Pacific Haven Subacute And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 12072 Trask Ave., Garden Grove, California 92843
- CMS Provider Number
- 055575
- Inspections on file
- 22
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pacific Haven Subacute And Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure RNs were properly trained or assessed for competency in reconstituting and administering IV medications, resulting in a medication error involving amphotericin B that contributed to the death of a resident with severe fungal infection and respiratory failure. The RN involved had not received training on the medication, did not verify the product or dosage, and was not signed off for competency in IV medication preparation.
A resident with a complex medical history received a fatal overdose of amphotericin B after the pharmacy dispensed the wrong formulation and a nurse failed to verify the medication against the physician's order. The nurse administered over three times the maximum recommended dose at an excessive rate and concentration, resulting in the resident's rapid decline and death. The pharmacy also failed to label the medication as high alert, and facility policies for medication verification were not followed.
A resident with mild oropharyngeal dysphagia and a physician-ordered mechanical soft, chopped diet was served long pieces of napa cabbage instead of chopped vegetables as required. Staff, including an LVN, the DSS, and the Speech Therapist, confirmed that the vegetables did not meet the prescribed size and texture, despite clear orders and facility policy.
Surveyors found that expired and unlabeled medications, as well as unclean and unsanitary supplies, were not removed from multiple medication carts. Medications for internal and external use were stored together, and medication carts and treatment supplies were left unlocked and unattended. Expired medical and breathing supplies were found unsecured in a closet, and bedside medications were left on a resident's cabinet without proper documentation or secure storage. Staff interviews confirmed a lack of awareness and inconsistent adherence to facility policies regarding medication and supply storage.
Surveyors identified multiple failures in the infection prevention and control program, including inaccurate infection surveillance documentation, improper classification of infections, inconsistencies between surveillance logs and screening forms, and incomplete infection mapping. Environmental sanitation issues were observed, such as unsanitary storage of clean linens and resident personal items, and lapses in infection control practices for residents with indwelling medical devices, including catheter bags touching or dragging on the floor and missing evidence-based practice orders for a resident with a permacatheter.
A resident was found self-administering Alphagan eye drops without a physician's order, self-administration assessment, or care plan in place. Facility staff confirmed that these requirements were not met, despite facility policy mandating them for safe self-administration of medications.
A resident with no decision-making capacity received repeated PRN lorazepam orders for anxiety, but the facility did not document the physician's clinical rationale for extending these orders beyond 14 days, as required by policy. Medical records and staff interviews confirmed the absence of this documentation despite multiple renewals and administrations of the medication.
The facility did not develop care plans for two residents' use of medical devices, including padded side rails, an IV device, and a sequential compression device, as well as for a third resident's diabetes management and related medications. Staff confirmed these omissions during interviews, and medical record reviews showed the care plans lacked these essential interventions.
A resident with documented interests in watching TV and listening to music was frequently observed awake in bed without access to these activities, as the TV was either off, lacked sound, or the remote was out of reach. Staff did not consistently assist the resident in accessing preferred activities, despite care plan interventions specifying the need for individualized engagement, leading to unmet psychosocial needs.
A resident with multiple diagnoses and no decision-making capacity developed a hand wound that was observed by staff but not documented, reported to the physician, or communicated to the responsible party, despite care plan requirements. Staff acknowledged the wound and applied ointment but failed to follow reporting and documentation protocols.
Two residents with significant mobility impairments did not consistently receive restorative nursing care as ordered, including ROM exercises and application of splints. Documentation was incomplete or missing for several days, and staff could not confirm whether care was provided or simply not recorded. Observations found required splints not in use, and there was no evidence of resident refusal. Staff cited documentation issues and oversight during a system transition as contributing factors.
A resident experienced significant weight loss over a three-month period, and the facility failed to ensure the RD's nutritional recommendations were communicated to the physician or addressed by the IDT. The resident's weight status was not monitored as required, and interviews with the ADON and Food & Nutrition Services Director confirmed that proper tracking and intervention did not occur.
Surveyors found that two residents receiving enteral tube feedings did not have their head of bed (HOB) elevated to the required 30 degrees or above during feedings, as ordered by physicians and facility policy. Additionally, expired enteral feeding formula bottles were found stored in the subacute storage unit. Nursing staff and the DON confirmed these lapses in care and policy adherence.
Two residents did not receive proper respiratory care when staff failed to change and label nebulizer equipment and suction devices as ordered, and did not provide the correct type of emergency tracheostomy set for a resident on mechanical ventilation.
The facility failed to ensure proper documentation and administration of controlled medications, including hydrocodone-acetaminophen and tramadol, and did not adhere to physician orders for medication parameters and patch removal for several residents. Medications were administered without proper narcotic record documentation, a controlled medication was stored without a count sheet, a lidocaine patch was not removed as ordered, and medications were given outside of prescribed blood pressure and blood glucose parameters.
Surveyors observed multiple food safety and sanitation deficiencies, including improper storage of cleaning solutions near food, personal items in food storage areas, and unlabeled or expired food items in the kitchen and refrigerators. The Food & Nutrition Services Director was unable to provide required information on several food items, and these practices did not align with facility policies.
Surveyors identified failures in maintaining accurate quality control records for glucometers, improper use of whiteout to correct documentation, and medication refrigerator temperatures exceeding required limits. Additionally, ice buildup was observed in the kitchen walk-in freezer, with all findings verified by facility staff.
A resident with end stage renal disease and multiple catheters did not have complete documentation in the medical record for required catheter care and Quinton catheter monitoring on two PM shifts. Both an LVN and the ADON confirmed the missing entries, acknowledging that the care may have been provided but was not documented, resulting in an incomplete clinical record.
A resident with severe cognitive impairment did not have a copy of their advance healthcare directive obtained or filed in the medical record, despite facility policy and a POLST form indicating its existence. Staff interviews confirmed the document was not present, though a financial power of attorney was on file.
A staff member was observed adding low sodium broth instead of the required warm milk to pureed potatoes prepared for nine residents on pureed diets, including two on no added salt diets. This action did not follow the facility's established recipe, as confirmed by document review and staff verification.
Surveyors observed that pureed meals, served to nine residents, were prepared with lumps and excess water, failing to meet the required smooth consistency. The puree salad was also served at 60°F, which was not considered appetizing, and the temperature was not documented after cooling. The Food and Nutrition Services Director could not explain the issues with the salad's appearance or temperature.
The facility failed to ensure proper hand hygiene and glove use when handling ready-to-eat food, affecting 59 residents. An observation revealed a cook scratching his face with a gloved hand and then handling food without changing gloves or washing hands. Interviews confirmed staff were aware of proper procedures but did not consistently follow them.
The facility failed to ensure proper disinfection of glucometers according to the manufacturer's instructions, leading to potential spread of bloodborne pathogens. Observations and interviews revealed that staff were not following the correct disinfection procedures, and there was a general misunderstanding of the instructions for the disinfectant wipes used.
A resident with asthma and COPD self-administered three puffs of an inhaler instead of the prescribed one puff due to the failure of an LVN to follow physician's orders and facility policy. The resident was not assessed for self-administration, and no physician's order was obtained to allow it.
A facility failed to ensure that only licensed staff documented medications they administered. An LVN administered medication to a resident but did not document it, leading another LVN to sign the MAR incorrectly. This was confirmed by both LVNs and the DON, who stated that the practice was against facility policy.
Failure to Ensure RN Competency in IV Medication Preparation and Administration
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) were properly trained and competent in the preparation and administration of intravenous (IV) medications, specifically regarding the reconstitution of IV medications and the administration of amphotericin B. The Nursing Skills Competency Checklist for RNs did not include reconstitution of IV medications as a required competency, and RN 3 had not received training or been signed off as competent in this area. Additionally, RN 3 administered amphotericin B for the first time without researching the medication or recognizing the difference between amphotericin B and amphotericin B liposomal (AmBisome), as ordered by the physician. A resident with a history of mucormycosis, respiratory failure, tracheostomy, and ventilator dependence was ordered to receive amphotericin B liposomal (AmBisome) 350 mg in dextrose 5% 250 ml IV. The pharmacy delivered amphotericin B 50 mg vials and dextrose 5% solution to RN 3, who then administered the medication without verifying the specific product or dosage warnings. The packaging of the amphotericin B delivered did not match the physician's order, and RN 3 did not double-check the medication or consult additional resources prior to administration. This resulted in a medication error that contributed to the resident's death. Interviews with facility staff revealed that RNs had not been observed or signed off for competency in reconstituting IV medications, and the Director of Nursing (DON) expected nurses to look up unfamiliar medications but did not ensure this was done. The Clinical Consultant confirmed that RNs should have been trained and signed off for competency before reconstituting IV medications, but this had not occurred. The lack of proper training and competency assessment for IV medication preparation and administration led directly to the medication error and adverse outcome.
Medication Dispensing and Administration Error Leads to Resident Death
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, resulting in a significant medication error. The pharmacy dispensed conventional amphotericin B instead of the prescribed amphotericin B liposomal (AmBisome), which are different formulations with distinct dosing requirements. The physician's order specified amphotericin B liposomal 350 mg in 250 ml D5W to be administered over two hours, but the pharmacy delivered seven vials of amphotericin B 50 mg each, along with a 250 ml bag of D5W. The medication delivered did not match the physician's order, and the packaging included a warning that the maximum daily dose should not exceed 1.5 mg/kg, which was not observed. The nurse (RN) who administered the medication did not recognize the difference between the two formulations and prepared the entire 350 mg dose of amphotericin B in 250 ml D5W, administering it at a rate of 125 ml/hr. This resulted in the resident receiving over three times the maximum recommended dose of amphotericin B, at a concentration and rate higher than recommended by the manufacturer. The nurse did not double-check the medication label against the physician's order, nor did he research the medication prior to administration, despite the packaging containing a clear warning about dosing limits. The nurse also stated this was the first time he had administered amphotericin B and did not notice the discrepancy in medication names. The resident, who had a history of mucormycosis, respiratory failure, a tracheostomy, and was ventilator dependent, experienced a rapid deterioration in condition shortly after the infusion began and was found without a pulse a few hours later. The pharmacy's Chief Compliance Officer confirmed the error in dispensing and noted that the medication was not labeled with a high alert warning as required for high-risk medications. The Director of Nursing acknowledged that the nurse did not follow the facility's policy for verifying the right medication and dose prior to administration.
Failure to Provide Chopped Vegetables as Ordered for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of a resident with a physician-ordered mechanical soft, chopped diet. The resident, who had mild oropharyngeal dysphagia and reduced dentition, was observed during lunch receiving long pieces of napa cabbage, exceeding one inch in size, instead of the required chopped vegetables of approximately half an inch. The meal ticket and physician orders specified chopped meats and vegetables, and the facility's policy for dysphagia mechanical diets also required cooked vegetables to be chopped to about half an inch and soft to a mashable texture. Multiple staff, including an LVN, the Dietary Services Supervisor (DSS), and the Speech Therapist, confirmed that the vegetables served did not meet the prescribed dietary modification. The DSS and Speech Therapist both verified that the vegetables should have been chopped to thumbnail size, and the LVN acknowledged the discrepancy between the meal ticket and the food served. The resident's medical record and therapy notes supported the need for a mechanical soft, chopped diet to facilitate ease of swallowing.
Medication and Supply Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and medical supplies throughout the facility. Observations revealed that expired medications and supplies were not removed from several medication carts, including Medication Carts A, B, D, and E. In some instances, supplies were found to be unclean, with dust and residue present in trays and on equipment. Additionally, medications were found without proper labeling, and internal and external medications were stored together in the same compartments, contrary to facility policy and accepted professional standards. Further inspection showed that medication carts and treatment supplies were left unlocked and unattended, allowing potential unauthorized access. In one case, a medication cart was observed parked in a hallway, unlocked and unattended. Treatment supplies were also left unsupervised at a resident's bedside during care, and staff interviews confirmed that this was a common practice. In another instance, a can of orange juice without an expiration date was found in a medication room snack drawer, and bedside medications were observed on a resident's cabinet without proper documentation or secure storage. The facility also failed to ensure that medical, breathing, and treatment supplies were properly secured and stored. Large quantities of expired supplies, including skin protectant ointments, normal saline, and tracheostomy supplies, were found in an unlocked closet adjacent to a resident's room, exposed to dust and debris. Staff interviews indicated a lack of awareness regarding the proper storage and monitoring of these items, and some staff cited past supply shortages as a reason for improper storage. The facility's policies required that all medications and supplies be stored securely, labeled appropriately, and kept clean and sanitary, but these standards were not consistently met.
Infection Control Program Deficiencies and Environmental Sanitation Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, documentation, and environmental sanitation. The Infection Preventionist (IP) did not accurately document the onset of infection symptoms, instead recording the antibiotic start date as the onset date for all residents on the surveillance logs. Additionally, infections were not properly classified as healthcare-associated (HAI) or community-acquired (CAI), with some being marked as recurrent, maintenance, or prophylactic without supporting documentation. The surveillance logs and infection screening evaluation forms contained inconsistent information, and the monthly mapping of infections did not include all cases or specify the microorganisms involved. Environmental observations revealed unsanitary storage of clean linens and resident personal items. In the laundry area, clean linens were stored near non-linen items such as keys, water bottles, and cleaning supplies, and clean curtains were not fully covered. Resident closets in multiple rooms contained exposed and disorganized diapers, gowns, and linens, some of which were stored on the floor or in contact with potentially contaminated surfaces. These conditions were verified by staff during interviews and acknowledged as having the potential for contamination. Direct care observations identified lapses in infection control practices related to indwelling medical devices. For example, one resident's indwelling urinary catheter bag and tubing were observed touching the floor, and another resident's urinary catheter privacy bag was seen dragging across the floor while the resident was in a wheelchair. Additionally, a resident with a permacatheter for hemodialysis did not have an order for evidence-based practices (EBP) for infection prevention, despite facility policy requiring such measures for residents with indwelling medical devices. These failures were confirmed by staff and through medical record review.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering Alphagan eye drops without the necessary clinical safeguards in place. The resident had two bottles of the medication in the bedside drawer and reported self-administering the drops since admission. Review of the resident's medical record revealed there was no physician's order for the medication, no assessment to determine the resident's ability to self-administer, and no care plan addressing self-administration. The facility's policy requires that residents be informed of their right to self-administer medications and that appropriate assessments and care plans be completed. Interviews with facility staff, including an LVN, the ADON, and the DON, confirmed that medications must have a physician's order, a self-administration assessment, and a care plan before a resident can self-administer. Staff verified that none of these requirements were met for the resident in question. The absence of these safeguards meant the resident was self-administering medication without documented clinical oversight or planning.
Lack of Physician Rationale for Extended PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not documenting the physician's clinical rationale when extending PRN lorazepam orders beyond 14 days. According to the facility's policy, PRN orders for psychotropic drugs should be limited to 14 days unless the prescribing practitioner documents the rationale and indicates the duration for the extended order. Medical record review showed that the resident had multiple PRN lorazepam orders renewed and administered over several periods, but there was no documentation of the clinical rationale for these extensions in the medical record. The resident in question was noted to lack capacity to understand and make decisions, and had a history of anxiety manifested by hyperventilation, for which lorazepam was prescribed and administered via gastrostomy tube. Despite repeated renewals of the PRN lorazepam orders, the required physician documentation justifying the continued use was not present in the medical record, as confirmed by a registered nurse during interview and record review.
Failure to Develop Comprehensive Care Plans for Resident-Specific Needs
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of three residents. For one resident, there was no care plan created to address the use of bilateral padded side rails and an intravenous (IV) device, despite physician orders for both interventions and repeated observations of their use. Staff interviews confirmed the absence of care plans for these devices, and there was no documentation of the resident or representative's request for the padded side rails in the medical record. Another resident had a physician's order for the application of a sequential compression device to both lower extremities for deep vein thrombosis (DVT) prophylaxis. However, the care plan did not include this intervention. Staff interviews verified that the care plan was missing this essential component, and it was acknowledged that the resident required assessment and a care plan for the device. A review of a closed medical record for a third resident revealed diagnoses of Type 2 diabetes mellitus (DM), diabetic chronic kidney disease, and diabetic ophthalmic complications. The resident had active orders and administration of insulin and oral antidiabetic medications, but there was no care plan developed to address the management of DM or the use of these medications. Staff confirmed the absence of a comprehensive care plan for the resident's diabetes management.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident who was identified as enjoying activities such as watching TV, keeping up with the news, and listening to music. Multiple observations revealed that the resident was often awake in bed without the TV on or with the TV on but without sound, and the remote control was frequently out of the resident's reach. The resident was unable to operate the TV independently and required assistance to turn it on or adjust the sound, which was not consistently provided by staff. The resident's care plan included interventions to provide independent activities of choice and daily one-on-one visits, especially in the context of isolation due to a respiratory infection. Despite this, staff did not ensure that the resident had access to preferred activities, such as watching TV with sound or listening to music, as documented in the activity assessment. Interviews with staff confirmed that while activities staff visited the resident several times a week, there were lapses in ensuring the resident could engage in their chosen activities, resulting in unmet psychosocial needs.
Failure to Report and Document Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses including sepsis, Parkinson's Disease, schizophrenia, and dementia, who lacked capacity to make decisions, developed a red circular wound between the first and second fingers of the left hand. During observation and interview, a CNA reported the wound was likely due to the resident banging his hands and stated she had reported the wound to an LVN, who advised leaving it open to air. The resident's care plan required that skin conditions be reported to the physician and responsible party. Despite this, there was no documentation in the medical record regarding the wound, no physician's orders for treatment, and no evidence that the resident's responsible party or physician had been notified. The wound was observed on two consecutive days, and staff confirmed that no formal reporting or documentation had occurred, constituting a failure to provide appropriate treatment and care according to orders and the resident's care plan.
Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide necessary restorative nursing care and services to maintain or improve range of motion (ROM) for two residents with significant mobility impairments. For one resident with functional quadriplegia, physician orders and care plans required active and passive ROM exercises to the upper and lower extremities five times per week. However, documentation revealed multiple days where these exercises were not recorded as completed, and both restorative nursing assistants (RNAs) could not confirm whether the care was provided or simply not documented. The transition from electronic to paper records contributed to missed or incomplete documentation, and weekly summaries were also missing for certain periods. The resident reported receiving exercises less frequently than ordered and was not informed when sessions were missed. Another resident with severe cognitive impairment and contractures was ordered to receive passive ROM exercises and have splints applied to the left hand, elbow, and knee for specified durations. Observations on several occasions found the resident in bed without the required splints, and staff confirmed the splints were not in use at those times. Documentation for the application of splints and provision of ROM exercises was incomplete, with missing staff initials on several days and no record of the actual hours the splints were worn, as required to assess tolerance. Staff acknowledged that only the minutes spent applying splints were documented, not the duration of wear. Interviews with staff and review of records confirmed that restorative nursing interventions were not consistently provided or documented as ordered for both residents. There was no evidence of resident refusal for the missed interventions, and staff attributed the lapses to documentation issues and oversight during a system transition. The lack of consistent care and documentation posed a risk for further decline in ROM and functional mobility for the affected residents.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss in one resident, as evidenced by a lack of timely follow-up on the recommendations made by the Registered Dietitian (RD). The resident experienced a weight loss of 11 lbs, or 11.1%, over three months, which met the facility's criteria for significant weight change. Despite the RD recommending nutritional interventions, including the provision of a high-calorie nutritional formula and additional supplements, there was no documentation that these recommendations were communicated to the physician or addressed by the Interdisciplinary Team (IDT) Nutrition. The resident's weight status was not monitored as required, and the facility's policy for early identification and assessment of weight changes was not followed. Interviews with the Assistant Director of Nursing (ADON) and the Food & Nutrition Services Director confirmed that the resident's weight loss was not properly tracked or managed. The ADON was unable to provide evidence that the RD's recommendations were implemented or that the resident's ongoing weight loss was monitored. The Food & Nutrition Services Director also stated that the resident's weight should have been monitored weekly, indicating a lapse in adherence to facility protocols for nutritional monitoring and intervention.
Failure to Ensure Proper Enteral Feeding Administration and Storage
Penalty
Summary
The facility failed to ensure proper management and administration of enteral feeding services for two residents. Surveyors observed expired enteral feeding formula bottles stored in the subacute storage unit, which was confirmed by Central Supply staff. Additionally, the facility's policy required the head of the bed (HOB) to be elevated at least 30 degrees during enteral feeding to prevent complications, but this was not consistently followed. For both residents reviewed, medical records indicated they lacked capacity to make medical decisions and had physician orders specifying HOB elevation between 30 to 45 degrees during feedings. Direct observations showed that both residents were receiving enteral tube feedings with the HOB elevated less than 30 degrees. Nursing staff and the DON acknowledged that the HOB was not properly elevated during feedings, and the facility did not have a device to measure the exact angle of elevation. These failures were confirmed through interviews and concurrent observations with nursing staff, who verified that the required procedures were not followed during the administration of enteral feedings.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring respiratory support. For one resident, the nebulizer mask, tubing, and bag were not changed weekly as ordered by the physician, with equipment at the bedside dated beyond the required change interval. Both a registered nurse and a respiratory care practitioner confirmed that the equipment should have been changed and properly labeled, but it was not, as evidenced by the dates observed on the items. For another resident with a tracheostomy and on mechanical ventilation, the facility did not ensure the correct emergency tracheostomy set was available at the bedside. Instead of a cuffed tracheostomy set as ordered, an uncuffed set was provided. Additionally, the suction device (Yankauer catheter) was not changed weekly as per physician's orders, with an outdated device found at the bedside. Staff interviews confirmed these lapses in following physician orders and facility policy.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for several residents, resulting in multiple deficiencies related to the administration and documentation of controlled medications and adherence to physician orders. For one resident, a controlled medication (hydrocodone-acetaminophen) was administered without immediate documentation in the narcotic record, and the delivery receipt was not signed or dated when received. The nurse confirmed the medication was given before it was properly logged, and the ADON acknowledged that the delivery receipt should have been completed at the time of receipt. Another resident's controlled medication (tramadol) brought from home was found in a medication room without an accompanying narcotic count sheet. The ADON stated that the medication was received by staff during admission, but a new narcotic sheet was not started as required by facility policy. The existing count sheet was from a previous admission and did not reflect the current receipt and handling of the medication. Additionally, a resident with a physician's order for a lidocaine patch to be removed at a specific time was found to have the patch still in place past the ordered removal time. The nurse verified the patch was not removed as scheduled, despite documentation indicating otherwise. Another resident with orders for midodrine and insulin had medications administered outside of prescribed parameters: midodrine was given when blood pressure was above the ordered threshold, and insulin was not administered when blood glucose levels indicated it was needed. These failures were confirmed by staff review of the medical records and interviews.
Food Safety and Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to meet food safety and sanitation requirements as evidenced by multiple observations during a kitchen tour and review of facility policies. A red bucket containing sanitizing solution was stored next to food items such as sugar and food thickener, and a staff portable radio was found on the beverage preparation area. Inside the refrigerator, two bell peppers were noted to be soft, wrinkled, and blackened, and a bag of croissants was stored with an open date but without clear indication of when it should be discarded. Additionally, an unlabeled package of mushrooms was present, with no purchase date available, and the Food & Nutrition Services Director was unable to confirm when it was bought. Further, a staff's personal water bottle was found stored on the floor beneath ready-to-eat fruit in the walk-in refrigerator. In the walk-in freezer, a frozen pizza and a bag of tamales were both stored in plastic bags without labels or expiration dates, and the Food & Nutrition Services Director could not provide information on their purchase or expiration. These findings were verified with the Food & Nutrition Services Director and were not in accordance with the facility's policies, which require food storage areas to be used only for food and mandate weekly checks for expiration and use-by dates.
Deficiencies in Equipment Maintenance, Documentation, and Temperature Control
Penalty
Summary
The facility failed to ensure that essential resident care equipment and medication storage areas were maintained in safe operating condition. During an inspection of Medication Cart C, a glucometer was found with quality control records that did not accurately reflect the reference ranges listed on the test strip bottle. The quality control log documented incorrect reference ranges for both normal and high controls, which did not match those on the bottle. The LVN interviewed confirmed that the night shift nurse was responsible for quality control, and acknowledged the discrepancy in documentation. Further review of quality control records for two other glucometers revealed improper correction of documentation errors. Whiteout was used to alter entries on the Quality Control Records for Glucometers A and B, which completely erased the original information and made it impossible to refer back to previous entries. Both the ADON and DON confirmed that the facility's process should involve crossing out errors and initialing corrections, not using whiteout, and acknowledged that the observed practice was incorrect. Additionally, the medication refrigerator in Medication Room A was not maintained within the required temperature range. Multiple temperature checks showed readings above the acceptable limit, with the refrigerator containing various medications including insulin and Epogen. The presence of condensation and wet medication trays was also noted. In the kitchen, the walk-in freezer was observed with ice buildup along the door frame and on storage bins, which was verified by the Food and Nutrition Services Director.
Incomplete Documentation of Catheter Care and Monitoring
Penalty
Summary
The facility failed to maintain a complete medical record for one resident reviewed for closed records. Specifically, there was inconsistent documentation regarding the monitoring and care of an indwelling urinary catheter and the checking of a Quinton catheter, which is used for hemodialysis access. The resident in question had diagnoses including end stage renal disease, dependence on renal dialysis, obstructive and reflux uropathy, and required both a Foley catheter and a Quinton catheter. Facility documentation required catheter care and monitoring every shift, with specific instructions to check for signs of infection, bleeding, and other complications, and to document these checks. Upon review of the resident's Treatment Administration Record (TAR) for April, it was found that there was no nursing documentation for the required catheter care and Quinton catheter checks on two PM shifts. Interviews with an LVN and the ADON confirmed the missing documentation, with both acknowledging that the care may have been provided but was not recorded. This lack of documentation resulted in the medical record being incomplete, as required by federal regulations and facility policy.
Failure to Obtain and File Advance Healthcare Directive
Penalty
Summary
The facility failed to obtain and include a copy of an advance healthcare directive in the medical record for one resident who was reviewed for advance directives. According to the facility's policy, staff are required to obtain a copy of the advance directive and ensure it is placed in the resident's health record. During the review, it was found that although the resident's POLST form indicated that an advance directive was available and had been reviewed, there was no documented evidence in the medical record that the actual advance healthcare directive had been obtained or filed. The resident in question had a severe cognitive impairment and had a California General Durable Power of Attorney for financial matters documented in the record, but not the advance healthcare directive. Interviews with the RN, Social Services Director, and Social Services Resource staff confirmed that the social services department was responsible for following up on advance directives. They verified that while the POLST referenced the existence of an advance directive, the document itself was not present in the resident's medical record.
Failure to Follow Pureed Diet Recipe During Food Preparation
Penalty
Summary
The facility failed to follow the prescribed menu and recipe for pureed potatoes during food preparation for nine residents on pureed diets, including two residents on no added salt pureed diets. During an observation, a staff member was seen adding low sodium broth to the pureed potatoes instead of the warm milk specified in the facility's recipe. This deviation from the established recipe was confirmed by the staff member involved. The review of facility documents and direct observation confirmed that the menu and recipe were not followed as required for residents receiving pureed meals.
Pureed Food Served with Poor Consistency and Inadequate Temperature Control
Penalty
Summary
The facility failed to ensure that food prepared in the kitchen, specifically pureed meals, was attractive in appearance and served at an appetizing temperature. During an observation of puree salad preparation, the salad was found to have lumps and water surrounding it, which did not meet the expected smooth, applesauce-like consistency as described by the staff. The staff member preparing the salad stated that the consistency would improve as it cooled, but the salad remained lumpy and watery at the time of observation. Further observation during trayline service revealed that the puree salad was served at 60 degrees Fahrenheit, which was not considered an appetizing temperature. The Food and Nutrition Services Director was unable to explain the presence of lumps and water in the salad and confirmed that the temperature of the salad after cooling was not documented on the food temperature log. Nine residents on puree diets were affected by the pureed meals prepared in the facility's kitchen.
Improper Hand Hygiene and Glove Use in Food Handling
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene and glove use when handling ready-to-eat food, affecting 59 residents who received meals from the kitchen. During an observation, Cook #1 was noted to scratch the side of his face with a gloved hand and then continued to pick up meat and cilantro without changing his gloves or washing his hands. Interviews with Cook #1, Cook #2, the Dietary Manager (DM), the Registered Dietitian (RD), the Administrator, and the Director of Nursing revealed that staff were aware of the proper procedures for glove use and hand hygiene but did not consistently follow them. The facility's policy on glove use, dated 2020, emphasized the importance of changing gloves when switching tasks to prevent foodborne illness. Despite this, Cook #1 did not adhere to the policy, and the DM confirmed that staff had been in-serviced on the correct procedures. The RD and the Administrator both stated that staff should not touch anything other than the food they are handling while wearing gloves. The Director of Nursing reiterated that staff were taught to wash their hands before putting on gloves and to change gloves if they touched anything else. This lapse in protocol was observed and confirmed through multiple interviews, highlighting a significant deficiency in the facility's food handling practices.
Improper Disinfection of Glucometers
Penalty
Summary
The facility failed to ensure staff properly cleaned glucometers according to the manufacturer's labeled specifications for use as a disinfectant to help prevent the spread of bloodborne pathogens. Observations revealed that two out of thirteen glucometers were not disinfected correctly during medication pass. Licensed Vocational Nurse (LVN) #4 was observed using Sani-Cloth AF3 wipes and bleach wipes interchangeably without following the correct disinfection procedure. LVN #5 was seen placing a used glucometer back into the cart without disinfecting it and later using Sani-Cloth AF3 wipes incorrectly, not adhering to the required wet-dwell time specified by the manufacturer. Interviews with other nursing staff, including LVNs #6, #7, and #8, revealed a general misunderstanding of the disinfection process and the meaning of the red 3 on the disinfectant wipe containers. The staff believed that the red 3 indicated a three-minute air-dry time, whereas the manufacturer's instructions required a three-minute wet-dwell time. The Infection Preventionist (IP) and the Director of Nursing (DON) also demonstrated a lack of awareness regarding the specific disinfection instructions for the Sani-Cloth AF3 wipes and bleach wipes. The DON acknowledged the confusion among the staff and admitted to being unaware of the specific directions on the disinfectant wipes. The Administrator also recognized the error and emphasized the need for staff to clean the glucometers before use, between residents, and before storing them in the cart, following the manufacturer's instructions. The facility's infection control policy required the disinfection of shared blood glucose meters after every use per the manufacturer's instructions, which was not being followed correctly by the staff.
Failure to Follow Medication Administration Policies
Penalty
Summary
The facility failed to ensure a resident who had not been assessed as safe to self-administer medications did not self-administer an inhaler, failed to follow physician's orders for administration of an inhaler, and failed to follow facility policy for medication administration. Resident #299, who was admitted with diagnoses including asthma, COPD, and chronic bronchitis, was observed self-administering three puffs of an inhaler instead of the prescribed one puff. The resident was not assessed for the ability to self-administer medications, and no physician's order was obtained to allow self-administration, nor was the order clarified to include 'May Keep at Bedside' as per facility policy. During an observation, LVN #5 handed the inhaler to Resident #299, who then self-administered three puffs consecutively. LVN #5 did not intervene or provide instructions to the resident to swish and spit out water after using the inhaler, as required by the physician's order. Instead, the resident swished water in their mouth and swallowed it. LVN #5 admitted to assuming the resident could self-administer the inhaler due to their cognitive status and did not consider it self-administration. The Director of Nursing (DON) confirmed that Resident #299 had taken three puffs of the inhaler and had a habit of swishing and swallowing water after using the inhaler at home. The DON also stated that the resident did not wish to self-administer medications and preferred nursing staff to administer them. The facility's policy and the physician's orders were not followed, leading to the resident receiving an incorrect dosage of medication.
Improper Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure that only licensed staff documented medications they administered during medication administration. During an observation, it was noted that a Licensed Vocational Nurse (LVN) administered medication to a resident but did not document the administration on the Medication Administration Record (MAR). Instead, another LVN signed the MAR, indicating that she had administered the medication, which was not the case. This discrepancy was confirmed during interviews with both LVNs and the Director of Nursing (DON), who stated that the expectation was for nurses to sign out medications at the time they were administered and only for medications they personally administered. The incident involved Resident #299, who was administered cholecalciferol 125 micrograms by LVN #5. However, the MAR showed LVN #9's initials, indicating she had administered the medication. LVN #5 admitted to forgetting to document the administration, and LVN #9 acknowledged signing the MAR despite not administering the medication. The DON and the Administrator both confirmed that this practice was against facility policy and expectations, emphasizing that each nurse should document only the medications they personally administered at the time of administration.
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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