Overland Terrace Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3515 Overland Avenue, Los Angeles, California 90034
- CMS Provider Number
- 055504
- Inspections on file
- 58
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Overland Terrace Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with multiple behavioral health diagnoses, including PTSD and major depressive disorder, repeatedly exhibited extreme agitation, verbal and physical aggression, and used racial slurs toward a roommate and the roommate’s family. Despite documented incidents and ongoing complaints, the facility’s interventions were limited and did not effectively address the resident’s behavioral health needs, resulting in continued risk and negative psychosocial impact on others.
Two residents with multiple medical and cognitive conditions experienced disrespectful and non-person-centered care during an overnight shift, including delayed responses to call lights, lack of staff introductions, and rude interactions when requesting incontinence care. Staff interviews denied inappropriate conduct, but facility policy and the DON confirmed expectations for respectful and dignified care.
The facility did not maintain required room temperatures, with several rooms found below the federally mandated range, resulting in a resident feeling cold and uncomfortable. Additionally, a shared bathroom was observed to have chipped paint, holes, and dried fecal matter on the walls and bedside commode, with staff confirming inadequate cleaning and risk of contamination.
A resident with dementia and a history of falls experienced multiple unwitnessed falls, including one resulting in a laceration requiring hospital transfer. Despite repeated incidents, fall risk assessments were incomplete, care plan interventions were delayed, and recommended increased supervision was not implemented. Staff interviews revealed gaps in injury reporting and understanding of policy requirements.
A resident's expired medication was found stored in a food bag inside the residents' refrigerator, an area not designated for medication storage. The Dietary Supervisor and LVN confirmed that licensed nurses are responsible for checking all food and bags stored in the refrigerator, and facility policy requires medications to be stored in locked or designated areas accessible only to authorized personnel. Other medication storage areas were found compliant.
A dietary staff member was observed preparing a meal without following the prescribed recipe, specifically by not measuring black pepper as required. The staff member admitted to not using measuring utensils, and the dietary supervisor confirmed that all cooks are expected to follow recipes. The facility's menu and recipe documentation supported that the meal in question was served to all residents.
Surveyors found that the facility did not properly store, label, or date various food items in the kitchen and residents' food storage areas, with several containers missing expiration or use-by dates. Additionally, the residents' refrigerator and freezer temperatures were not maintained or recorded as required, and the Dietary Supervisor was unaware of their responsibility for these tasks, contrary to facility policy.
Staff failed to use required PPE while providing care to a resident on enhanced barrier precautions, and a shared bathroom used by two residents was found with dried fecal matter on the wall and bedside commode. Despite facility policies and available supplies, these lapses in infection control and environmental cleanliness were confirmed by staff interviews and direct observation.
Two residents with cognitive impairment and a history of falls experienced unwitnessed falls resulting in injuries that required transfer to a general acute care hospital. Despite facility policy requiring reporting of such incidents to CDPH within 24 hours, staff did not report the events due to misinterpretation of injury severity and lack of understanding of reporting requirements.
A resident with PTSD and hypertension was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that no care plan addressing PTSD was created at admission, despite the diagnosis being documented. Facility policy mandates timely care planning to address residents' needs, which was not followed in this case.
A resident with an indwelling urinary catheter and multiple urological conditions was observed with the catheter drainage bag positioned above the bladder, contrary to care plan and physician orders. Staff confirmed the improper placement was due to the wheelchair lacking an appropriate attachment, and acknowledged the risk for infection. Facility policy required the drainage bag to be below the bladder, but this was not followed, resulting in a deficiency related to UTI prevention.
A resident with cognitive impairment and multiple medical conditions was found with an unlabeled tube feeding syringe and tubing set, and a water bag labeled with a date several days old. Staff confirmed that tube feeding equipment should be changed and labeled daily, in accordance with facility policy and physician orders, but this was not done.
A resident with dementia, generalized weakness, and diabetes was admitted without natural teeth or dentures and had a physician order for a dental consultation as needed. Despite facility policy requiring prompt referral to outside services, the resident was not referred to a dentist, and staff confirmed the dental consultation was not completed.
A review of facility records and observations revealed that 28 resident rooms did not meet the required minimum square footage per resident, with several multi-occupancy rooms falling below federal standards. Despite this, both residents and staff were observed to have sufficient space to move and provide care safely.
A facility failed to conduct a personal property inventory for a resident upon admission, as required by its policy. The resident, admitted with diabetes, heart failure, and insomnia, reported not receiving an inventory list during her stay. The DON confirmed the oversight, acknowledging that the inventory list was not completed, leaving personal property unaccounted for.
A resident with multiple health issues, including neoplasm of bone and morbid obesity, did not receive adequate care for mobility and incontinence needs. The resident required significant assistance for ADLs, but the care plan did not reflect current limitations, and staff struggled to meet the resident's frequent requests for repositioning and diaper changes. The facility's policies on care planning and incontinence management were not effectively implemented.
A resident with multiple medical conditions, including neoplasm of bone and morbid obesity, did not receive timely assistance for repositioning and diaper changes, leading to discomfort and potential risk of pressure injuries. The care plan failed to address the resident's mobility limitations and preferences, resulting in unmet physical and psychosocial needs. Staff interviews confirmed delays in providing necessary care due to the requirement of multiple staff members for repositioning.
A resident with Parkinson's disease, anoxic brain damage, and a history of falls was inaccurately assessed as low risk for falls upon admission. The facility's fall risk assessment failed to account for the resident's predisposing conditions and medications, leading to a deficiency in providing necessary preventive care. The DON acknowledged the assessment was not correctly coded, which could have resulted in inadequate fall prevention measures.
Failure to Provide Necessary Behavioral Health Services for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health diagnoses received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including diabetes, hypertension, stroke, PTSD, major depressive disorder, and Cluster B personality disorder, exhibited repeated episodes of extreme agitation, verbal and physical aggression, and use of racial slurs and derogatory language towards a roommate and the roommate’s family members. These behaviors were documented on multiple occasions, including incidents of yelling, screaming, hitting, spitting, and making threatening or abusive remarks, particularly when the resident felt his personal space was encroached upon or when interacting with the roommate’s visitors. Despite the ongoing and escalating behavioral issues, the facility’s interventions were limited to offering room changes, which the resident refused, and implementing care plan interventions such as discussing behaviors with the resident, removing the resident from situations, and arranging for psychiatric and psychological consults as indicated. The care plan was updated to reflect the resident’s behavioral problems and included goals to reduce agitation, but the interventions did not effectively address or mitigate the resident’s aggressive and abusive behaviors. Staff interviews revealed that the resident’s behaviors were well-known, and there was reluctance to move the resident due to anticipated issues with other roommates. The roommate’s family expressed concerns for safety and documented their experiences in a letter to the facility, but the underlying behavioral health needs of the resident were not adequately addressed. The facility’s policy on behavior management required appropriate treatment for residents displaying mental disorders or psychosocial adjustment difficulties, including the use of non-pharmacological interventions before psychoactive medications. However, the documentation and interviews indicate that the facility did not ensure the resident received comprehensive behavioral health care and services as required, resulting in ongoing risk and negative psychosocial impact on the roommate, the roommate’s family, other residents, and staff.
Failure to Provide Respectful, Person-Centered Care to Two Residents
Penalty
Summary
Two residents were not treated with respect, dignity, or person-centered care, as evidenced by their experiences during the overnight shift. One resident, with diagnoses including muscle weakness, depression, and anxiety, reported that a CNA assigned to her care expressed reluctance to provide incontinence care and did not respond when asked if there was an issue. The resident also noted that staff on the overnight shift appeared angry, did not introduce themselves, and failed to greet her when called for assistance with activities of daily living, leading her to feel scared and fear abandonment. Another resident, who had spinal stenosis, muscle weakness, COPD, cognitive impairment, and anxiety disorder, stated that he waited two hours for a call light response during the same shift. When a female nurse finally arrived, she did not introduce herself, addressed him rudely, and stated she had other residents to attend to before leaving the room without providing the requested incontinence care. The resident was unable to identify the staff member because staff wore their badges in a way that obscured their names. Facility records confirmed the staff assignments for the shift in question. Interviews with the involved CNAs denied any inappropriate behavior, but the Director of Nursing confirmed that staff are required to be polite, introduce themselves, and treat residents with dignity and respect. Facility policies reviewed also emphasized the importance of treating residents with kindness, respect, and dignity, and providing care in a person-centered manner.
Failure to Maintain Safe Room Temperatures and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary, and homelike environment for its residents in two key areas. First, the facility did not keep resident room temperatures within the federally required range of 71 to 81 degrees Fahrenheit. During observations, five resident rooms, including one occupied by a resident with Parkinson's disease, anemia, and high blood pressure, were found to have temperatures ranging from 62 to 68 degrees Fahrenheit. The resident reported feeling cold and uncomfortable, which made it difficult to sleep. The DON was unaware of the specific temperature requirements, and facility policy emphasized the importance of comfortable temperatures for residents. Second, the facility did not provide a clean and sanitary environment in a shared bathroom between two resident rooms. Observations revealed chipped paint, holes, and dried brown smears identified as fecal matter on the walls and bedside commode. A resident confirmed the presence of fecal matter and stated that housekeeping only cleaned the toilet and floor daily. The Director of Staff Development acknowledged that the fecal matter placed residents at risk of contamination and did not reflect good hygiene. Facility policies required cleanliness and infection control to maintain a safe and comfortable environment.
Failure to Prevent Repeated Falls and Injury Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and dementia from repeated falls, resulting in injury. The resident experienced multiple falls over several months, including incidents on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. Despite these repeated events, fall risk assessments were either incomplete or did not accurately reflect the resident's fall history, and the total risk scores were not documented. The care plans were updated only after several falls had already occurred, and interventions to address the resident's high risk for falls were not clearly documented or implemented in a timely manner. On 2/28/2025, the resident suffered another unwitnessed fall, resulting in a laceration to the left eyebrow that required first aid and transfer to a general acute care hospital for further evaluation and treatment. Documentation indicated that the resident was found in a crouching position in bed, confused and disoriented, with a bleeding cut above the left eye. The injury was managed by nursing staff, and emergency services were called. The resident's family had previously suggested increased supervision, such as moving the resident closer to the nurse's station, but this was not implemented prior to the incident. Interviews with facility staff revealed gaps in communication and understanding of the significance of the injury. The administrator did not report the unwitnessed fall to the state health department, stating he did not consider the laceration and bleeding to be significant, and was unaware of the medical implications due to lack of clinical training. Facility policy required safety risk evaluations and reporting of unwitnessed falls with significant injury, but these procedures were not consistently followed, contributing to the deficiency.
Improper Storage and Labeling of Medication in Resident's Refrigerator
Penalty
Summary
Facility staff failed to ensure that medications were properly labeled and stored in accordance with professional standards for one resident. During an observation of the residents' outside food storage refrigerator, multiple food items were found without expiration dates, along with expired foods and expired medication in a resident's food bag. The Dietary Supervisor stated that it is the responsibility of licensed nurses to check residents' outside food items before storage. Further interviews and observations confirmed that the resident's refrigerator is not a designated area for medication storage, and that only licensed nurses, pharmacy personnel, and those lawfully authorized are permitted access to medications, which should be stored in locked compartments or designated areas. Additional observations of medication carts and storage rooms showed that all other medications and narcotics were properly stored, dated, and accounted for. However, the presence of expired medication in a resident's food bag within the refrigerator indicated a lapse in following facility policy and procedures regarding medication storage. Both the LVN and DON acknowledged that medications should not be stored in the resident's refrigerator and that it is the licensed nurses' responsibility to check all food and bags being stored there.
Failure to Follow Food Recipe During Meal Preparation
Penalty
Summary
During an observation and interview, a dietary staff member was seen preparing lunch and not following the facility's recipe for ground beef, specifically by pouring black pepper without using measuring utensils. The dietary staff member, who has worked at the facility for eight years, admitted to not following the recipe and acknowledged that not measuring seasonings could result in using too much, which could make residents sick. The dietary supervisor confirmed that all dietary cooks are required to follow recipes and stated that staff had been in-serviced on this requirement two weeks prior. A review of the facility's recipe for Southern Style Pattie indicated that only 1/8 teaspoon of black pepper should be used, and the menu for the day confirmed that this dish was served for lunch to all residents.
Failure to Properly Store, Label, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and date food items in both the kitchen and the residents' food storage areas. Multiple food containers, including ground spices, sauces, mayonnaise, and salad dressing, were found without original labels, expiration dates, or use-by dates. Additionally, a review of dietary purchase invoices did not show records for several of these food items, and the Dietary Supervisor confirmed that if residents consume expired foods, it could make them very sick. The Registered Dietician also stated that all food items should be labeled and dated to prevent residents from consuming expired foods. Further observations revealed that the residents' outside food refrigerator and freezer were not maintained at appropriate temperatures, with the freezer above zero degrees and the refrigerator at 43 degrees Fahrenheit. There was no documented evidence that temperatures for these storage units were checked or recorded for the required period. The Dietary Supervisor was unaware of their responsibility to maintain and record these temperatures, despite facility policy stating otherwise. Facility policies also required that perishable food brought in by visitors be labeled, dated, and discarded after specific timeframes, but these procedures were not followed.
Failure to Follow Infection Control Protocols and Maintain Sanitary Environment
Penalty
Summary
Facility staff failed to adhere to infection control measures in two key areas. First, a certified nursing assistant (CNA) was observed providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP) without donning the required personal protective equipment (PPE), despite signage indicating the need for PPE and the availability of supplies nearby. The CNA acknowledged awareness of the requirement but stated that PPE was not present in the room at the time. Interviews with the infection prevention nurse and the director of nursing confirmed that staff are expected to use PPE when caring for residents on EBP, and that PPE is accessible for staff use. Second, the facility failed to maintain a clean and sanitary environment in a shared bathroom used by two residents. Observations revealed a dried, hard brown smear by the light switch and fecal matter on a bedside commode (BSC) inside the bathroom. A resident reported that while housekeeping cleans the toilet and floor daily, the fecal matter on the walls remained. The director of staff development confirmed the presence of fecal matter and acknowledged that housekeeping is responsible for cleaning resident bathrooms. Facility policies reviewed indicated the expectation for maintaining a safe, clean, and sanitary environment, as well as adherence to infection control procedures.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two separate incidents of unwitnessed falls with injury to the Department of Health Services (CDPH), Licensing and Certification, and the local health officer within twenty-four hours as required by facility policy. In the first incident, a resident with a history of falls, osteoporosis, cognitive impairment, and dementia experienced an unwitnessed fall in the hallway, resulting in a skin tear to the right upper eyebrow. The resident was assessed, provided first aid, and transferred to a general acute care hospital (GACH) for further evaluation. Despite the injury and transfer, the event was not reported to the appropriate authorities within the required timeframe. In the second incident, another resident with a history of falls and unspecified dementia was found on the floor with a cut to the left eyebrow after an unwitnessed fall. The resident required moderate to maximum assistance with activities of daily living and did not have the capacity to make medical decisions. The registered nurse supervisor applied pressure and steri-strips to the wound and called 911 for transfer to GACH. Although the incident involved a significant injury and emergency transfer, it was not reported to CDPH within 24 hours, as required by facility policy. Interviews with facility staff, including the DON and Administrator, revealed a lack of understanding and miscommunication regarding what constitutes a significant injury and the reporting requirements. The DON and Administrator both acknowledged that the incidents should have been reported but failed to do so, citing misinterpretation of the severity of the injuries. Facility policy clearly states that unusual occurrences affecting resident welfare, safety, or health must be reported to the appropriate agency within 24 hours by telephone and confirmed in writing, which was not followed in these cases.
Failure to Initiate Baseline Care Plan for Resident with PTSD Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and hypertension. The resident was admitted with a documented history of PTSD, and the diagnosis was entered into the medical record on the day of admission. Despite this, a review of the resident's electronic medical chart revealed that no care plan addressing PTSD was created at the time of admission, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. The LVN acknowledged the absence of a care plan for PTSD and stated that such a plan is necessary to identify triggers and implement interventions to manage the resident's condition. Further interviews with facility staff, including the Director of Nursing (DON), confirmed that the facility's policy requires a care plan to be completed upon admission or the following day, especially for residents with behavioral health diagnoses such as PTSD. The facility's policy on Comprehensive Person-Centered Care Planning specifies that a baseline care plan must be developed and implemented within 48 hours of admission, reflecting the resident's goals and including interventions for identified needs. The lack of a timely care plan for the resident with PTSD constituted a failure to meet these requirements.
Improper Placement of Catheter Drainage Bag Increases UTI Risk
Penalty
Summary
Facility staff failed to ensure proper placement of an indwelling urinary catheter drainage bag for a resident with a history of obstructive and reflux uropathy, chronic kidney disease, and benign prostatic hyperplasia. The resident, who was moderately cognitively impaired and required partial assistance with activities of daily living, had a care plan and physician orders specifying that the catheter drainage bag should be positioned below the level of the bladder to prevent urinary tract infections (UTIs). However, during observation, the drainage bag was found attached to the side of the resident's wheelchair at waist level, with the tubing looped and the bag positioned above the bladder, resulting in urine not draining properly. Staff interviews confirmed that the improper placement was due to the lack of an appropriate attachment on the wheelchair, and both the LVN and DON acknowledged that the drainage bag should be below the bladder to prevent infection. Facility policy also required the catheter and tubing to be free from kinking and the collection bag to be kept below the bladder. The failure to maintain the correct position of the catheter drainage bag constituted a deficiency in providing appropriate care to prevent UTIs.
Failure to Label and Change Tube Feeding Equipment as Required
Penalty
Summary
The facility failed to properly label and change tube feeding equipment for a resident with significant medical needs. Specifically, a tube feeding syringe was observed hanging from the resident's feeding pole without a label indicating the date or time, and the tube feeding set also lacked a label to show when it had last been changed. The water bag attached to the feeding pole was labeled with a date several days prior to the observation, suggesting that the tubing set may not have been changed as required. The resident involved had diagnoses including encephalopathy, generalized weakness, and adult failure to thrive, and was dependent on staff for activities of daily living due to cognitive impairment. During interviews, staff confirmed that the tube feeding set, including the tubing, bottle, and water bag, should be changed daily and labeled with the resident's name, date, and time of change. The facility's policy also required that feeding bags and tubing be labeled and changed every 24 hours. The lack of labeling and failure to change the tube feeding set as required constituted a deviation from both facility policy and physician orders.
Failure to Provide Timely Dental Referral per Physician Order
Penalty
Summary
The facility failed to provide a dental referral for a resident as required by physician orders and facility policy. The resident was admitted with diagnoses including dementia, generalized weakness, and diabetes mellitus, and was noted to have no natural teeth or dentures. A physician order for a dental consultation on an as-needed basis was present from the time of admission, but the referral was not made. The Social Services Director confirmed that the resident had not been seen by a dentist, despite the order and the resident's lack of teeth, which was documented in both the admission record and the social services assessment. The facility's policy requires that referrals to outside services, such as dental care, be coordinated by the Director of Social Services in accordance with physician orders or the care plan. Interviews with facility staff, including the DON and Social Services Director, indicated that the process is to initiate the referral the day the order is received. However, this process was not followed for this resident, resulting in the resident not receiving the required dental consultation.
Resident Room Square Footage Below Regulatory Minimums
Penalty
Summary
The facility failed to ensure that 28 out of 39 resident rooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, rooms designed for two, three, and four residents did not provide at least 80 square feet per resident, with several rooms falling short of the 160, 240, and 320 square foot minimums for 2-, 3-, and 4-person rooms, respectively. This deficiency was identified through observation, interview, and record review, including a Client Accommodation Analysis and a facility letter requesting a room waiver. Despite these findings, observations indicated that both residents and staff had enough space to move about freely and that nursing staff could safely provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Conduct Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its own Policy and Procedure (P&P) by not conducting and completing a personal property inventory for a resident upon admission. This oversight was identified during a review of the resident's admission records and confirmed through interviews. The resident, who was admitted with conditions including diabetes mellitus, heart failure, and insomnia, reported that the facility staff did not offer a personal property inventory list during her stay. The Director of Nursing (DON) acknowledged that the inventory list was not completed as required by the facility's policy, which mandates that a personal property inventory be conducted upon admission. The facility's P&P on personal property, reviewed in January 2024, outlines the procedures for safeguarding residents' belongings. It specifies that the Admissions Staff should inform residents or their representatives about marking belongings and updating the inventory list as items are added or removed. Additionally, a Certified Nursing Assistant (CNA) or designee is responsible for conducting the inventory and placing it in the medical record. The failure to complete this process for the resident left personal property unaccounted for, as confirmed by the DON during an interview.
Deficient Care for Resident's Mobility and Incontinence Needs
Penalty
Summary
The facility failed to provide necessary care and assistance for a resident, resulting in a lack of mobility and inadequate incontinent care. The resident, who was readmitted with multiple diagnoses including neoplasm of bone, morbid obesity, and muscle weakness, required maximal assistance for lower body dressing and moderate assistance for activities of daily living (ADLs). Despite these needs, the resident's care plan did not reflect current mobility limitations, and interventions were not adequately implemented to prevent episodes of incontinence. Interviews with the resident and staff revealed that the resident frequently requested to be repositioned and have their diaper changed, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which hindered their ability to perform tasks independently. Staff acknowledged the challenges in meeting the resident's needs due to the requirement of multiple staff members to assist with repositioning. The facility's policies on person-centered care planning and bowel and bladder training were not effectively followed, contributing to the deficiency in care provided to the resident.
Deficiency in Resident Care and Mobility Support
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as Resident 1, to maintain or improve their range of motion and mobility. Resident 1 was readmitted to the facility with multiple diagnoses, including neoplasm of bone, morbid obesity, muscle weakness, and anxiety disorder. The resident required maximal assistance for lower body dressing and moderate assistance for toileting hygiene. Despite these needs, the care plan did not adequately address the resident's current mobility limitations, and the interventions were not effectively implemented to meet the resident's physical and psychosocial needs. Observations and interviews revealed that Resident 1 frequently requested assistance to be repositioned in bed and for diaper changes, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which made it difficult to access personal items, and reported delays in receiving assistance. Staff interviews confirmed that repositioning the resident required at least four people, which sometimes led to delays in providing the necessary care. Additionally, the resident's care plan did not reflect the resident's preferences and needs, such as having personal items on the right side of the bed. The facility's policies and procedures for person-centered care planning and bowel and bladder training were not effectively followed, resulting in neglect of the resident's needs. The failure to provide timely and adequate care had the potential to increase the resident's discomfort and risk of developing pressure injuries, as well as contribute to psychosocial decline. The facility's neglect in addressing the resident's needs and preferences was identified as a deficiency in providing care according to professional standards of practice.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk upon admission, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including Parkinson's disease, anoxic brain damage, a history of falling, and diabetes mellitus, was incorrectly assessed as being at low risk for falls. The fall risk assessment did not account for the resident's predisposing conditions such as Parkinson's disease and the use of medications like anti-convulsants, hypoglycemics, and antihypertensives, which should have indicated a higher fall risk. The Director of Nursing acknowledged that the fall risk assessment was not correctly coded, failing to reflect the resident's actual risk factors. This oversight meant that the resident was not identified as being at high risk for falls, which could have led to inadequate preventive measures being implemented. The facility's policy required that fall risk factors be documented and interventions be included in the care plan, regardless of the fall risk evaluation score, but this was not done in this case.
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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