Northridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 7836 Reseda Blvd, Reseda, California 91335
- CMS Provider Number
- 056412
- Inspections on file
- 66
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Northridge Care Center during CMS and state inspections, most recent first.
A resident with CHF, chronic pulmonary edema, and orthostatic hypotension was admitted with a physician order for fluid restriction of 750 ml per day and no bedside water pitcher. Staff documented intake and output only for an initial period and then stopped monitoring and recording I/O, despite the ongoing restriction order. During interviews, an LVN and an RN acknowledged that licensed nurses had not continued I/O monitoring as required, even though facility policies mandate daily I/O documentation for residents on fluid restrictions for at least 30 days and ongoing monitoring when hydration concerns exist.
Surveyors found that staff failed to complete fall risk evaluations accurately for two residents. One resident with CHF, pulmonary edema, and orthostatic hypotension had a fall risk tool marked as having no SBP drop between lying and standing even though the resident could not stand, and the gait/balance and medication sections were left blank, resulting in a low fall score. For another resident with CHF and HTN, the MDS nurse documented no SBP drop between lying and standing without actually obtaining lying and standing BPs, relying instead on prior BP summaries that lacked standing readings, which also produced a non–high-risk fall score. These omissions and inaccurate entries meant the fall risk tools did not reflect the residents’ true fall risk status as required by facility procedures.
A resident with CHF and chronic pulmonary edema was readmitted with a hospital report and a physician telephone order indicating a 750 ml/day fluid restriction, but the order was not properly documented or incorporated into the active physician orders. The RN who received the hospital report acknowledged missing the entry of the fluid restriction, and the telephone order form lacked the signature and title of the person who transcribed it, making it impossible to identify who took the order or confirm that the person was licensed. The ADON and Medical Records Director were unable to locate the signed copy of the telephone order or any history of the fluid restriction in current or discontinued physician orders, contrary to facility P&P requiring licensed staff to document telephone orders with signature and title and for the physician to countersign them.
A resident with a history of falls, impaired cognition, and significant physical limitations was not provided with a properly functioning bed pad alarm as ordered by the physician. Staff confirmed the alarm was not working during inspection, and the responsible manager had not checked the alarm that day, contrary to facility policy requiring daily checks.
A resident with paraplegia, anxiety, and depression, who reported trauma from a gunshot injury, did not receive a complete trauma care evaluation or a care plan addressing past trauma and triggers. Despite the resident expressing that loud noises were a trigger, the trauma assessment was left incomplete and no individualized care plan was developed, contrary to facility policy. Both the SSD and DON acknowledged these omissions.
A facility failed to provide privacy during medication administration for four residents, violating their right to dignity and respect. An LVN was observed checking blood sugar levels and administering insulin without closing privacy curtains, despite the facility's policy on treating residents with respect and dignity.
The facility failed to revise care plans for two residents' activity needs and one resident's nutritional needs. Two residents with significant dependencies did not have their activity care plans evaluated or renewed quarterly, as required. Another resident with multiple health issues had a care plan that did not account for dialysis-related weight fluctuations, despite being at risk for malnutrition. These deficiencies were identified through interviews and record reviews, indicating non-compliance with facility policies.
The facility failed to properly label and store medications, including an Aplisol vial without an open date, an insulin pen not refrigerated, and Artificial Tears labeled with room numbers instead of resident names. Additionally, medications for a discharged resident were not removed from the cart, risking administration errors.
A facility failed to follow infection control guidelines when an RN did not remove an isolation gown and gloves after administering medication to a resident on enhanced barrier precautions. The resident, who was moderately cognitively impaired and dependent on staff, was receiving treatment for discitis and a urinary tract infection. The RN's actions were against the facility's policy, which requires removing PPE before exiting a resident's room to prevent infection spread.
A facility failed to complete a resident's Quarterly MDS assessment within the required timeframe, potentially affecting care provision. The resident, with asthma and Parkinson's, had an ARD of 11/29/2024, but the assessment was completed on 12/26/2024, beyond the 14-day requirement. This delay was confirmed by the MDS Nurse during interviews and record reviews.
A facility failed to develop a comprehensive care plan for a resident using bed rails, as required by their policy. The resident, who had intact cognitive skills but was dependent on staff for daily activities, did not have a safety assessment for the bed rails attached to their bed. This oversight was confirmed by the DON, who acknowledged the potential risk of injury due to entrapment. The facility's policy requires care plans to include medical, nursing, and psychosocial needs, but this was not followed in this case.
A resident with paraplegia, anxiety, and depression was not provided with consistent access to Bible studies, an activity of choice, due to a possible COVID-19 outbreak at the religious institution. The Activity Director could not provide participant lists or contact information, and the Director of Nursing acknowledged the importance of offering activities of choice to prevent increased anxiety and depression.
A resident in an LTC facility was found storing multiple bottles of supplements and vitamins at their bedside, accessible to other residents. Despite having intact cognition, the resident's medication storage posed a risk, as confirmed by staff interviews. Facility policies indicated that such storage is only allowed when it does not present a risk to other residents, which was not adhered to in this case.
A resident with multiple health conditions, including cerebral infarction and gastrostomy malfunction, was at risk of infection due to the facility's failure to cap the enteral feeding tube after disconnection. The oversight was confirmed by an LVN, IP, and DON, who acknowledged the increased risk of healthcare-acquired infections due to this deficiency.
A facility failed to label and timely discontinue an IV site for a resident receiving Ceftriaxone for RSV pneumonia. The IV site was undated, and the completion of the antibiotic therapy was not communicated to the physician, leading to a delay in discontinuing the IV. The facility's policy requires peripheral catheters to be removed when clinically indicated, but the nursing staff did not follow the protocol, resulting in a deficiency.
A facility failed to assess a resident for the risk of entrapment from bedside rails, as required by policy. The resident, with a history of muscle weakness and falls, was observed with both rails raised without a safety assessment. The DON confirmed the absence of an assessment, acknowledging the risk of injury. Facility policy mandates a restraint assessment and physician order for side rail use.
A facility failed to label and store food brought by a resident's family, risking foodborne illness. A resident's tamales were found on an over-bed table without proper labeling or refrigeration. The DON confirmed the food should have been labeled with the resident's name and use-by date and stored in a refrigerator, as per facility policy.
The facility failed to meet the minimum room size requirements for 27 resident rooms, with each room falling short of the required square footage for two or four residents. Despite this, residents did not express concerns, and observations showed adequate space for care and mobility. A Room Variance Waiver was submitted, indicating the rooms met residents' needs.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss over several months. Despite the physician being aware and providing interventions, the weight loss was not documented in the progress notes, violating the facility's weight change policy.
A resident with severe cognitive impairment and frequent pain was not administered the correct dosage of Percocet as per physician's orders. Despite reporting a pain level of eight, indicating severe pain, the resident received only one tablet instead of the prescribed two. Interviews with the LVN and DON confirmed the error, highlighting a failure to follow the facility's pain management policy.
A resident's Quarterly MDS assessment inaccurately reflected their need for assistance and risk for pressure ulcers. Despite being non-ambulatory and requiring extensive assistance with ADLs, the MDS indicated only supervision was needed for eating and no risk for pressure ulcers. Interviews with staff and review of records confirmed these inaccuracies, highlighting a failure to adhere to facility policies on accurate documentation.
A resident with cognitive impairment and multiple health conditions did not have heel protectors in place as ordered by the physician, which were necessary for preventing pressure ulcers. The CNA had removed the protectors earlier, and the DON confirmed they should have been in place according to the facility's policy on pressure sore management.
A resident with anxiety disorder did not receive timely delivery of Alprazolam due to the facility's failure to reorder the medication as per policy. The last dose was administered, and the refill was delayed despite confirmation from the pharmacy. The facility's policy required reordering when five doses remained, which was not followed, leading to a deficiency.
A resident with fully intact cognition punched another resident in the face after an accidental bump in the dining room. The incident was witnessed by a CNA and confirmed by the Social Services Director and DON. The facility's policy on abuse was not upheld, resulting in a failure to protect residents from physical abuse.
A facility failed to follow its infection control policy by not placing a C. Diff positive resident in isolation upon re-admission. Instead, the resident was cohorted with another resident who did not require isolation, contrary to the facility's policy. This oversight was acknowledged by the infection preventionist and the director of nursing, who confirmed that the resident should have been isolated immediately.
The facility failed to implement its TB Infection Control Program by not conducting an annual TB Risk Assessment. The Infection Preventionist was unaware of the policy, focusing instead on Covid, leading to no documented TB risk assessments. The Director of Nursing confirmed the IP should have known the policies to implement them effectively.
Failure to Monitor and Document I/O for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document intake and output (I/O) for a resident on physician-ordered fluid restriction, in accordance with professional standards and facility policy. The resident was originally admitted with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, and was dependent on staff for ADLs but cognitively intact. On readmission, the RN hospital-to-facility admission report and physician’s telephone orders specified a fluid restriction of 750 ml per day due to chronic pulmonary edema, and a subsequent physician’s order directed that no water pitcher be left at the bedside. The facility’s I/O record for this resident showed monitoring and documentation from 12/30/2025 to 1/7/2026 only. During interviews and concurrent record reviews, an LVN confirmed that licensed nurses did not monitor or document the resident’s I/O after 1/7/2026 despite the ongoing fluid restriction order. An RN similarly stated that, given the 750 ml per day fluid restriction and the order for no bedside water pitcher, licensed nurses should have continued to monitor I/O closely, particularly in light of the resident’s heart problems and history of edema. Review of facility policies titled “Fluid Intake and Output” and “Resident Hydration and Prevention of Dehydration” showed that intake and output must be recorded for residents with restricted fluids as ordered by the physician, with daily I/O documented for a minimum of 30 days, and that nursing will monitor and document fluid intake when inadequate intake or dehydration concerns are present. The facility did not follow these policies for this resident after 1/7/2026.
Inaccurate Fall Risk Evaluations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete fall risk evaluations for two residents, contrary to its policy for promoting safety and reducing falls. For the first resident, who had diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, the admission record showed readmission on 12/30/2025 and an MDS indicating intact cognition and dependence on staff for ADLs. The Fall Risk Evaluation dated 12/30/2025 documented that there was “no noted drop between lying and standing” for systolic blood pressure, even though the resident was not able to stand. The gait/balance section was left entirely unmarked, including the option for “not able to perform function,” and the medications section was also left blank, including the option indicating no relevant medications. The resulting fall score was four, which did not place the resident in the high-risk category. During interview and concurrent record review, the RN who completed this evaluation stated that the resident was not able to stand at the time of the assessment. The RN acknowledged marking “no noted drop between lying and standing” for systolic blood pressure because there was no “non-applicable” option, and admitted not completing the gait/balance and medication sections. The RN further stated that the total score of four, indicating no risk of fall, was not correct and confirmed that assessments are used to establish the plan of care to reduce fall risks. These statements confirmed that the fall risk evaluation for this resident was not completed thoroughly or accurately as required by the facility’s process. For the second resident, who had combined systolic and diastolic CHF and hypertension, the admission record showed readmission on 12/29/2020 and an MDS indicating intact cognition, with moderate assistance needed for oral/personal hygiene and supervision or touching assistance for toileting hygiene, dressing, and toilet transfer. The Fall Risk Evaluation dated 12/22/2025 recorded the resident as ambulatory and continent and again indicated “no noted drop between lying and standing” for systolic blood pressure, resulting in a fall score of eight, which did not meet the facility’s threshold for high fall risk. In an interview, the resident reported sometimes going to the bathroom alone and being able to self-clean. During a concurrent interview and record review, the MDS nurse who completed the evaluation stated she did not measure the resident’s systolic blood pressure in both lying and standing positions and instead relied on blood pressure summaries from other nurses, which did not include standing readings. She acknowledged that, as a result, the fall risk evaluation was not done correctly to assess the resident’s fall risks. The facility’s policy on promoting safety and reducing falls emphasized the need for caregivers to understand key fall risk factors, including gait and balance disturbances and the importance of residents rising slowly from lying or sitting positions, underscoring the expectation for accurate assessment of these parameters.
Failure to Properly Document and Countersign Physician Telephone Order for Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician telephone order for a fluid restriction was properly documented, signed, and incorporated into the resident’s active physician orders. A resident with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension was originally admitted and later readmitted with a hospital report indicating a fluid restriction of 750 ml per day. The resident’s MDS showed intact cognition and dependence on staff for ADLs. On readmission, the RN Hospital to RN Facility admission report documented the 750 ml/day fluid restriction, and a Physician’s Telephone Order form dated the same day also indicated a fluid restriction of 750 ml/day due to chronic pulmonary edema. However, the fluid restriction was not entered into the physician’s orders or reflected in the physician order recap covering the admission period. During interviews and record reviews, RN 1 stated he became aware of the fluid restriction from the hospital report but missed inputting the restriction into the physician’s orders. When reviewing the Physician’s Telephone Orders, RN 1 stated he did not transcribe the order and could not identify who did because there was no name or signature on the form. The ADON similarly could not determine who transcribed the telephone order, whether that person was a licensed nurse, or whether the order had been entered into the charting system, and confirmed the fluid restriction was not present in the physician order summary. The Medical Records Director reported that the white copy of the Physician’s Telephone Orders, which should have been returned within five days after the physician’s signature, could not be located, and there was no history of the fluid restriction order in the current or discontinued physician orders. The facility’s P&P required that telephone orders be received only by licensed personnel, reduced to writing with date, time, signature and title of the person transcribing, and countersigned by the physician at the next visit or electronically, which was not followed in this case.
Failure to Ensure Proper Functioning Bed Pad Alarm for Resident at Fall Risk
Penalty
Summary
A deficiency occurred when a resident with a history of falls, right femur fracture, hemiplegia, morbid obesity, dementia, and moderately impaired cognition was not provided with a properly functioning bed pad alarm as ordered by the physician. The resident required significant assistance with daily activities and was dependent on staff for toileting, showering, and dressing. The physician had ordered a bed pad alarm to decrease the potential for injury, and facility policy required daily checks of such alarms for proper functioning. During an observation, a CNA attempted to demonstrate the bed pad alarm but no alert was heard, and both the CNA and DON confirmed the alarm was not working. The Central Supply Manager stated that position change alarms are typically checked daily, but on this day, the resident's alarm had not been checked. The DON acknowledged that the alarm should be operational at all times and confirmed it was not working at the time of inspection, which was inconsistent with facility policy and physician orders.
Failure to Complete Trauma Evaluation and Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to complete a thorough trauma care evaluation and develop a comprehensive, person-centered care plan addressing past trauma and triggers for one resident. The resident, who had diagnoses including complete paraplegia, anxiety disorder, and depression, reported a history of being shot in the back, which resulted in paralysis and ongoing depression. During the psychiatric intake, the resident disclosed this trauma, and during an interview, stated that loud noises, such as staff slamming doors, triggered memories of the gunshot event. Despite this, the trauma care evaluation was incomplete, with only the first question marked as declined and the remaining questions left blank. The facility's policy required further information gathering from family or medical records if the resident declined to participate, but this was not done. Additionally, a review of the resident's care plans revealed that there was no care plan addressing the resident's past trauma or potential triggers, despite staff being aware of the trauma history. The Social Services Director acknowledged that more information should have been gathered and documented, and the DON confirmed that a care plan should have been created to address the trauma and triggers. The facility's policy required individualized care plans to minimize triggers and re-traumatization, but this was not implemented for the resident in question.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
The facility failed to provide privacy to four residents during medication administration, which violated their right to dignity and respect. The incidents involved Licensed Vocational Nurse 1 (LVN1) who was observed checking the blood sugar levels of the residents and administering insulin without closing the privacy curtains in their rooms. This lack of privacy occurred despite the facility's policy that emphasizes treating residents with respect and dignity at all times. Resident 54, who was admitted with dysphagia and type 2 diabetes, had intact cognitive skills but was dependent on staff for personal care. During a medication administration observation, LVN1 checked the resident's blood sugar in the room with the privacy curtain open. Similarly, Resident 35, with impaired cognitive skills and requiring maximal assistance, had their blood sugar checked by LVN1 in bed without the privacy curtain being closed. Resident 58, with intact cognitive skills but dependent on staff for personal care, also had their blood sugar checked and insulin administered by LVN1 without privacy. Lastly, Resident 3, with severely impaired cognitive skills, experienced the same lack of privacy during their medication administration. LVN1 acknowledged the oversight and stated that residents should not be put in situations that could cause embarrassment, emphasizing the importance of providing privacy during such procedures.
Failure to Revise Care Plans for Activity and Nutritional Needs
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plans for two residents, Resident 15 and Resident 69, regarding their activity needs. Resident 15, who was diagnosed with anxiety disorder and Parkinson's disease, had an intact cognitive ability for daily decision-making but was totally dependent on staff for various activities of daily living. The care plan for Resident 15's activity needs was not evaluated or renewed on the target date, which was supposed to be done quarterly. Similarly, Resident 69, diagnosed with quadriplegia and epilepsy, had severely impaired cognitive skills and was also totally dependent on staff. The care plan for Resident 69's activity needs was not evaluated or renewed on the target date. The Director of Nursing acknowledged that the care plans were not active and should have been reviewed quarterly to ensure ongoing activities were provided to address the residents' psychosocial needs. The facility also failed to revise the comprehensive person-centered care plan addressing the nutritional needs of Resident 25. Resident 25, with diagnoses including acute respiratory failure, type 2 diabetes, and end-stage renal disease, had moderately impaired cognitive skills and required moderate assistance from staff. The nutritional assessment indicated a risk for malnutrition, and the dietary note highlighted weight loss due to fluid shifts related to dialysis. However, the care plan did not reflect the resident's dialysis treatment, which could significantly contribute to weight fluctuation. The Director of Dietary Services and the Director of Nursing both noted that the care plan should have been person-centered and included all nutritional risk factors to meet the resident's needs. The facility's policies and procedures require that resident care plans be implemented on admission and reviewed at least quarterly. However, the care plans for the residents in question were not updated as required, potentially impacting the residents' care and services related to their activity and nutritional needs. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to adhere to its own policies and procedures regarding care plan evaluations and revisions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. In Medication Room A, a multi-dose vial of Aplisol was found without an open date, which is against the facility's policy and the manufacturer's instructions. The Director of Nursing (DON) confirmed that the vial should have been labeled with an open date and discarded after 28 or 30 days to prevent inaccurate test results for tuberculosis. This oversight increased the risk of residents receiving ineffective or potentially toxic medication. In another instance, an unopened insulin pen for a resident was improperly stored in Medication Cart 2 instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that the insulin pen should have been refrigerated to maintain its efficacy. The DON confirmed that improper storage could lead to the insulin losing its effectiveness, potentially causing hyperglycemia in the resident. Additionally, the facility failed to label a box of Artificial Tears with a resident's name, using a room number instead. This practice was observed during an inspection of one of the medication carts. The DON confirmed that medications should be labeled with the resident's name to prevent administration errors. Furthermore, medications for a resident who was discharged to a hospital were not removed from the medication cart, increasing the risk of another resident receiving the wrong medication.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control guidelines during a medication pass observation involving a resident on enhanced barrier precautions (EBP). Registered Nurse 1 (RN 1) was observed administering Cefazolin via a central line to a resident diagnosed with discitis, a urinary tract infection, and major depressive disorder. The resident was moderately impaired in cognition and dependent on staff for daily activities. After administering the medication, RN 1 exited the resident's room without removing the isolation gown and gloves, which is against the facility's policy for EBP. The incident was confirmed through interviews with the Infection Preventionist and the Director of Nursing, both of whom stated that RN 1 should have removed the gown and gloves before leaving the resident's room to prevent the spread of infection. The facility's policy on EBP, revised in March 2024, requires the use of personal protective equipment, including gloves and gowns, during high-contact resident care activities, especially for residents with indwelling medical devices. This oversight had the potential to increase the risk of spreading infection to other residents.
Delayed Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) was completed in a timely manner, as required by federal guidelines. The deficiency involved a resident who was admitted to the facility with diagnoses of asthma and Parkinson's disease. The resident had intact cognition and was dependent on staff for most activities of daily living. The Quarterly MDS, which is a standardized assessment and care screening tool, was not completed within the required timeframe, potentially affecting the provision of necessary care and services for the resident. During the review, it was found that the assessment reference date (ARD) was set for 11/29/2024, and the assessment should have been completed by 12/12/2024. However, the assessment was not completed until 12/26/2024, which was more than 14 days after the ARD. This delay was confirmed during interviews and record reviews with the MDS Nurse, who acknowledged the oversight and confirmed that the assessment was not completed within the required period as per the guidelines set by the Centers for Medicare and Medicaid Services (CMS) and the Omnibus Budget Reconciliation Act of 1987 (OBRA).
Failure to Develop Comprehensive Care Plan for Resident Using Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 58, who was investigated under accidents. The deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated that the resident had intact cognitive skills but was dependent on staff for various activities of daily living. Despite these needs, the facility did not conduct a safety assessment for the use of bed side rails, which were attached to the resident's bed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of a safety assessment and the potential risk of injury due to entrapment in the bed rails. The facility's policy on resident care plans, which aims to provide individualized nursing care and promote continuity of care, was not adhered to in this case. The policy requires that care plans include identification of medical, nursing, and psychosocial needs, with goals stated in measurable terms. However, the care plan for Resident 58 did not address the use of bed rails, nor did it include a timeframe for evaluating the effectiveness of this intervention. This lack of a comprehensive care plan had the potential to result in the resident not receiving necessary care and services to prevent potential injury from the bed rails.
Inconsistent Activity Provision for Resident
Penalty
Summary
The facility failed to provide appropriate and consistent activities for a resident, identified as Resident 52, which had the potential to negatively affect the resident's physical, cognitive, sense of belonging, and emotional health. Resident 52, who has diagnoses including paraplegia, anxiety, and depression, was admitted to the facility with intact cognition and required assistance for most activities of daily living. The resident expressed a preference for participating in Bible studies on Sunday afternoons, an activity that was discontinued without explanation, despite being listed on the facility's activities calendar. The Activity Director (AD) acknowledged that Bible studies had not been provided for the past 3-4 weeks due to a possible COVID-19 outbreak at the religious institution that facilitated these services. The AD was unable to provide a list of participants or contact information for the religious organization. The Director of Nursing (DON) confirmed that the facility should provide activities of choice to residents, as failing to do so could increase anxiety and depression. The facility's policy on spiritual and religious activities indicated that a variety of such activities should be available and scheduled through local religious organizations, encouraging residents to attend those of their choice.
Resident's Bedside Medication Storage Poses Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a resident to store medications at their bedside, which were readily accessible to other residents. This deficiency was identified during a review of a resident's care area for accidents. The resident, who had intact cognition and required supervision to moderate assistance for most activities of daily living, was observed with multiple bottles of supplements and vitamins stored in clear plastic drawers next to their bed. The resident confirmed that they self-administered these medications. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed concerns about the risk posed by the resident's bedside medication storage. The staff acknowledged that the presence of medications at the bedside could lead to other residents, particularly those who are confused and may wander into the room, consuming the medications and potentially experiencing adverse side effects. The facility's policy on self-administration of medication and storage of medication indicated that bedside storage is only permitted when it does not present a risk to other residents, highlighting a failure to adhere to these guidelines.
Failure to Cap Enteral Feeding Tube Increases Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident receiving enteral feeding, leading to a potential risk of infection. The deficiency was identified when the enteral feeding tube of a resident was observed to be disconnected and hanging on a pole without a cap covering the tip. This oversight was confirmed by a Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP), both of whom acknowledged that the tubing should be capped to prevent contamination and reduce the risk of healthcare-acquired infections. The resident involved had multiple diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, and schizophrenia. The resident was totally dependent on staff for all activities of daily living and had moderately impaired cognition. The facility's policy on enteral feeding safety precautions, last reviewed in March 2024, was not adhered to, as it required the capping of the tubing to prevent microbial growth. Interviews with the LVN, IP, and Director of Nursing (DON) confirmed the failure to cap the tubing increased the risk of infection for the resident.
Failure to Label and Discontinue IV Site as per Protocol
Penalty
Summary
The facility failed to label the insertion site of an intravenous (IV) catheter dressing for a resident, which is against the facility's protocol. This oversight was observed in one of the three sampled residents who had an IV access. The resident, identified as Resident 13, was admitted with diagnoses including hypertension and was receiving Ceftriaxone intravenously for RSV pneumonia. The IV site on the resident's left forearm was found to be undated during an observation, and there was no record of when the IV was started. The Director of Nurses (DON) and Registered Nurse 1 (RN 1) confirmed that the IV antibiotic treatment was completed by 12/29/2024, but the IV site was not discontinued until 1/06/2025. The facility's policy indicates that peripheral catheters should be removed when clinically indicated, at the completion of therapy, or if the site shows signs of complications. However, the registered nurses failed to notify the physician of the presence of the IV after the completion of the antibiotic therapy, which is a requirement to ensure the resident's safety. Interviews with the nursing staff revealed a lack of communication and documentation regarding the IV start date and the completion of the antibiotic therapy. RN 3, who administered the last dose of the antibiotic, did not notify the physician that the IV medication was completed, and the information was only endorsed to the next shift nurse. The facility's policy does not require a physician's order to remove a peripheral catheter, but the nurses are expected to notify the physician to confirm whether the IV should be discontinued or continued with a new order.
Failure to Assess Bed Rail Safety Risk
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from the use of bedside rails, as required by the facility's policy and procedure. Resident 58, who was originally admitted on 12/08/2021 and readmitted later, had diagnoses including muscle weakness and a history of falling. The Minimum Data Set (MDS) dated 02/08/2024 indicated that the resident's cognitive skills for daily decision-making were intact, and the resident was dependent on staff for various activities of daily living. An observation on 01/06/2024 noted that Resident 58 was lying in bed with both bedside rails raised. During a record review and interview with the Director of Nursing (DON) on 01/08/2025, it was revealed that Resident 58 did not have a safety assessment for the use of the bedside rails. The DON confirmed that a quarter bedside rail was attached to the resident's bed and acknowledged that every resident using a bed rail must be assessed for safety and risk of entrapment to prevent potential injury. The facility's policy, last reviewed on 03/15/2024, requires a physical restraint assessment form to be completed and an order from the attending physician for the use of side rails. The lack of assessment for Resident 58's use of bedside rails constituted a deficient practice with the potential for inappropriate use leading to entrapment and injury.
Improper Labeling and Storage of Food Brought by Family
Penalty
Summary
The facility failed to ensure that leftover food brought by a resident's family was properly labeled and stored, which could lead to foodborne illness. During an observation, a plastic bag containing tamales was found on a resident's over-bed table without any labeling or refrigeration. The Director of Nursing confirmed that the food should have been labeled with the resident's name and a use-by date and stored in a refrigerator to prevent potential foodborne illnesses. The resident involved was admitted with diagnoses including muscle weakness and a history of falling. The resident's cognitive skills for daily decision-making were intact, but they were dependent on staff for certain activities of daily living. The facility's policy required that food brought by family or visitors be labeled and stored separately from facility-prepared food, but this was not followed in this instance.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility failed to provide adequate room size for residents, as required by regulations. Specifically, 27 out of 43 resident rooms did not meet the minimum square footage requirements. The rooms in question were designed to accommodate two residents each but fell short of the 160 square feet minimum requirement, with sizes ranging from 151.20 to 158.68 square feet. Additionally, two rooms intended for four residents each were also undersized, measuring 309.54 square feet instead of the required 320 square feet. This deficiency was identified through observation, interviews, and record reviews. Despite the room size deficiency, during a Resident Council meeting, no concerns were expressed by the residents regarding their room sizes. Observations indicated that residents and staff had sufficient space to move freely, and the nursing staff could safely provide care. The rooms were equipped with necessary amenities such as closets, over-bed tables, nightstands, cubicle curtains for privacy, and call lights. The facility had submitted a Room Variance Waiver application, asserting that the rooms were adequate for the residents' needs and did not impede their well-being.
Failure to Document Resident's Weight Loss in Physician's Progress Notes
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding weight change by not ensuring that a resident's physician's progress notes addressed the resident's weight loss. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident had severely impaired cognition, as indicated by the Admission Minimum Data Set. Over several months, the resident experienced significant weight loss, with a 10% weight variance noted over a three-month period. Despite the resident's ongoing weight loss, the physician's progress notes from July to September did not reflect this issue. The Director of Nursing confirmed that the physician was aware of the weight loss and had given orders for interventions such as supplements, diet changes, and medication. However, the physician failed to document the weight loss in the progress notes, which was a requirement of the facility's weight change policy. This oversight had the potential to delay or prevent the delivery of necessary care and services for the resident.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as per the physician's orders for a resident who was admitted with a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident, who had severely impaired cognition, frequently experienced pain that interfered with daily activities. The physician had prescribed Percocet 5-325 mg, with one tablet for moderate pain and two tablets for severe pain. However, on a specific occasion, the resident reported a pain level of eight, which is categorized as severe pain, but was only given one tablet instead of the prescribed two tablets. Interviews with the LVN and the DON confirmed that the resident should have received two tablets for the reported pain level of eight. The facility's policy on pain assessment and management, which was last revised in March 2020, mandates that medication regimens should be implemented as ordered. The failure to administer the correct dosage as per the physician's order resulted in the potential for the resident to be undermedicated and left in pain.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's status. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident's Admission MDS indicated severely impaired cognition, partial/moderate assistance needed with eating, and a risk of developing pressure ulcers. However, the Quarterly MDS inaccurately reflected that the resident needed only supervision or touching assistance with eating and was not at risk for pressure ulcers. Interviews and record reviews revealed discrepancies between the resident's actual condition and the Quarterly MDS. The Interdisciplinary Team meeting notes and a Certified Nursing Assistant's (CNA) statements indicated that the resident was non-ambulatory, required extensive assistance with activities of daily living (ADLs), and was dependent on staff for all ADLs, including eating. The Director of Nursing (DON) and the MDS Coordinator confirmed the inaccuracies in the Quarterly MDS, acknowledging that it did not accurately reflect the resident's need for assistance and risk for pressure ulcers. The facility's policies emphasized the importance of accurate and complete documentation to develop appropriate care plans, which was not adhered to in this case.
Failure to Ensure Heel Protectors for Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for a resident. The resident, who was cognitively impaired and dependent on staff for various activities, was admitted with conditions including respiratory failure and type 2 diabetes mellitus. The physician had ordered heel protectors for the resident to manage skin integrity, with the order dated January 26, 2024. On October 15, 2024, during an observation and interview, it was noted that the resident was in bed without the heel protectors, which had been removed earlier that day by a CNA. The Director of Nursing confirmed that the resident should have had the heel protectors in place as per the physician's order to prevent further skin breakdown. The facility's policy on pressure sore management, dated March 2024, indicated that all available measures should be taken to reduce skin breakdown and pressure sores.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to implement its policy and procedure on Medication Ordering and Receiving from Pharmacy, resulting in a delay in the delivery of Alprazolam for a resident with an anxiety disorder. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety disorder. The resident's cognition was intact, and they required supervision with certain activities of daily living. The physician's order specified Alprazolam to be administered as needed for anxiety, but the medication was not reordered in a timely manner, leading to a lapse in availability. On 8/11/2024, the last dose of Alprazolam was administered, and the need for a refill was communicated to the Registered Nurse Supervisor, who faxed the order to the pharmacy. Despite receiving confirmation of the order, the medication was not delivered until 8/12/2024. The Director of Nursing confirmed that the facility's policy required medications to be reordered when there were five doses left, which was not followed in this case. The facility's policy emphasized timely medication ordering to ensure an adequate supply, which was not adhered to, resulting in the deficiency.
Resident-to-Resident Altercation and Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident struck another in the face with a closed fist. This incident involved two residents, where Resident 1, who had moderately intact cognition and required moderate assistance with daily activities, was wheeling his wheelchair in the dining room and accidentally bumped into Resident 2's wheelchair. Resident 2, who had fully intact cognition and required varying levels of assistance with personal care, became upset and punched Resident 1 in the face. The altercation was witnessed by a Certified Nursing Assistant (CNA), who confirmed that Resident 2 yelled and struck Resident 1. Interviews with the Social Services Director and the Director of Nursing corroborated the incident, with Resident 2 admitting to hitting Resident 1 due to feeling provoked. The facility's policy on abuse and mistreatment of residents emphasizes the right of residents to be free from abuse, yet this incident demonstrated a failure to uphold that policy.
Failure to Implement Infection Control Policy for C. Diff Positive Resident
Penalty
Summary
The facility failed to implement its infection control policy and procedures for isolation and transmission-based precautions for a resident who was positive for Clostridium Difficile (C. Diff). Upon re-admission, the resident was cohorted with another resident who did not require isolation and did not have a diagnosis of C. Diff. This action was contrary to the facility's policy, which mandates that residents with transmissible infections be placed in isolation to prevent the spread of infection. The infection preventionist and the director of nursing both acknowledged that the resident should have been placed in an isolation room immediately upon re-admission. The resident in question had a history of encephalopathy, enterocolitis due to C. Diff, and cirrhosis of the liver. The resident required significant assistance from staff for daily activities, including toileting hygiene and bathing. Despite a physician's order and a care plan indicating the need for contact and spore isolation, the resident was placed in a shared room with another resident who had severe cognitive impairment and required maximum assistance from staff for daily activities. Interviews with staff revealed that the infection preventionist had instructed the registered nurse supervisor to place the resident in an isolation room, but this was not done. The registered nurse involved could not recall the specific events but admitted to possibly making an error. The director of nursing confirmed that the facility's policy on isolation was not followed, thereby placing the second resident at risk for acquiring a C. Diff infection. The facility's policy clearly states that transmission-based precautions should be initiated for residents with confirmed infections to prevent transmission to others.
Failure to Conduct Annual TB Risk Assessment
Penalty
Summary
The facility failed to implement its Tuberculosis (TB) Infection Control Program by not conducting an annual TB Risk Assessment (TBRA). During an interview and record review, the Infection Preventionist (IP) admitted to not being aware of the facility's TB Risk Assessment policy. The IP stated that his focus had been on Covid and he had not reviewed all policies related to tuberculosis. Consequently, there was no documented evidence of any TB risk assessments being conducted. The Director of Nursing (DON) confirmed that the IP should have been aware of the TB policies to implement them effectively. The facility's policy, last reviewed on 3/15/2024, emphasized the importance of an annual TB Risk Assessment to evaluate the risk of TB transmission and establish appropriate controls. The lack of awareness and implementation of this policy had the potential to place residents at risk for tuberculosis.
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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