Olympia Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1100 S. Alvarado St, Los Angeles, California 90006
- CMS Provider Number
- 056321
- Inspections on file
- 40
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Olympia Convalescent Hospital during CMS and state inspections, most recent first.
Two residents with significant medical and cognitive impairments experienced changes in condition and tested for COVID-19, with one confirmed positive. The DON verified that these cases, occurring within a short timeframe, were not reported to the State Agency as required by the facility's infection control policy.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A deficiency was cited when a nursing home area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and oversight was insufficient to ensure resident safety.
The facility did not complete required annual performance evaluations, skills competencies, or maintain up-to-date training records for nurses, CNAs, and housekeeping staff. Staff interviews and record reviews revealed missing or expired licenses, training, and documentation, with leadership confirming that employee files were incomplete or not maintained as required.
Surveyors found that food was stored on cracked and rusted shelves in the walk-in refrigerator, with ready-to-cook items placed directly on or under these surfaces. Multiple staff, including the dietary supervisor and administrator, confirmed the racks were rusty and needed replacement, in violation of the facility's food storage policy.
Essential equipment in both patient bathrooms and the kitchen was not maintained in safe operating condition, including broken toilets, running faucets, and damaged or missing kitchen equipment such as the ice maker, food warming trays, and refrigerator racks. Staff confirmed these issues had persisted for days to weeks, with no formal documentation or timely repairs, despite facility policies requiring safe and operable equipment.
Two residents with urinary catheters did not have their catheter bags covered with dignity bags, leaving the bags visible in their rooms. Both residents had significant medical and cognitive impairments and required extensive assistance. Staff interviews and facility policy confirmed that catheter bags should be covered to maintain privacy and dignity, but observations showed this was not done.
A resident with multiple chronic conditions was found with a topical corticosteroid cream at the bedside, which staff had not assessed for self-administration capability nor obtained a physician's order for. The LVN was unaware of the medication, and the DON confirmed that facility policy requires assessment and secure storage for self-administered medications, which was not followed in this case.
A resident with cognitive impairment and multiple chronic conditions experienced a significant change in urinary status, but staff failed to complete and document a required change of condition (COC) assessment as per facility policy. This omission was confirmed through interviews and record review, indicating a lapse in timely monitoring and communication among the care team.
A resident with new diagnoses of dementia, anxiety disorder, and Alzheimer's disease did not receive a required PASRR Level I screening upon readmission, and the mental health agency was not promptly notified. Additionally, care plans addressing these diagnoses were not developed, and staff interviews revealed confusion about responsibility for completing the PASRR process.
A resident with a history of diabetes, TIA, and dysphagia was admitted with a g-tube, but staff did not initiate a care plan for g-tube feeding as required by facility policy. Interviews with nursing staff confirmed that the absence of a care plan left staff without necessary guidelines for monitoring and managing the resident's g-tube care needs.
The facility did not provide the required minimum of 80 square feet per resident in 11 multiple-occupancy rooms, with measurements showing as little as 44.4 square feet per resident. Despite observations indicating sufficient space for movement and care, the documented room sizes did not meet federal standards.
A resident with cognitive impairments sustained multiple rib fractures of unknown origin, and the facility failed to report the injury to the SSA within the required 24-hour period. Despite the resident's severe pain and confirmed fractures, the facility delayed reporting until a second opinion was obtained, contrary to their policy requiring immediate reporting of such incidents.
A resident with a history of aggression physically assaulted another resident, causing injury. Despite documented aggressive behavior and interventions like medication and room changes, the facility failed to prevent the incident, resulting in harm to a resident with severe cognitive impairment and physical dependencies.
A resident with dementia and high elopement risk left the facility unsupervised despite wearing a wander guard bracelet. The alarm was triggered but not properly addressed by staff, leading to the resident's elopement. The resident was later found by police and returned without injury. Staff interviews revealed a lack of immediate response to the alarm, contributing to the incident.
A resident with dementia and high elopement risk left the facility unsupervised despite wearing a wander guard bracelet. The alarm was triggered, but staff did not respond immediately. The resident was found hours later by police. The facility's policy on elopement risk was not effectively implemented, leading to the resident's unsupervised departure.
The facility failed to treat residents with dignity and respect by referring to those needing feeding assistance as 'feeders.' This term was used by multiple staff members, including the CNA, ADSD, and DSD, and a list labeled 'RNA FEEDERS' was posted in the dining area. The DON later acknowledged the issue and removed the list.
The facility failed to maintain proper records and documentation for pharmaceutical services, including the usage and inventory of emergency medication supplies and the automated dispensing cabinet (STATSAFE). Additionally, the administration of a controlled substance to a resident was not documented in the electronic medication administration record (eMAR).
The facility failed to provide effective dietetic service oversight due to the dietary manager not meeting state and federal requirements and the registered dietitian working on a consulting basis. This led to issues with staff competency, food safety, and therapeutic diet accuracy.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to the use of incorrect sanitizer test strips and improper preparation of pureed diets. The Dietary Manager confirmed the lack of recent training and documentation.
The facility failed to follow standardized recipes and portion sizes for lunch, resulting in residents receiving incorrect meals and portions. This discrepancy was observed during lunch preparation and tray line service, and both cooks admitted to not following the menu due to a lack of ingredients. The dietary manager and registered dietitian confirmed the deviations and emphasized the potential impact on residents' nutritional intake.
The facility failed to provide the correct food textures for residents on finely chopped, minced, and pureed diets, serving inconsistent and large pieces of meat and soupy rice instead of the required textures. This was confirmed by the Registered Dietitian, Speech Therapist, and Dietary Manager, posing a risk for residents with chewing and swallowing difficulties.
The facility failed to ensure safe and sanitary food storage and preparation practices, including expired food items in the refrigerator, unsanitary ice machine conditions, improper storage of scoops in bulk food containers, and a banana left on top of a resident's closet. These deficiencies pose risks of foodborne illness and contamination.
The facility failed to document the range of motion treatment for a resident on multiple occasions, despite the resident's need for assistance with self-care, mobility, and cognition. Staff interviews and record reviews revealed missing documentation and inconsistencies with the facility's policies and procedures.
The facility failed to implement its hand hygiene policy, with a CNA and an LVN not sanitizing hands between resident interactions. Additionally, a urinal in a resident's room was not labeled, risking cross-contamination. Both staff members acknowledged their lapses, and the DON and IPN emphasized the importance of these protocols.
The facility failed to monitor signs and symptoms of a UTI and did not irrigate an indwelling catheter as required for a resident with bladder neck obstruction and other diagnoses. Staff did not notify the MD when the resident developed cloudy urine with sediment, leading to a potential UTI and blocked catheter.
A facility failed to date a resident's Isosource bag used for G-tube feeding, despite multiple observations and the resident's significant weight loss and swallowing disorder. The LVN admitted to not dating the bag, contrary to facility policy and manufacturer's guidelines.
A resident with severe cognitive impairment and hemiparesis had their call light out of reach, contrary to facility policy. The CNA responsible admitted to not checking the call light's placement, and the DON emphasized the importance of call light accessibility for resident safety.
The facility failed to provide at least 80 square feet per resident in 24 out of 35 resident rooms, with measurements ranging from 73.0 to 78.9 square feet per resident. Despite claims that the room sizes would not interfere with care or safety, the facility was in violation of federal regulations.
Failure to Report COVID-19 Cases to State Agency
Penalty
Summary
The facility failed to follow its infection control policy and procedure by not reporting positive COVID-19 cases to the State Agency for two of three sampled residents. One resident, with diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder, had severe cognitive impairment and required significant assistance with daily activities. This resident experienced a change in condition with a fever, was tested for COVID-19 (result negative), transferred to the hospital, and later readmitted and tested for COVID-19 upon return. Another resident, with abnormalities of gait and mobility, hypertension, hyperlipidemia, and anemia, and moderate cognitive impairment, also required substantial assistance and was found to be COVID-19 positive after a change in condition. The Director of Nursing confirmed that these cases occurred within seven days of each other and acknowledged that they should have been reported to the State Agency, as required by the facility's infection prevention and control program policy. The policy specifically states the duty to notify appropriate government agencies of reportable contagious or infectious diseases. The failure to report these cases constituted a breach of the facility's established infection control procedures.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision measures were insufficient to prevent potential accidents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of appropriate oversight in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Annual Staff Evaluations, Competencies, and Trainings
Penalty
Summary
The facility failed to ensure that nurses, nurse aides, and housekeeping staff had completed required annual performance evaluations, skills competencies, and trainings. Interviews with staff members revealed that several could not recall the last time they completed annual evaluations, skills competencies, or specific trainings such as sexual harassment, abuse prevention, fire safety, or CPR. Record reviews confirmed that employee files were missing documentation of current licenses, annual evaluations, skills competencies, training records, vaccination records, and background checks for multiple staff members, including both nursing and housekeeping personnel. The Director of Staff Development and the Administrator acknowledged that all employee files should be kept up to date and maintained on site, but files for both facility-employed and contracted staff were incomplete or missing required documentation. The facility's own policy indicated that performance evaluations should be conducted annually or as needed, but this was not consistently followed. The lack of up-to-date employee files and missing documentation for required trainings and competencies affected all reviewed staff, including nurses, CNAs, and housekeeping staff. This deficiency was identified through interviews, record reviews, and policy review, with staff and leadership confirming the importance of maintaining current records to ensure staff competency and compliance with facility requirements.
Unsanitary Food Storage Due to Rusted Refrigerator Shelves
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen, specifically in the walk-in refrigerator where four shelves were found to be cracked and rusted. Ready-to-cook foods were stored on or directly under these rusted shelves. Multiple staff members, including the dietary supervisor and the administrator, acknowledged that the racks in the refrigerator were rusty and needed replacement. The facility's policy and procedures for food storage, reviewed earlier in the year, required food items to be stored, thawed, and prepared in accordance with good sanitary practice, which was not followed in this instance.
Failure to Maintain Safe Operating Condition of Resident and Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition in both patient care areas and the kitchen. Observations revealed that two sampled patient bathrooms had significant issues: one bathroom had a toilet that ran constantly after flushing and a very loose, broken toilet seat, while another had a hot water faucet that would not turn off and a discolored, broken toilet seat. The maintenance aide, who had been employed for one month, confirmed these issues during rounds but did not have documentation or records of repairs or daily rounds. Maintenance repair logs at the nurses' stations did not contain any repair requests for these issues. Both the maintenance aide and a housekeeper acknowledged the danger posed by broken toilet seats, including the risk of resident falls and injury. In the kitchen, multiple pieces of equipment were found to be in disrepair. All four racks in the main refrigerator were rusty, the ice maker was not working, one of four food warming trays was broken and had been nonfunctional for four weeks, and one of three food preparation tables was unsteady and appeared weak. Additionally, one food preparation table was missing, and there was no light in the walk-in freezer. Staff interviews confirmed that the ice maker had been broken for several days without ice being purchased, and the broken food warmer and missing table had not been addressed for weeks. The maintenance aide was aware of these issues but did not keep formal records, relying instead on informal notes and awaiting approval for replacements. Facility policies reviewed indicated that the maintenance department is responsible for keeping all areas, equipment, and grounds in safe and operable condition at all times. The policies also require the development and maintenance of a schedule for maintenance services and the prompt repair or replacement of equipment to ensure safety. Despite these policies, the lack of documentation, delayed repairs, and ongoing equipment failures in both resident and dietary areas contributed to the deficiencies identified during the survey.
Failure to Cover Urinary Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents by not ensuring that their urinary catheter bags were covered with privacy (dignity) bags. For one resident, who was admitted with acute kidney failure, encephalopathy, and hypertension, and was cognitively impaired and required extensive assistance with activities of daily living, observations revealed that the urinary catheter bag was hanging from the bed frame without a dignity cover. Both a CNA and a treatment nurse confirmed during interviews that the catheter bag should have been covered to maintain the resident's privacy and dignity, and the DON acknowledged that the lack of a dignity bag could affect the resident's psychosocial wellbeing. For another resident, who had a pressure ulcer, depression, and severely impaired cognition, the care plan specifically indicated that the indwelling Foley catheter should remain in a privacy bag at all times. However, observation showed the catheter bag was full and visible to anyone entering or passing by the room. The resident's CNA, the Director of Staff Development, and the DON all stated in interviews that the catheter bag should have been covered for privacy and dignity. A review of facility policies and in-service training materials confirmed that staff were instructed on the importance of providing privacy and dignity to residents, including the use of dignity bags for catheter care. Despite these policies and training, the facility did not ensure that the dignity bags were in place for the two residents, resulting in a failure to provide care in a manner that maintained or enhanced their dignity and respect.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident was properly assessed and determined capable of self-administering medication that was left at the bedside, and did not obtain a physician's order for self-administration. The resident, who had diagnoses including atrial fibrillation, hypertension, congestive heart failure, type 2 diabetes, and peripheral vascular disease, was found to have a tube of triamcinolone acetonide cream at the bedside. The resident reported using the cream for itching and stated it was prescribed by a physician, but later indicated that a family member had brought the cream to the facility. Staff interviews revealed that the LVN was unaware of the medication at the bedside and confirmed there was no physician's order for self-administration. The DON stated that medications should only be kept at the bedside if the resident has been assessed as capable and has a physician's order, and that such medications should be stored in a locked container. Facility policy requires assessment by the IDT and a physician's order before allowing self-administration, with medications to be kept securely. These procedures were not followed in this instance.
Failure to Complete Change of Condition Assessment and Documentation
Penalty
Summary
The facility failed to complete a change of condition (COC) assessment in accordance with its policy and procedures for one resident. Specifically, a cognitively impaired resident with diagnoses including diabetes, dementia, and hypertension was observed to have urine with sediments and clumps, which was identified as a significant change from baseline. Despite this observation, there was no documented evidence that a COC assessment was completed at the time the change was noticed, as required by facility policy. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a COC should have been completed immediately upon identification of the change to ensure timely monitoring and intervention. The facility's policy requires prompt reporting and documentation of signs and symptoms that may represent an acute change of condition, as well as timely notification of the resident, physician, and legal representative. The failure to complete the COC assessment and documentation as outlined in the policy had the potential to delay necessary care for the resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required documentation and adherence to established procedures.
Failure to Complete PASRR Screening and Develop Care Plans for Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level I assessment for a resident upon readmission, despite the resident having new diagnoses of dementia, anxiety disorder, and Alzheimer's disease. The facility also did not promptly notify the mental health agency after these diagnoses were made, nor did it develop care plans addressing the resident's dementia, anxiety disorder, or Alzheimer's disease. These actions were identified through interviews and record reviews, which showed that the PASRR Level I screening was not completed as required by facility policy, and that there was confusion among staff regarding responsibility for completing the PASRR process. The resident in question had a history of Alzheimer's disease, unspecified dementia, major depressive disorder, and anxiety disorder, and was noted to have severely impaired cognition and lacked capacity to make decisions. Despite these significant mental health diagnoses and cognitive impairments, the facility's documentation did not reflect the completion of required assessments or the development of care plans tailored to the resident's needs. Interviews with the MDS Coordinator, MDSC Assistant, and DON confirmed that the PASRR Level I was not completed and that care plans for the new diagnoses were not created.
Failure to Initiate G-Tube Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a gastrostomy tube (g-tube) in accordance with its own care planning policy and procedures. Upon admission, the resident, who had a history of diabetes, transient ischemic attack, and dysphagia, was identified as having a g-tube for feeding due to swallowing difficulties. Record reviews showed that the resident was cognitively impaired, required moderate to total assistance with activities of daily living, and was incontinent of bowel and bladder. Despite these complex needs, there was no care plan initiated for the g-tube feeding upon admission. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a care plan for the g-tube should have been created at the time of admission to guide staff in providing appropriate care, such as monitoring for patency, aspiration precautions, infection prevention, and managing bloating. The absence of a care plan meant that staff lacked clear guidelines for the resident's g-tube care, which was not in accordance with the facility's policy requiring a comprehensive, person-centered care plan for each resident based on their assessed needs.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms for 11 out of 39 rooms, each containing three beds. Record review and room measurements confirmed that these rooms ranged from 44.4 to 78.9 square feet per resident, all below the federal requirement. The deficiency was identified through observation, interviews, and review of facility documentation, including a waiver request letter and a client accommodations analysis submitted by the administrator. The waiver letter stated that the room sizes would not interfere with daily nursing care, safety, or residents' dignity and privacy, and that there was sufficient space for care and equipment. During general observations, it was noted that residents had ample space to move freely within the rooms, and there was enough space for beds, side tables, and care equipment. However, the documented square footage per resident in these rooms did not meet the federal minimum standard for multiple occupancy rooms, which is 80 square feet per resident. The report does not mention any specific adverse effects on residents' health or safety at the time of the survey.
Failure to Timely Report Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its Unusual Occurrence Reporting policy by not reporting a resident's injury of unknown cause to the State Survey Agency (SSA) within the required 24-hour timeframe. The resident, who was confused and had a history of Alzheimer's Disease, dementia, glaucoma, and osteoporosis, sustained multiple left rib fractures. The injury was discovered after the resident complained of severe pain, and an x-ray confirmed the fractures. Despite the policy requiring immediate reporting of such injuries, the facility delayed reporting until they received a second opinion on the x-ray results. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Staff Development, revealed that the staff was unaware of how the injury occurred, and the resident was unable to communicate the cause due to cognitive impairments. The Administrator acknowledged the delay in reporting, stating that the injury was considered of unknown origin and should have been reported within 24 hours. The facility's policy mandates that unusual occurrences be reported to the appropriate agency by telephone within 24 hours and confirmed in writing, which was not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, who had a known history of aggressive behavior. Resident 2, who had been previously aggressive towards other residents and staff, physically assaulted Resident 1 by hitting him several times on the left side of the face, resulting in a scratch on the chin and bleeding. Despite Resident 2's documented history of aggression, including attempts to strike others and verbal aggression, the facility did not adequately prevent the incident from occurring. Resident 1, who was admitted with severe cognitive impairment and physical dependencies due to conditions such as hemiplegia and atrial fibrillation, was unable to defend himself against the attack. The facility's records indicated that Resident 1 was dependent on staff for basic activities and had a care plan addressing the risk of emotional distress, but this was only initiated after the incident. The facility's failure to anticipate and mitigate the risk posed by Resident 2's behavior resulted in harm to Resident 1. Resident 2's aggressive behavior was documented in care plans and psychiatric evaluations, which noted episodes of mood disorder and aggression. Despite this, the facility's interventions, such as medication and room changes, were insufficient to prevent the assault on Resident 1. The facility's policy on abuse prevention emphasized the right of residents to be free from abuse, yet the measures in place did not effectively protect Resident 1 from harm.
Failure to Prevent Resident Elopement Due to Inadequate Response to Alarm
Penalty
Summary
The facility failed to prevent the elopement of a resident who was assessed as high risk for elopement and had a wander guard bracelet. On the specified date, the resident left the facility unsupervised and unnoticed by staff, despite the wander guard alarm being triggered. The alarm emitted an audible sound for 43 seconds, but no staff responded to it. The resident was later found by the police and returned to the facility without injury. The resident had been admitted with diagnoses including dementia, delusional disorders, and psychosis, and was assessed as having severely impaired cognitive skills. The care plan for the resident included the application of a wander guard bracelet and monitoring for wandering behavior every shift. However, on the day of the incident, the alarm was not properly addressed by the staff, leading to the resident's elopement. Interviews with staff revealed that the licensed vocational nurse was on a lunch break when the incident occurred, and the medical record director, who was covering the front desk, did not inform anyone about the triggered alarm. The director of nursing confirmed that the alarm should have prompted an immediate response from all staff, but this did not happen, resulting in the resident leaving the facility unsupervised.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was assessed as high risk for wandering and elopement. The resident, diagnosed with dementia, delusional disorders, and psychosis, was wearing a wander guard bracelet designed to emit an audible alarm if the resident attempted to leave the facility. On the day of the incident, the resident managed to exit the facility through the front door, triggering the wander guard alarm. However, the staff did not respond immediately to the alarm, allowing the resident to leave the premises unsupervised. The incident occurred while the licensed vocational nurse (LVN) was on a lunch break, and the medical record director (MRD) was covering the front desk. The MRD, who was on a phone call at the time, did not see the resident leave and mistakenly thought the alarm was triggered by a different door. Despite resetting the alarm, the MRD did not inform other staff members about the alarm or take immediate action to investigate the cause. As a result, the resident was not found until the police were notified and located the resident several hours later. The facility's policy on wandering and elopement, which emphasizes the importance of identifying residents at risk and minimizing injury, was not effectively implemented. The director of nursing (DON) confirmed that staff should have responded promptly to the alarm and communicated with each other to ensure the resident's safety. The lack of immediate response and communication among staff members contributed to the resident's unsupervised departure from the facility.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that seven sampled residents were treated with dignity and respect, as staff referred to them as 'feeders.' This term was used to describe residents who required assistance with eating, including Residents 28, 61, 3, and 7. Resident 28, who had severe cognitive impairment and required significant assistance with daily activities, was observed being referred to as a 'feeder' by a Certified Nurse Assistant (CNA). Similarly, during a dining observation, Residents 61, 3, and 7 were also referred to as 'feeders' by the Assistant Director of Staff Development (ADSD) and the Director of Staff Development (DSD). The DSD even maintained a list labeled 'RNA FEEDERS' in the dining area to identify residents needing feeding assistance. The Director of Nursing (DON) later acknowledged that residents should not be called 'feeders' under any circumstance and stated that staff would be trained to respect residents and avoid using derogatory terms. The DON removed the list of residents labeled as 'feeders' from the dining hall. However, the initial use of the term and the posting of the list demonstrated a failure to treat residents with the dignity and respect they deserve, potentially causing them humiliation and embarrassment.
Failure to Maintain Proper Pharmaceutical Records and Documentation
Penalty
Summary
The facility failed to maintain proper records and documentation for pharmaceutical services, specifically regarding the usage and inventory of emergency medication supplies and the automated dispensing cabinet (STATSAFE). The STATSAFE was used for accessing emergency medication supplies and first doses, but the facility did not keep a logbook of its activity. The Director of Nursing (DON) confirmed that the STATSAFE did not have a printer attached and that the facility did not keep a record of its activities. Additionally, the DON stated that any controlled substances activity at the STATSAFE required a call to the pharmacy to verify the order and obtain a code, but it was observed that access could be gained without this prompt. The DON also admitted to not receiving any STATSAFE reports from the pharmacy and not keeping records of resolved discrepancies. For Resident 70, there was a failure to document the administration of a controlled substance (Ativan) in the electronic medication administration record (eMAR). The lorazepam count sheet indicated a dose was removed, but the eMAR did not reflect this administration. The nurse responsible for administering the medication confirmed that she forgot to document it. The facility's policies and procedures for medication administration and STATSAFE activities were not followed, as evidenced by the lack of documentation and record-keeping. The facility's emergency pharmacy service and emergency kits policy did not align with the observed practices, further contributing to the deficiencies noted in the report.
Deficient Dietetic Service Oversight
Penalty
Summary
The facility failed to provide effective dietetic service oversight when the dietary manager did not meet the state and federal requirements for the position, and the registered dietitian worked on a consulting basis. This resulted in lapses in the delivery of food services associated with staff competency, safe and sanitary food storage and food preparation practices, and therapeutic diet texture accuracy, wrong portion sizes, and not following the menu. During the annual recertification survey, multiple issues were identified, including the oversight of food safety, sanitation, and storage of food in the kitchen, the evaluation of dietary staff competency, and the overall evaluation of food production in relation to therapeutic diets, puree diets, portion control, and following the menu. The dietary manager, who had a certification from an accredited certified dietary manager program, did not receive the required six hours of in-service training on the specific California dietary service requirements. The registered dietitian, who was new to the facility and worked once a week, was not aware of the identified concerns in the kitchen. The dietary manager admitted to not knowing about the need for the six-hour training and acknowledged issues with missing ingredients and incorrect menu items for pureed diets. The facility's job description for the Supervisor of Food Service indicated responsibilities that were not being met, contributing to the deficiencies observed during the survey.
Deficiencies in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties. Dishwasher 1 (DW1) and Dietary Aide 1 (DA1) were observed using the wrong sanitizer test strip for the dish machine sanitizer. Both staff members were using a QUAT sanitizer test strip instead of the required chlorine test strip. The Dietary Manager (DM) confirmed that there had been no recent training or in-services on checking dish machine sanitizer effectiveness and test strips. Additionally, the dish machine sanitizer log lacked documentation of checks, indicating a lapse in proper sanitation practices. Cook 1 did not follow the menu and standardized recipes when preparing a pureed diet. During an observation, Cook 1 was found to be boiling tofu and rice instead of following the prescribed menu, which included Bean Dregs Stew with blanched zucchini and steamed rice. Cook 1 also did not add thickener to the pureed rice, resulting in a soupy and thin liquid consistency. The Registered Dietitian (RD) and Speech Therapist (ST) confirmed that the pureed rice did not meet the required texture standards, which should be smooth and pudding-like. The Dietary Manager (DM) admitted that there were no recent training sessions or in-services on puree diet preparation or following the menu and recipe. The facility's in-service records for 2024 showed no documentation of training on these topics. The DM acknowledged the deficiencies and stated that in-service training would be provided to address these issues. However, the lack of routine staff competency evaluations and proper training led to these deficiencies in food safety and diet preparation.
Failure to Follow Standardized Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes for the lunch menu were followed on 4/29/24. Specifically, 15 residents on a pureed diet did not receive the prescribed pureed pork and kimchi stew and pureed zucchini; instead, they were served pureed tofu and pureed peas. Additionally, 24 residents on a regular diet and 18 residents on a mechanical soft diet received only 3 ounces of pork and kimchi stew instead of the 6 ounces specified in the menu. This discrepancy was observed during lunch preparation and tray line observation, and it was confirmed through interviews with the cooks and the dietary manager (DM). The DM acknowledged that the pureed food did not match the regular menu and that the portion sizes were incorrect, which could lead to decreased nutritional intake and potential weight loss among residents. During an observation in the kitchen, Cook 1 was seen preparing pureed tofu with vegetables and pureed peas instead of the prescribed menu items. Cook 1 admitted to not following the recipe for the Korean food menu because she did not have the necessary ingredients and was not responsible for the Korean food menu. Cook 2, who was responsible for the regular and mechanical soft diet on the Korean food menu, also admitted to not following the recipe due to a lack of ingredients. Both cooks stated that the DM was aware of these deviations from the menu. The registered dietitian (RD) confirmed that the lunch menu and ingredients were changed without her approval and emphasized that cooks should always follow the menu. During the tray line service, it was observed that residents on a pureed diet received 4 ounces of pureed tofu instead of the 5 1/3 ounces specified in the menu, and residents on regular and mechanical soft diets received only 3 ounces of pork and kimchi stew instead of 6 ounces. The DM confirmed that the portion sizes were incorrect and acknowledged that serving less food could lead to reduced nutritional intake and weight loss. Both Cook 1 and Cook 2 admitted to using incorrect portion sizes, and the RD reiterated that serving smaller portions could result in weight loss among residents.
Failure to Provide Correct Food Textures for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that 12 residents on a finely chopped diet and 14 residents on a minced diet received meat in the appropriate texture as per their dietary needs. During meal preparation, the cook served regular diet meat with inconsistent sizes and large chunks instead of the required finely chopped or minced forms. This was observed during a meal preparation and tray line service, where residents on modified diets received pork and kimchi stew with large pieces of pork and kimchi, contrary to the menu specifications. The Registered Dietitian and Speech Therapist confirmed that the served food did not meet the required texture, posing a risk for residents who have difficulty chewing or swallowing. The Dietary Manager acknowledged the error and noted that the kitchen did not serve the correct texture diet for these residents, which could lead to choking hazards. Additionally, 15 residents on a pureed diet received rice that was thin and soupy instead of having a smooth, pudding-like consistency. During the tray line service, it was observed that the cook added liquid to the rice because it did not blend well, resulting in a thin consistency. The Registered Dietitian and Speech Therapist confirmed that the pureed rice was not served at the correct texture, which could pose a risk for residents who require thicker pureed food to prevent aspiration. The Dietary Manager admitted that the pureed rice was not prepared correctly and stated that an in-service would be provided to the cooks on diet textures. The facility's policies on mechanical or dental soft, finely chopped, and pureed diets were reviewed and indicated specific requirements for food textures that were not met. The policies outlined that finely chopped foods should be the consistency of coleslaw, minced foods should be ground, and pureed foods should be smooth and pudding-like. The facility's portion and serving guide also specified the correct textures for different diets, which were not adhered to during the meal preparation and service observed on the specified date.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. During an observation in the kitchen, a small container of previously cooked rice and a small container of cooked meat with an expired use-by date were found in the reach-in refrigerator. Additionally, a container of milk with an open date exceeding the storage period was also stored in the refrigerator. Nutritional supplements labeled to be used within 14 days of thawing were not monitored for their thaw dates, leading to the potential for expired products being used. The Dietary Manager confirmed that these items should have been dated and discarded before their use-by dates but were not, posing a risk of foodborne illness to residents on nutritional supplements in the facility. The U.S. Food and Drug Administration Food Code requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date by which the food shall be consumed, sold, or discarded if held for more than 24 hours, which was not adhered to in this case. The facility's ice machine was also found to be unsanitary. A clean paper towel swipe of the ice storage bin ceiling and sides produced a pink residue, indicating a buildup of contaminants. The Maintenance Supervisor, responsible for cleaning the ice machine, admitted that he did not remove the baffle before cleaning and acknowledged that the residue should not be present as it could contaminate the ice. The U.S. Food and Drug Administration Food Code mandates that surfaces of utensils and equipment contacting food must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms, which was not followed in this instance. Additionally, improper storage practices were observed in the kitchen dry storage area, where scoops were stored inside bulk food containers with the handles in contact with the food. The Dietary Manager acknowledged that this could result in contamination of the food. Furthermore, during a tour of a resident's room, a banana was found on top of the resident's closet, which could lead to gnat or bug infestation and pose a food safety issue. The Director of Nursing confirmed that food should not be left on top of residents' closets as it could cause infection and environmental safety issues. The facility's policy on food brought in by visitors states that perishable food requiring refrigeration should be discarded after two hours at the bedside, which was not adhered to in this case.
Failure to Document Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that the range of motion treatment for one resident was properly documented. A review of the resident's Medical Data Set indicated that the resident required assistance with self-care, indoor mobility, and functional cognition. However, the Administrative Restorative Nursing Assistant Log did not show that the resident received range of motion treatment on several dates in April 2024. During interviews, the Director of Staff Development and Restorative Nursing Assistants could not explain the missing documentation, and it was revealed that the RNAs might have forgotten to document or were too busy to do so at the time. Further review of the facility's policies and procedures indicated that daily and weekly documentation of treatment specifics should be maintained, but the staff could not demonstrate where these items were documented. The Medical Records audit also showed missing signatures, and although the audit report was given to the Director of Staff Development, the issue of missing documentation persisted. The failure to document the range of motion treatment as required by the facility's policies and procedures led to this deficiency.
Failure to Implement Hand Hygiene and Labeling Protocols
Penalty
Summary
The facility failed to implement its hand hygiene policy, resulting in multiple instances of non-compliance by staff. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene between assisting Resident 25 and Resident 81. Similarly, Licensed Vocational Nurse 1 (LVN 1) did not use hand sanitizer or wash hands before entering residents' rooms 142 and 143. Both staff members acknowledged their failure to follow hand hygiene protocols during interviews, citing reasons such as being in a hurry or forgetting the procedure. Resident 25, who has dementia, depression, and hypertension, required substantial assistance with daily activities. Resident 81, also diagnosed with dementia and delusional disorders, needed moderate assistance. During an observation, CNA 1 was seen assisting Resident 25 with cutting bread and then immediately handling a glass of milk for Resident 81 without sanitizing hands in between. LVN 1 admitted to not using hand sanitizer before entering the rooms of residents, explaining that he was in a hurry and forgot the procedure. Additionally, the facility failed to label a urinal in Resident 82's room, who has a fractured femur, hyperlipidemia, and hypertension. The urinal lacked any identifying marks such as initials, room number, or bed number, which could lead to cross-contamination. CNA 3 confirmed that the urinal was not labeled and explained that labeling is a standard practice to prevent mix-ups. The Director of Nursing (DON) and the Infection Preventionist Nurse (IPN) both emphasized the importance of hand hygiene and proper labeling to prevent the spread of infections.
Failure to Monitor and Manage Indwelling Catheter Leading to Potential UTI
Penalty
Summary
The facility failed to monitor signs and symptoms of a urinary tract infection (UTI) and did not irrigate the indwelling catheter as per the treatment administration record (TAR) for one resident. Resident 48, who was admitted with diagnoses including bladder neck obstruction, UTI, and benign prostatic hyperplasia (BPH), had fluctuating capacity to understand and make decisions and was dependent on staff for daily activities. The care plan indicated that the resident should show no signs and symptoms of urinary infection, but the progress notes did not indicate that a medical doctor (MD) was notified when the resident developed cloudy urine with sediment. Additionally, the TAR showed that the foley catheter was not irrigated as needed on specific dates, leading to the resident developing cloudy urine with sediment and a potential UTI and blocked catheter. Observations and interviews with staff revealed that the indwelling catheter was not properly monitored. Licensed Vocational Nurse 3 (LVN 3) and Licensed Vocational Nurse 4 (LVN 4) both acknowledged the presence of cloudy urine with sediment and the need to notify the MD, but this was not done. The Director of Nursing (DON) confirmed that the facility's policy required reporting signs and symptoms of infection to the MD, which was not followed in this case. The facility's policy and procedures for catheter care emphasized the importance of preventing infections and reporting any signs or symptoms of UTI, which were not adhered to, resulting in the deficiency.
Failure to Date Isosource Bag for G-Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident's Isosource bag, used for G-tube feeding, was properly dated. This deficiency was observed multiple times over two days. The resident, who had a documented swallowing disorder and significant weight loss, had an Isosource bag that was not dated to indicate when it was opened. This was first observed in the morning and again later in the day, with the Licensed Vocational Nurse (LVN) confirming that the bag was not dated and acknowledging the importance of dating the bags. The LVN admitted to setting up the bags the previous day but failing to date the Isosource bag. The facility's policy requires that all equipment and products be labeled with the date and time they were first used or opened. The manufacturer's instructions for the Isosource bag also specify that the bag can hang for up to 48 hours once spiked. Despite these guidelines, the Isosource bag in Resident 64's room remained undated, which could lead to the bag being used beyond the recommended time frame, potentially causing harm to the resident.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of the residents, identified as Resident 28. Resident 28 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for moderate to maximal assistance with activities of daily living (ADLs). During an observation, it was noted that Resident 28's call light was hanging on the wall behind the bed, out of the resident's reach. Certified Nursing Assistant 2 (CNA 2) acknowledged that the call light was not checked and placed within reach when CNA 2 started the shift that morning. CNA 2 admitted it was their responsibility to ensure the call light was accessible to the resident. The Director of Nursing (DON) confirmed that the call light system is crucial for residents to call for help and emphasized that it should always be within reach for safety reasons. The facility's policy, dated 10/24/22, mandates that call cords be placed within the resident's reach in their rooms. The failure to adhere to this policy had the potential to prevent Resident 28 from receiving timely assistance, which could lead to adverse outcomes such as falls or unmet needs.
Failure to Provide Adequate Room Size for Residents
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 24 out of the 35 resident rooms. These rooms, which consisted of 3 beds each, did not meet the federal regulation requirement, with measurements ranging from 73.0 to 78.9 square feet per resident. This deficiency was identified through observation, interview, and record review, and it was noted that the inadequate space had the potential to result in insufficient usable living space for residents and working space for health caregivers. A review of the Request for Room Size Waiver letter submitted by the Administrator indicated that the room sizes would not interfere with daily nursing care or the safety of the residents. The letter claimed that there was enough space to provide for each resident's care, dignity, and privacy, and that the spaces would not adversely affect the residents' health and safety. However, the facility's Client Accommodations Analysis confirmed that the rooms did not meet the required square footage per resident. Despite the observations that residents had ample space to move freely and that there was sufficient space for beds, side tables, and resident care equipment, the facility was still in violation of the federal regulation.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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