Ocean Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 2828 Pico Boulevard, Santa Monica, California 90405
- CMS Provider Number
- 555786
- Inspections on file
- 42
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Ocean Park Healthcare during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was discharged without a care-planned discharge process or a complete discharge summary/post-discharge plan of care. The discharge documentation lacked key elements such as the discharge destination, dates, physician follow-up, post-discharge plans, equipment needs, medication reconciliation, and nursing details on functional status, vitals, activity, nutrition, and skin condition. The DON confirmed that the IDT meeting form before discharge was incomplete and that there was no discharge care plan, contrary to facility P&Ps requiring comprehensive discharge planning, documentation, and review with the resident/representative.
A resident with dysphagia, adult failure to thrive, and severe cognitive impairment had a care plan and physician orders requiring close monitoring of nutritional status, including regular weights and documentation of poor PO intake. Records showed inconsistent and often poor meal intake, missing weight documentation for two consecutive months, and no RD follow-up after an initial assessment despite ongoing low intake. CNAs and an LVN reported the resident frequently refused meals, ate as little as 0–25% of meals, and primarily consumed Ensure. The DON confirmed that the resident’s nutritional and hydration needs were not closely evaluated by the RD and that the resident was not consistently eating according to facility documentation, in contrast to facility policies requiring comprehensive, regularly updated nutrition care.
The facility did not ensure that nurses and nurse aides had documented annual competency assessments, as four out of five employee files reviewed lacked proof of required training. Both the DSD and DON confirmed that competency evaluations are necessary to assess staff skills in areas such as ADL, medication administration, and IV infusion, but missing documentation indicated that these assessments were not consistently performed.
The facility did not post actual hours worked by licensed and unlicensed nursing staff responsible for resident care, instead displaying only projected hours with incomplete information for each shift. The Director of Staff and Development confirmed that actual hours were not being posted, contrary to facility policy requiring this information to be updated and accessible within two hours of each shift's start.
Surveyors found expired IV medical supplies, including StatLock catheter stabilization devices and IV start kits, in a medication storage cart. A nurse supervisor confirmed the supplies were expired and acknowledged they should have been removed according to facility policy.
Surveyors identified improper sanitation and food handling practices, including grime buildup on juice/soda gun dispenser tubing, lack of labeling on bulk juice containers, and improper storage of a dry food scoop on top of a storage bin. These deficiencies were confirmed by dietary staff and were not in accordance with the facility's policies for maintaining clean and sanitary food service areas.
A resident with severe cognitive impairment and multiple diagnoses was placed in a geri-chair with a lap tray and had bed siderails raised without proper physician orders, care plan documentation, or informed consent. Staff confirmed that these devices, which restrict movement, require specific assessment and consent per facility policy, but these steps were not completed, resulting in a violation of the resident's rights.
A resident with cognitive impairment and total dependence on staff for ADLs was found in a room with a strong urine odor, with wet bedding and clothing, as observed by surveyors and confirmed by a CNA. The CNA stated the odor was due to the resident not being changed as required, and the DON acknowledged the need for a pleasant, odor-free environment per facility policy.
Two residents with cognitive and mobility impairments were subjected to physical restraints, including bed siderails and a geri-chair with a lap tray, without proper physician orders, informed consent, or care plan documentation. Staff acknowledged that these devices restricted movement and were used inappropriately, contrary to facility policy requiring assessment, documentation, and consent for restraint use.
A resident with cognitive impairment and multiple medical conditions was discharged to an ALF, but the facility failed to send the required advance transfer/discharge notice to the Ombudsman as outlined in policy. The DON sent the notification after the discharge, contrary to the requirement for a 30-day advance notice.
A resident was incorrectly documented as having schizophrenia on the MDS without supporting evidence, despite having other diagnoses such as chronic pulmonary edema, atrial fibrillation, and anxiety disorder. The MDS nurse acknowledged the error, and the DON confirmed that proper documentation was lacking, contrary to facility policy requiring accurate and substantiated assessments.
The facility did not obtain or document required PASARR Level II evaluations for two residents with mental health diagnoses and cognitive impairment, despite positive Level I screenings indicating the need for further assessment. Staff interviews and record reviews confirmed that no follow-up with the PASARR office was documented, and the facility's policy to coordinate PASARR recommendations with care planning was not followed.
A resident with severe cognitive impairment and multiple medical conditions was observed with bed siderails in use, but there was no physician order or care plan addressing this intervention. Both nursing staff and the DON confirmed that facility policy requires a care plan for devices that may restrict movement, but none was developed in this case.
A resident was incorrectly documented as having schizophrenia in the MDS without sufficient supporting evidence or meeting DSM-V criteria. The MDS nurse and DON confirmed that the necessary documentation and symptoms were not present, resulting in an inaccurate assessment entry.
A resident with cognitive impairment and total dependence for ADLs was observed being transported in a geri chair with feet dragging on the floor and head partially unsupported. The CNA acknowledged the improper positioning and stated an intention to reposition the resident. The DON confirmed that proper positioning is required for safety, and facility policy emphasizes accident prevention. This incident reflects a failure to ensure safe positioning during mobility.
A resident with cognitive impairment and total dependence for ADLs was observed being transported in a geri chair with feet dragging on the floor and the head not fully supported. The CNA acknowledged the improper positioning, and the DON confirmed that residents should be fully supported and properly aligned in the chair to prevent injury, in accordance with facility policy.
Two residents' medical records were found to be incomplete or inaccurate: one had an Advance Directive Acknowledgement form with missing information, and another had a physician's progress note dated after discharge. These issues were confirmed by the MDSC and DON, with the physician attributing the error to high patient turnover and late entry practices.
A review of room sizes and a waiver request confirmed that 11 out of 12 rooms did not meet the required 80 square feet per resident in multiple occupancy rooms. Despite this, observations indicated that residents and staff had sufficient space to move and provide care, with necessary furniture and equipment accommodated.
A resident with a history of atrial fibrillation was admitted with a physician order for apixaban/Eliquis, but the medication was not transcribed into the MAR or administered. Nursing staff, pharmacy, and the attending physician all confirmed the omission, which was not detected during medication reconciliation or chart audits, resulting in missed doses of a high-risk medication.
A resident with a history of atrial fibrillation was admitted with physician orders for apixaban/Eliquis, but the medication was not transcribed into the facility's records or administered. Nursing staff did not complete medication reconciliation, and the pharmacy did not receive an order to dispense the drug. The DON confirmed the omission, and facility policy requiring accurate medication reconciliation was not followed, resulting in an incomplete and inaccurate medical record.
A resident with severe cognitive impairment and high fall risk was not provided with the required 1:1 supervision, as a CNA was assigned to supervise two residents at once. The CNA was not within arm's length when the resident attempted to get out of bed, resulting in a fall that caused a hip fracture. The incident was not immediately reported or documented, delaying assessment and intervention.
A resident with severe cognitive impairment was administered psychoactive medications without proper informed consent. The facility's records lacked necessary signatures from the resident or a legal representative, and the resident was without a surrogate decision-maker. The facility's policy required a bioethics committee for complex decisions, but none was in place, leading to uncoordinated care and delayed decision-making.
A facility failed to separate two residents after a reported physical altercation, contrary to its policy. One resident, with dementia and cognitive impairment, was hit by another resident. Despite being informed, the DON did not change their room arrangements, as both residents were cognitively impaired and did not recall the incident.
A resident with severe cognitive impairment and multiple diagnoses did not receive necessary ADL care, including toileting and bathing, from CNAs. Despite the care plan requiring maximal assistance, CNAs failed to perform duties such as repositioning and checking incontinent briefs. Interviews confirmed that CNAs did not adhere to facility policies requiring comprehensive resident care.
A resident with severe cognitive impairments did not receive necessary repositioning and incontinence care as per their care plan. CNAs failed to perform ADL care, including repositioning and checking incontinent briefs, during their shifts. Facility policies required such care to maintain residents' health and prevent complications.
A resident was not allowed to return to their original SNF after hospitalization, despite having the capacity to make medical decisions and expressing a preference to return. The facility failed to obtain a physician's order for a 7-day bed hold and did not document the resident's wishes, resulting in the resident being transferred to another SNF against their preference.
The facility failed to revise the care plan for a resident with impaired vision, resulting in a decline in daily activities and social interactions. The resident's missing eyeglasses were not addressed in the care plan, despite being essential for functioning and reducing fall risk.
The facility failed to ensure that training records for mandated reporter on abuse were completed for 2022. Interviews with staff confirmed they received annual training and knew the reporting procedure, but the administrator admitted that the 2022 training documents were missing. This indicates non-compliance with the facility's policy to maintain training records for four years.
A resident with a history of traumatic subarachnoid hemorrhage, muscle weakness, and other conditions was missing their corrective eyeglasses, leading to a decline in physical and psychosocial well-being. Despite informing the Social Services Director and being provided with unsuitable reading glasses, the resident could not engage in hobbies or socialize, increasing the risk of falls and isolation.
Failure to Complete Required Discharge Planning and Documentation
Penalty
Summary
Surveyors found that the facility failed to provide an effective and safe discharge for one resident by not following its own transfer and discharge policies and procedures. The resident had diagnoses including UTI, dysphagia, and adult failure to thrive, and an MDS assessment showed severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. Despite these needs, there was no care plan initiated regarding the resident’s discharge, including goals and interventions. The resident’s admission record showed a discharge date, and progress notes documented that the resident was discharged to a board and care facility, but the required discharge planning elements were not completed. Review of the discharge summary/post-discharge plan of care revealed that it was undated and missing multiple required components, including the discharge plan, effective date, discharge date, discharge destination, physician follow-up appointments, post-discharge plans and community referrals, equipment needs, medication reconciliation, and nursing details such as functional status, vital signs, activity, nutrition status, and skin assessment. The DON confirmed that the IDT meeting form held prior to discharge lacked information on the discharge location, discharge date, post-discharge plans, equipment needs, physician follow-up visits, and functional status, and acknowledged that the discharge plan was incomplete with no information ensuring continuity of care. These omissions did not comply with the facility’s written policies on facility-initiated transfers/discharges and discharging the resident, which require comprehensive documentation, resident/representative notification and orientation, and a post-discharge plan reviewed at least 24 hours before discharge.
Failure to Monitor and Follow Up on Poor Nutritional Intake for a Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to provide nutritional and hydration care and services consistent with a resident’s comprehensive assessment and care plan. The resident had diagnoses including dysphagia, UTI, and adult failure to thrive, with severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. The care plan for nutritional problems and dehydration risk, initiated on 12/17/2025, included goals to prevent malnutrition and interventions such as RD evaluation with diet change recommendations as needed and weekly or monthly weights as ordered. A physician order dated 12/26/2025 directed staff to monitor episodes of poor oral intake every shift and document meal percentages. Record review showed that the RD documented in July 2025 that the resident weighed 97 lbs, had a usual body weight range of 120–130 lbs, was on a regular diet with mechanical soft, finely chopped texture, and that weights and PO intake would continue to be monitored. The weight record showed weights of 102 lbs on 7/29/2025, 105 lbs on 8/5/2025, 110 lbs on 9/3/2025, and 106 lbs on 12/4/2025, but there were no documented weights for October and November 2025. The January 2026 intake log indicated the resident typically consumed 0–25% of most meals, with 25–100% at other times, reflecting inconsistent and often poor intake. Staff interviews confirmed ongoing poor intake and lack of effective follow-up. CNAs reported the resident frequently refused to eat, would spit food out, throw food away, or eat only about 25% at dinner, sometimes refusing meals entirely even when offered alternate trays. An LVN stated the resident did not eat much, had little appetite, and mostly drank Ensure rather than eating food on the tray. The DON acknowledged that facility documentation showed the resident was not consistently eating, that the last RD progress note was from July 2025, and that there had been no RD follow-up regarding the resident’s nutritional needs and risk of nutritional problems and dehydration, despite the resident’s poor and inconsistent intake and lack of appetite. Facility policies required comprehensive, person-centered care planning, regular review and updating of care plans, and multidisciplinary assessment of nutritional needs, but the documented monitoring and RD follow-up did not occur as outlined.
Failure to Document Annual Nursing Staff Competency Assessments
Penalty
Summary
The facility failed to ensure that nursing staff met the required skills and competency evaluation requirements. During a review of employee files, it was found that four out of five files lacked documented proof of annual competency training. The Director of Staff Development (DSD) confirmed that competency training is required upon hire and annually, but acknowledged that missing documentation meant staff were not properly assessed in their skills related to resident care, including activities of daily living (ADL), medication administration, and intravenous infusion. The DSD stated that the absence of competency training could result in a decline in the quality of care provided to residents. The Director of Nursing (DON) also confirmed that employee competencies are intended to ensure nursing staff are assessed in their skills and remain up to date in performing their job duties. The DON described the process for skill assessment, which involves using a form to check required skills and document whether staff meet the necessary standards. Review of the facility's policy indicated that all nursing staff must meet specific competency requirements and participate in a facility-specific, competency-based training program. However, the lack of documented annual competency assessments for most reviewed staff files demonstrated noncompliance with this policy.
Failure to Post Actual Nursing Staff Hours as Required
Penalty
Summary
The facility failed to post the actual nursing hours worked by licensed and unlicensed nursing staff directly responsible for resident care for three consecutive sampled days. Observations on multiple days revealed that only projected hours were posted at the nursing station, with incomplete information for each shift. There was no calculation or posting of actual hours worked by unlicensed nursing staff, and no staffing information was posted for the previous day on each occasion. These postings did not meet the requirements for displaying actual staffing data, as only projected hours were visible to residents and visitors. During an interview, the Director of Staff and Development confirmed responsibility for the staffing postings and acknowledged that only projected hours were being posted, not the actual hours worked by staff. A review of the facility's policy and procedures indicated that actual hours worked by both licensed and unlicensed staff must be calculated and posted within two hours of each shift's start. The policy also required that the staffing information be accessible in a prominent location and include the resident census and shift schedule, which was not being followed as observed during the survey.
Expired IV Medical Supplies Not Removed from Storage
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and procedures regarding the storage and disposal of medical supplies. During an inspection of the IV medication storage cart, a Registered Nurse Supervisor confirmed the presence of expired medical supplies, including one StatLock catheter stabilization device, nine StatLock PICC Plus catheter stabilization devices, and four IV start kits. These items were found to be past their use-by or expiration dates. The facility's policy, as reviewed by surveyors, requires that all drugs, biologicals, and medical supplies be stored in a safe, secure, and orderly manner, and that discontinued, outdated, or deteriorated items must not be used and should be removed or destroyed. The expired supplies were still present in the storage cart at the time of the survey, indicating a failure to adhere to these procedures.
Improper Sanitation and Food Handling in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple sanitation and food handling deficiencies in the facility's kitchen and food storage areas. The juice/soda gun dispenser tubing was found to have a brown grime buildup on two separate occasions, which was confirmed by both a Dietary Aide and the Dietary Supervisor. The responsible staff indicated that cleaning the tubing was typically assigned to the person who cleans the ice machine, while the Dietary Supervisor stated that the company maintaining the juice/soda gun dispenser should handle the cleaning. Additionally, two bulk juice containers connected to the juice gun system were not labeled with received or use by dates, a fact verified by the Dietary Aide, who noted that it usually takes about a week to use up a bag or box of juice. Further, a large dry food storage scoop was observed sitting on top of a dry food storage container in the dry food storage room, rather than being stored in a manner that prevents contact with the outside of the containers. The Dietary Supervisor confirmed this improper storage method. Review of the facility's policy and procedures indicated that all food service areas, utensils, and equipment are to be kept clean and maintained in good repair, which was not adhered to in these instances.
Failure to Obtain Informed Consent for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint by not completing informed consent for the use of bed siderails and a geri-chair with lap tray, as required by individualized assessment. The resident in question had diagnoses including encephalopathy, COPD, and unspecified dementia, with severely impaired cognitive skills and required moderate assistance for activities of daily living. Despite these conditions, there was no physician order for the use of bed siderails, and the care plan did not address their use. Additionally, the medical record lacked informed consent documentation for both the bed siderails and the geri-chair with lap tray. Observations over several days showed the resident sitting in a geri-chair with a lap tray in the hallway, sometimes unattended, and later lying in bed with bed siderails up. Staff interviews confirmed that there should have been orders and care plans for these devices, and that informed consent was necessary due to the potential for these devices to restrict movement. The physical restraint assessment recommended the use of a geri-chair with tray due to poor safety judgment, but documentation was incomplete and did not reflect proper assessment or consent procedures. Facility policy required that any device restricting a resident's movement, such as bedrails or a geri-chair with a tray, be considered a restraint if the resident could not remove it independently. The policy also mandated a physician's order and informed consent for such devices, specifying the reason, benefit, type, and duration of restraint. In this case, these requirements were not met, resulting in a violation of the resident's right to be treated with respect and dignity regarding the use of physical restraints.
Failure to Maintain Odor-Free, Clean Environment for Dependent Resident
Penalty
Summary
The facility failed to maintain a clean, odor-free, and well-kept environment for one of five sampled residents by not ensuring that the resident's room and adjacent hallway were free from foul odors. During an observation, two surveyors detected a strong urine odor in the resident's room and the nearby hallway. Further inspection with a CNA revealed that the resident's bedding, draw sheet, under pad, and pants were wet with urine, and the CNA acknowledged that the odor was due to the resident not being changed in a timely manner. The CNA also stated that residents should be changed every two hours to prevent such issues. The resident involved had cognitive impairment and was dependent on staff for activities of daily living, including toileting and personal hygiene. The facility's own policy required a clean, sanitary, and pleasant-smelling environment, including clean bed linens. The Director of Nursing confirmed the expectation for a home-like, odor-free environment. The failure to provide timely incontinence care resulted in a foul-smelling environment in the resident's room and adjacent hallway, directly contravening facility policy and resident rights.
Failure to Ensure Residents Are Free from Physical Restraints Without Proper Assessment and Documentation
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints unless required for medical treatment. For one resident with severe cognitive impairment and multiple diagnoses, including encephalopathy, COPD, and dementia, there was no physician's order for the use of bed siderails, and no informed consent was obtained for the use of bed siderails or a geri-chair with a lap tray. The care plan did not address the use of bed siderails, and the physical restraint assessment was not properly documented. Observations showed the resident was repeatedly placed in a geri-chair with a lap tray and left unsupervised, and was also found in bed with siderails up, without the necessary documentation or consent. Another resident with cognitive impairment, abnormal gait, Parkinson's disease, and psychosis was found with a geri-chair parked alongside the bed, restricting movement. Staff interviews confirmed that placing the geri-chair in this manner could restrict the resident's ability to get out of bed and potentially lead to entrapment or injury. Staff acknowledged that this practice constituted a restraint and was unsafe for the resident. Facility policy requires that restraints only be used for the safety and well-being of residents, with a physician's order and informed consent, and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraints as any device that restricts a resident's freedom of movement and cannot be easily removed by the resident. The observed practices did not comply with these requirements, as devices were used in ways that restricted residents' movement without proper assessment, documentation, or consent.
Failure to Provide Timely Discharge Notification to Ombudsman
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer/discharge to the Office of the State Long-Term Care Ombudsman for a resident who was discharged to an assisted living facility. According to the facility's policy, both the resident and the Ombudsman are to receive a 30-day written notice prior to an impending transfer or discharge. However, the record review showed that the discharge notification for the resident was sent to the Ombudsman via fax on the same day as the surveyor's interview, which was after the resident had already been discharged. The resident involved had a history of epilepsy, chronic pancreatitis, and muscle weakness, and required moderate assistance with activities of daily living due to moderately impaired cognitive skills. The DON confirmed during the interview that the notification was sent after the discharge and initially believed there was a 30-day window post-discharge to notify the Ombudsman, but upon reviewing the policy, acknowledged that advance notice was required. This failure to provide timely notification was contrary to the facility's own procedures and could have impacted the resident's rights regarding the discharge process.
Inaccurate MDS Assessment Entry for Resident Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of assessment entries for a resident by incorrectly documenting a diagnosis of schizophrenia on the Minimum Data Set (MDS) without sufficient supporting documentation. The resident, who had a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder, was assessed as having severely impaired cognitive skills for daily decisions. However, the MDS included an active diagnosis of schizophrenia, which was not substantiated by the resident's medical records or behavioral observations. Interviews with the MDS nurse revealed that the schizophrenia diagnosis was entered in error, as there was no documentation meeting DSM-V criteria to support it. The Director of Nursing confirmed that a proper diagnosis requires supporting documentation from a medical professional, which was not present in this case. Facility policy requires the interdisciplinary team to conduct accurate and timely assessments using the MDS and other relevant forms, but this process was not followed for the resident in question.
Failure to Obtain and Document PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASARR) Level II evaluation was obtained and maintained in the charts for two residents who screened positive for mental disorders or intellectual disabilities. For both residents, documentation showed that they had diagnoses such as anxiety, dementia, and depressive disorder, and were dependent on staff for activities of daily living. Their PASARR Level I screenings indicated the need for a Level II evaluation, but there was no evidence in the records that the required follow-up with the PASARR Level II office occurred, nor was there documentation of any contact or response from the PASARR office. Interviews with the MDS nurse and the Director of Nursing confirmed that the facility's process requires follow-up with the PASARR Level II office if no response is received within three days. However, in both cases, the facility did not document any follow-up actions or communications. The facility's policy states that staff should coordinate recommendations from the PASARR Level II determination with resident assessments and care planning, but this was not done for the two residents identified in the report.
Failure to Develop Care Plan for Bed Siderail Use
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing the use of bilateral bed siderails for a resident with multiple diagnoses, including encephalopathy, COPD, and unspecified dementia. The resident was assessed as having severely impaired cognitive skills and required moderate assistance to supervision for activities of daily living. Despite these needs, there was no physician order or care plan in place for the use of bed siderails, as confirmed by a review of the resident's records and care plan documentation. Observations on the specified date revealed the resident lying in bed with the bed siderails up. Both a registered nurse and the director of nursing acknowledged during interviews that a care plan and physician order should have been present for the use of bed siderails, especially since such devices may restrict movement and are considered restraints if the resident cannot remove them independently. Facility policies reviewed also indicated that care plans must be developed for any device that may restrict a resident's movement, but no such plan was found for this resident.
Inaccurate MDS Diagnosis Entry Due to Lack of Supporting Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by inaccurately documenting a resident's diagnosis in the Minimum Data Set (MDS). Specifically, a resident with a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder was incorrectly assessed as having an active diagnosis of schizophrenia on the MDS. This entry was made without sufficient supporting documentation or evidence that the resident met the diagnostic criteria for schizophrenia as outlined in the DSM-V. The MDS nurse acknowledged that the documentation did not support the diagnosis and that the resident did not exhibit symptoms such as hallucinations or delusions. Interviews with facility staff, including the MDS nurse and the Director of Nursing (DON), confirmed that the required criteria and supporting documentation for a schizophrenia diagnosis were not present. The DON stated that a medical professional's documentation is necessary before such a diagnosis can be recorded in the MDS. The facility's policy requires the interdisciplinary team to conduct accurate and appropriate resident assessments using the MDS, but this process was not followed in this instance, resulting in an inaccurate assessment entry for the resident.
Failure to Ensure Safe Positioning During Geri Chair Mobility
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment and dependence on staff for activities of daily living was observed being transported in a geri chair with their feet dragging on the floor and their head partially unsupported. The certified nursing assistant (CNA) acknowledged during the observation that the resident's position was not good, noting that the feet were dragging and the head was not fully resting on the chair, which could potentially cause harm. The CNA stated she intended to reposition the resident to correct these issues. Further interview with the Director of Nursing (DON) confirmed that residents should be properly positioned in a geri chair, with feet off the ground, body in straight alignment, and head resting on the back of the chair for comfort and safety. Review of facility policy indicated a commitment to maintaining a safe environment and providing supervision and assistance to prevent accidents. The observed failure to ensure proper positioning during mobility represented a lapse in following these standards for resident safety.
Failure to Ensure Proper Positioning in Geri Chair During Resident Transport
Penalty
Summary
Facility staff failed to ensure that a resident was safely positioned while being transported in a geri chair. During an observation, a certified nursing assistant (CNA) was seen pushing a resident in a geri chair with the resident's feet dragging on the floor and the resident's head only partially supported by the headrest, leaving it partially in midair. The CNA acknowledged that the resident's position was not good, noting that the feet were dragging and the head was not fully resting on the chair, and stated an intention to reposition the resident to prevent potential harm. The resident involved had cognitive impairment and was dependent on staff for activities of daily living, as documented in the Minimum Data Set. The Director of Nursing confirmed that residents should be properly positioned in the geri chair, with feet off the ground and the head fully supported, to ensure comfort and prevent injury. The facility's policy emphasized the importance of maintaining an environment free from accident hazards and providing adequate supervision and assistance to prevent accidents.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for two residents. For one resident with severe cognitive impairment and multiple diagnoses including diabetes, dementia, and schizophrenia, the Advance Directive Acknowledgement form was found incomplete, as neither option indicating whether an advance healthcare directive had been executed was checked. This omission was confirmed during a review with the Minimum Data Set Coordinator, who acknowledged the missing information on the form. For another resident, also with severe cognitive impairment and several medical conditions such as diabetes, schizophrenia, bipolar disorder, and Parkinson's disease, a physician's progress note was dated after the resident's discharge. The Director of Nursing verified the discrepancy, noting that the physician often enters notes in batches, which may have led to the error. The physician later confirmed that the incorrect dating was likely a mistake due to high patient turnover. Facility policy requires that all entries, including late entries, be accurately dated in the medical record.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 11 out of 12 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined through observation, interview, and record review. The Client Accommodation Analysis and a room waiver request provided by the Maintenance Director and DON confirmed that the majority of rooms were below the required square footage per resident, with calculations showing most rooms ranged from approximately 71.66 to 78.44 square feet per resident. During general observations, it was noted that both residents and staff had enough space to move about freely, and nursing staff were able to provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Transcribe and Administer Prescribed Anticoagulant Medication
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and administer a prescribed anticoagulant medication, apixaban/Eliquis, for a resident who was admitted from a general acute care hospital. The resident had a documented history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily as part of the hospital physician's transfer orders. Upon review, it was found that the medication was not entered into the facility's Medication Administration Record (MAR) and was not administered during the resident's stay. Interviews with nursing staff revealed that the admitting nurse was responsible for reviewing and reconciling the medication list from the transferring hospital, but the apixaban/Eliquis order was omitted during transcription. The pharmacy did not receive an order for the medication and therefore did not dispense it. The attending physician confirmed that the resident was supposed to be on an anticoagulant and had approved the existing transfer medications, but the omission was not identified until after the resident's transfer to another facility. Facility policy required that all new admission charts be audited within 72 hours and that medication reconciliation be performed to ensure all prescribed medications are accurately transcribed and administered. Despite these policies, the omission of apixaban/Eliquis was not detected during the admission process or subsequent chart audits, resulting in the resident missing prescribed doses of a high-risk medication.
Failure to Transcribe and Administer Prescribed Anticoagulant Following Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete and accurate by not transcribing a prescribed medication, apixaban/Eliquis, from the hospital transfer orders into the facility's records. The resident, who had a history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily, was admitted from a general acute care hospital with clear physician orders for this anticoagulant. However, upon review, there was no entry for apixaban/Eliquis in the resident's order summary report or medication administration record (MAR), and no documentation that the medication was administered during the resident's stay. Interviews with nursing staff revealed that the admitting nurse was responsible for reviewing and reconciling the medication list from the transferring facility, but the medication was not transcribed or administered. The LVN assigned to the resident did not recall seeing an order for a blood thinner and did not administer one. The pharmacy supervisor confirmed that the pharmacy did not receive an order for apixaban/Eliquis and therefore did not dispense it. The RN supervisor acknowledged that the medication reconciliation was not completed due to a shift change, and the resident was transferred to another facility within two days, further complicating the process. The attending physician stated that he had approved the existing medications from the hospital transfer orders, including the anticoagulant, but the omission occurred during the transcription and reconciliation process. The DON confirmed that the medication should have been included in the MAR and administered as ordered. Facility policy required accurate medication reconciliation upon admission, but this process was not followed, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Provide Adequate 1:1 Supervision and Timely Reporting Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls due to severe cognitive impairment, generalized muscle weakness, impaired mobility, and dementia, was not adequately supervised as required by their care plan. The resident had a documented need for 1:1 sitter supervision to prevent falls, as recommended by the interdisciplinary team. However, the assigned CNA was responsible for supervising two residents simultaneously during the overnight shift, contrary to the facility's policy and the care plan's requirements for dedicated, focused supervision. On the night in question, the CNA was not within arm's length of the resident at all times and was unable to immediately assist when the resident attempted to get out of bed. The CNA reported being seated by the door or at the foot of the bed, and when the resident began to get up, the CNA rushed to assist but was not close enough to prevent the resident from lowering himself to the floor. The incident was not immediately reported to a licensed nurse, and there was no documentation of the fall in the sitter log. The CNA also admitted to assisting the resident back to bed with the help of another CNA, without notifying nursing staff as required by facility policy. As a result of the lack of close supervision and failure to follow reporting protocols, the resident sustained a comminuted, mildly displaced intertrochanteric fracture of the left hip. The injury was only discovered later when the resident complained of pain during care, prompting assessment and subsequent transfer to an acute care hospital. The facility's policies on fall prevention, sitter responsibilities, and incident reporting were not followed, contributing to the delay in assessment and intervention for the resident's injury.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, received care and support through informed decision-making, which respects the resident's values, needs, and interests. The deficiency involved the administration of psychoactive medications without obtaining proper informed consent. Resident 2 was admitted with diagnoses including psychosis, depression, anxiety, and Parkinson's disease. Despite being able to communicate needs, Resident 2 was assessed as unable to make medical decisions, with severely impaired cognition noted in the Minimum Data Set. The facility's records indicated that informed consent for several psychoactive medications was obtained, but the documentation lacked the necessary signatures from the resident, a responsible party, or the physician. The facility had applied for probate conservatorship for Resident 2, but the application was denied, leaving the resident without a legal representative or surrogate decision-maker. Interviews with facility staff revealed that the Interdisciplinary Team was making medical decisions for Resident 2, but there was no bioethics committee in place to assist with complex decision-making. The facility's policy for unrepresented residents required referral to a bioethics committee for interdisciplinary case review in situations where non-routine medical decisions were needed. However, this procedure was not followed for Resident 2, as the Director of Nursing confirmed the absence of a bioethics committee. This oversight resulted in a lack of coordinated care planning and delayed complex decision-making for Resident 2, violating the resident's right to informed consent and ethical decision-making in their care.
Failure to Separate Residents After Altercation
Penalty
Summary
The facility failed to immediately separate two residents following a reported allegation of physical abuse, which involved a resident-to-resident altercation. The incident occurred when one resident hit another on the hand. Despite the facility's policy and procedures requiring immediate separation of residents involved in altercations to prevent further aggression, the residents remained in the same room. The Director of Nursing (DON) was informed of the incident shortly after it occurred but decided not to conduct a room change because both residents were cognitively impaired and did not recall the incident. Resident 1, who was involved in the altercation, had been admitted to the facility with diagnoses including dementia, generalized muscle weakness, and metabolic encephalopathy. The resident's Minimum Data Set (MDS) indicated cognitive impairment and a need for partial/moderate staff assistance with activities of daily living. The facility's policy on abuse prevention emphasizes protecting residents from further harm during investigations, which was not adhered to in this case, potentially placing Resident 1 at risk for further abuse.
Failure to Provide Necessary ADL Care by CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) provided necessary activities of daily living (ADL) care for a resident, resulting in unmet toileting and bathing needs. The resident, who was admitted with diagnoses including encephalopathy, urinary tract infection, unspecified dementia, and Alzheimer's Disease, required maximal assistance for ADLs due to severely impaired cognitive skills. Despite the resident's care plan indicating the need for assistance with turning and repositioning every two hours, the CNAs did not perform these duties as required. Interviews revealed that CNA 6, who worked as a sitter, did not perform any ADL care, and CNA 5, who was assigned to the resident, only checked on the resident at the end of the shift. The Director of Staff and Development and the Director of Nursing confirmed that CNAs assigned as sitters are expected to perform ADL care, including checking incontinent briefs and repositioning. The facility's policy and procedure documents also outlined the expectation for CNAs to provide comprehensive resident care, including bathing, repositioning, and maintaining personal hygiene, which was not adhered to in this case.
Failure to Provide Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and services to a resident who required maximal assistance with repositioning and was incontinent of bladder. The resident, who had severe cognitive impairments and was unable to make medical decisions, was not repositioned every two hours as per their care plan. Interviews revealed that a Certified Nursing Assistant (CNA) assigned as a sitter did not perform any activities of daily living (ADL) care, including repositioning, during their shift. Another CNA, who was also assigned to the resident, only checked on the resident at the end of the shift, contrary to the facility's policy that sitters should assist with ADL care. Additionally, the resident was not kept clean to prevent urinary tract infections and skin injury, as required by the facility's policy on urinary incontinence. The Director of Staff Development and the Director of Nursing confirmed that CNAs working as sitters are expected to assist with ADL care, including checking incontinent briefs and repositioning. The facility's policies emphasized the importance of providing care to maintain or improve residents' ability to carry out ADLs and to manage urinary incontinence effectively.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return to their original skilled nursing facility (SNF 1) after being transferred to a general acute care hospital (GACH). The resident, who had a history of anxiety disorder and asthma, was initially admitted to SNF 1 and had the capacity to make medical decisions. Despite this, the resident was transferred to another skilled nursing facility (SNF 2) against their preference. The Admissions Director (AD) claimed not to have received any communication from the GACH regarding the resident's desire to return to SNF 1, and the Administrator admitted there was no documentation indicating the resident did not want to return. The facility's policy required a 7-day bed hold for residents transferred to a hospital, but there was no physician's order for such a hold for this resident. The Director of Nursing (DON) acknowledged that the nurse should have obtained this order and that there was no follow-up with the GACH's Case Manager before the resident was transferred to SNF 2. The facility's policy stated that residents should be allowed to return to an available bed in their previous location, but this was not adhered to in this case, leading to the resident being placed in a different facility without their consent.
Failure to Revise Care Plan for Vision
Penalty
Summary
The facility failed to revise the care plan for vision for Resident 32, who was readmitted with diagnoses including a history of falling, major depressive disorder, and generalized anxiety disorder. The Minimum Data Set (MDS) indicated that Resident 32 wore corrective lenses and had moderately impaired cognition. Despite this, the care plan was not updated to address the resident's missing eyeglasses, which were essential for daily functioning and social activities. The Social Services Director (SSD) confirmed that no care plan was made regarding the missing eyeglasses, and the Director of Nursing (DON) acknowledged the oversight, stating that Resident 32 had difficulty functioning without the eyeglasses and did not socialize or enjoy activities like watching TV and reading due to the lack of corrective lenses. The facility's policy and procedure for comprehensive, person-centered care plans require that measurable objectives and timetables be included to meet the resident's needs. However, this was not followed in the case of Resident 32. The DON admitted that the care plan was not followed up on and should have been revised by the SSD. The failure to update the care plan resulted in a decline in Resident 32's activities of daily living and social interactions, as well as an increased fall risk due to impaired vision.
Failure to Maintain Training Records on Mandated Reporter on Abuse
Penalty
Summary
The facility failed to ensure that training records for mandated reporter on abuse were completed for the year 2022. This deficiency was identified during interviews and record reviews. Licensed Vocational Nurse 3 (LVN 3) and Certified Nursing Assistant 3 (CNA 3) both stated they received annual training on mandated reporter on abuse and knew the procedure to report abuse within two hours to the facility's abuse coordinator, who is the administrator (Adm). However, during an interview, the Adm admitted that the facility could not find the training documents for 2022. The Social Services Director (SSD) also confirmed receiving annual training on mandated reporter on abuse and stated that any abuse allegations should be reported within two hours to the Adm, DON, or any supervisors. A review of the facility's policy and procedures, dated 02/2021, indicated that in-service and training records should be maintained for four years. The absence of the 2022 training documentation indicates a failure to comply with this policy, potentially leaving staff members uninformed about resident rights and facility responsibilities regarding mandated reporting of abuse.
Failure to Provide Corrective Eyeglasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. Resident 32, who has a history of traumatic subarachnoid hemorrhage, abnormalities of gait and mobility, muscle weakness, history of falling, major depressive disorder, and generalized anxiety disorder, was missing their corrective eyeglasses since 03/18/2024. The resident's Minimum Data Set indicated that they wore corrective lenses and had moderately impaired cognition. Despite the resident informing the Social Services Director about the missing eyeglasses and being provided with a pair of reading glasses, these were not suitable as the resident required tri-focal eyeglasses. This led to the resident giving up hobbies such as watching TV and reading newspapers and feeling unsafe due to impaired vision, which increased the risk of falls and social isolation. Interviews with various staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, confirmed that Resident 32 was known to wear eyeglasses all the time and enjoyed activities like watching TV and reading newspapers. However, since the eyeglasses went missing, the resident was no longer engaging in these activities and was observed to be staying in their room more often instead of socializing with other residents. The Director of Nursing also acknowledged the difficulty Resident 32 faced without their eyeglasses, noting that the resident did not go to the dining room to socialize and was at an increased risk of falls. The facility's policy on investigating incidents of theft and misappropriation of resident property indicated that residents have the right to be free from theft and that the facility provides measures to safeguard resident valuables. Despite this policy, the facility did not take timely and effective action to replace Resident 32's missing eyeglasses, leading to a decline in the resident's physical and psychosocial well-being. The Social Services progress notes indicated that the resident's medical power of attorney was involved in the process of obtaining a replacement prescription, but the insurance did not cover the cost, delaying the replacement of the eyeglasses.
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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