maintenance supervisor, it was noted that the trash should have been placed inside the dumpster to prevent the attraction of vermin such as rats and insects, which pose an infection control issue. The maintenance supervisor acknowledged that the kitchen staff left the trash on the ground instead of disposing of it in the dumpster. In an interview with the Dietary Supervisor, it was revealed that the company responsible for trash collection sometimes leaves the dumpster on the street, preventing the staff from disposing of trash properly. As a result, trash is left outside the building temporarily. The facility's policy and procedure on garbage disposal, revised in December 2022, states that garbage should not accumulate or be left outside the dumpster, and storage areas should be maintained to prevent attracting insects and rodents. This failure to adhere to the policy had the potential to attract vermin and pose a disease threat to residents.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to uphold the privacy, dignity, and respect of a resident during a medication administration procedure. The resident, who was admitted with diagnoses including gastrostomy and hypertension, was observed to have impaired cognitive skills and was totally dependent on staff for basic needs. During a medication pass, a Licensed Vocational Nurse (LVN) did not close the resident's door or pull the privacy curtain while administering medication via the resident's G-tube. This oversight occurred despite the resident being in a vulnerable state, lying in bed with their blouse lifted and abdominal binder adjusted for the procedure. The LVN acknowledged the failure to provide privacy during an interview, recognizing the importance of maintaining the resident's dignity by ensuring privacy measures such as closing doors and curtains. The Director of Nursing also affirmed that the resident's privacy and dignity should always be maintained, as outlined in the facility's policy on resident rights. The policy emphasizes the resident's right to personal privacy during medical treatment and care, which was not adhered to in this instance.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in three of the five sampled rooms, leading to unsanitary and unsafe conditions. In Rooms A and B, the bathroom toilet was found to have fecal matter, specifically a dry dark brown to blackish stool, during an observation. This was confirmed by a Licensed Vocational Nurse (LVN 3), who acknowledged that the toilet should have been cleaned to prevent infection, as per the facility's Policy and Procedure (P&P) titled 'Safe and Homelike Environment.' The P&P emphasizes the importance of providing a sanitary environment to ensure residents can receive care safely. In Room D, the bathroom light was observed to be in disrepair, with the light bulb and wires exposed due to the absence of a cover. This was noted during an observation and confirmed by the Maintenance Supervisor (MS), who stated that the lights should be covered to protect residents and staff in case of a light bulb explosion. The MS also referenced the facility's P&P, which underscores the necessity of maintaining a safe and homelike environment for residents.
Failure to Develop Baseline Care Plan for Hemodialysis
Penalty
Summary
The facility failed to develop an individualized baseline care plan within 48 hours of admission for a resident receiving hemodialysis. The resident, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and hypertension, required substantial assistance with daily activities and was receiving hemodialysis three times a week. Despite these needs, the baseline care plan did not include interventions for hemodialysis, which was confirmed during a record review and interview with the Minimum Data Set Nurse (MDSN). The Director of Nursing (DON) acknowledged the absence of a baseline care plan for the resident's hemodialysis, emphasizing its importance for guiding staff in delivering appropriate care. The facility's policy required the development of a baseline care plan that includes instructions for effective and person-centered care, addressing special needs such as dialysis. The failure to include hemodialysis in the baseline care plan was identified as a deficiency, potentially impacting the resident's safety and wellbeing.
Failure to Develop Care Plan for Medication Non-Compliance
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 285, who exhibited non-compliance with medication administration. The resident was admitted with diagnoses including diabetes mellitus and cerebral infarction and was noted to have intact cognitive skills for decision-making. Despite this, the resident often refused to take medications on time, as observed during an interaction with an LVN. The LVN acknowledged that a care plan should have been created to address the resident's non-compliance, which was not done. The Quality Assurance Nurse and the Director of Nursing both confirmed that a care plan should have been initiated to manage the resident's behavior of refusing medication, particularly insulin, which is critical for managing diabetes. The facility's policy requires the development of comprehensive care plans that include measurable objectives and timeframes, and documentation of any refusal of treatment. However, this was not adhered to, leaving the resident without a structured plan to address their non-compliance with medication, potentially impacting their health.
Failure to Follow Eye Drop Administration Protocol
Penalty
Summary
The facility failed to meet professional standards of quality in the administration of eye medication for one resident. During a medication pass, a Licensed Vocational Nurse (LVN) administered Artificial Tear Ophthalmic Solution to a resident without applying gentle pressure to the lacrimal duct, as required by the facility's policy. This step is crucial to prevent systemic absorption of the medication. The LVN also allowed the resident to use the same tissue to wipe excess medication from both eyes, which could lead to cross-contamination. The resident involved had a history of Alzheimer's disease and hyperlipidemia and was cognitively intact, requiring moderate assistance with daily activities. The Director of Nursing confirmed that the LVN should have applied pressure to the tear duct and used a clean tissue for each eye. The facility's policy clearly outlined these procedures, indicating that the LVN's actions were not in compliance with the established standards of practice.
Failure to Maintain Functioning Pressure Ulcer Prevention Equipment
Penalty
Summary
The facility failed to ensure that a Low Air Loss (LAL) mattress, intended to prevent and treat pressure ulcers, was functioning properly for a resident. The resident, who was admitted with diagnoses including abnormalities of gait and mobility, repeated falls, and a pressure ulcer in the sacral region, was observed on multiple occasions with a LAL mattress that was soft and slightly deflated. This malfunction was noted by both a Licensed Vocational Nurse (LVN) and a Treatment Nurse (TN), who acknowledged that the mattress sometimes worked and sometimes did not. The facility had contacted the mattress company to address the issue, but the problem persisted, leaving the resident at risk of their pressure ulcer worsening. The resident's Minimum Data Set (MDS) indicated they were at risk for developing pressure ulcers and had existing unhealed pressure ulcers. The resident's care plan included the use of a LAL mattress for wound management, yet the mattress was not functioning as required. The facility's policy on pressure injury prevention and management emphasized the importance of pressure-redistributing support surfaces, but the lack of a properly functioning mattress contradicted this policy. The resident's Braden Scale score indicated a moderate risk for pressure injury development, further underscoring the need for effective pressure ulcer prevention measures.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as Resident 182, who was receiving hemodialysis treatment. The deficiency was noted in the failure to assess the resident's right upper chest dialysis access site on specific dates, as required by the facility's policy. This oversight had the potential to lead to complications such as bleeding or infection from the central venous catheter. Resident 182 was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and hypertension, and required substantial assistance with daily activities. The facility's records indicated that Resident 182 was scheduled for hemodialysis every Monday, Wednesday, and Friday. However, the dialysis communication records for several dates were incomplete and inaccurate. The records failed to document essential information such as the type of dialysis access site, and incorrectly noted the presence of bruit and thrill, which are not applicable for a central venous catheter. The documentation errors were confirmed by both a registered nurse and the Director of Nursing, who acknowledged the incomplete and incorrect assessments. The facility's policy required ongoing assessment and communication with the dialysis center to ensure proper care. However, the dialysis communication records lacked critical information, including access site assessment, lab results, food consumed, medications given, and the resident's response to dialysis treatment. The Director of Nursing stated that the receiving nurse should have contacted the dialysis center to address the incomplete records, emphasizing the importance of accurate documentation to ensure proper care for the resident.
Failure to Administer Calcitonin Solution
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Calcitonin Solution nasal spray as indicated on the physician's order. This medication is used to treat bone loss, and its omission could potentially lead to the resident's bones becoming more fragile or low in bone mass, increasing the risk of fractures. The resident, who was admitted with a diagnosis including Parkinson's disease, had severely impaired cognitive skills and required assistance with daily activities. During a medication administration observation, an LVN prepared and administered several medications to the resident but failed to include the Calcitonin Solution. The LVN later acknowledged the omission, recognizing that failing to administer medication per the physician's order could lead to medical complications. The Director of Nurses confirmed that the Calcitonin should have been administered as ordered, and its omission could result in bone weakening. The facility's policy on medication administration requires that medications be administered as ordered by a physician.
Failure to Provide Adaptive Feeding Equipment and Assistance
Penalty
Summary
The facility failed to ensure that a resident who required adaptive feeding equipment utilized a plate guard during meals, as indicated by the physician's order. The resident, who was admitted with diagnoses including bilateral nuclear cataract, dementia, and abnormalities of gait and mobility, was observed eating without using the provided utensil and plate guard. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for extensive assistance with daily activities, including eating. Despite the presence of a plate guard on the meal tray, the resident was seen eating with her hands, and staff did not provide the necessary reminders or assistance to use the adaptive equipment. Interviews with staff, including a Restorative Nurse Assistant, Occupational Therapist Assistant, Director of Rehabilitation, Licensed Vocational Nurse, and Registered Nurse, revealed that the resident required verbal cues and hand-over-hand assistance due to visual impairment. The staff acknowledged the need for periodic checks during meals to ensure proper use of utensils and the plate guard. However, it was noted that the resident did not have a care plan addressing her visual impairment and the need for cuing and adaptive equipment. The facility's policies on Activities of Daily Living and Use of Assistive Devices emphasized the importance of providing necessary services and assistance to maintain residents' abilities and dignity, which were not adequately followed in this case.
Failure to Follow Infection Control Policy for Resident on ESP
Penalty
Summary
The facility failed to ensure staff adhered to its infection control policy for a resident who was on Enhanced Standard Precaution (ESP) due to a gastrostomy tube and a history of sepsis and urinary tract infection. The resident, who lacked the capacity to make decisions and had severe cognitive impairment, required staff to use gowns and gloves during high-contact care activities to prevent the transmission of multi-drug resistant bacteria. However, during an observation, a Certified Nursing Assistant (CNA) was seen entering the resident's room without wearing a gown while intending to clean the resident's soiled diaper, which is considered a high-contact activity. Interviews with the Quality Assurance Nurse, Infection Preventionist Nurse, and Director of Nursing confirmed that the resident was on ESP and that staff should wear appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. The facility's policy and procedure documents also indicated the necessity of using gowns and gloves for such activities to prevent the spread of infections. The CNA admitted to forgetting to wear a gown, acknowledging the requirement due to the resident's ESP status.
Inaccessible Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathroom for one of the residents, identified as Resident 39. During an observation, it was noted that the call light in Resident 39's bathroom did not have a string attached, making it inaccessible to the resident, especially if they were on the floor. The call light switch was positioned about three feet above ground level, between the bathroom door and the toilet, which was confirmed by the Maintenance Supervisor to be unreachable in such a situation. This deficiency was highlighted during an interview with Resident 39, who expressed a need for a pull string cord light to feel safe and secure in the bathroom, particularly during emergencies. Resident 39 was admitted to the facility with a diagnosis of Parkinson's disease, which affects motor skills and requires the resident to have partial assistance for toilet hygiene and lower body dressing. The resident's care plan included the use of a bell to call for assistance, but the lack of an accessible call light in the bathroom posed a risk of delayed care. The Director of Nurses acknowledged that the bathroom should have a call light with a string to allow the resident to call for help. The facility's policy on call lights emphasized the need for accessibility at each toilet and bath or shower facility, including for residents lying on the floor.
Room Size Deficiency in Multiple Resident Room
Penalty
Summary
The facility failed to ensure that one of its 29 resident rooms, specifically Room E, met the minimum square footage requirement of 80 square feet per resident for multiple resident rooms. Room E, which measured 223 square feet, was occupied by three residents, resulting in less than the required space per resident. Despite this deficiency, observations during the survey period indicated that the residents appeared comfortable, and there were no complaints from residents or staff regarding the room size. The facility had submitted a room waiver request, indicating that the residents' needs were accommodated without adverse effects on their health, safety, or welfare. The Department recommended the waiver request for Room E.
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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