Pacifica Hospital Of The Valley Dp Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Sun Valley, California.
- Location
- 9449 San Fernando Road, Sun Valley, California 91352
- CMS Provider Number
- 555217
- Inspections on file
- 33
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Pacifica Hospital Of The Valley Dp Snf during CMS and state inspections, most recent first.
A resident with a history of head trauma and a skin lesion had a dermatology appointment canceled due to staffing shortages, but the conservator was not consulted prior to the cancellation. Facility staff confirmed that the conservator, who holds exclusive authority for medical decisions, was only notified after the fact, violating the resident's rights to participate in care planning and informed consent.
A facility failed to inform a resident's family about the care plan and changes in condition, causing family anxiety due to lack of input in treatment. The resident, with a history of traumatic SDH and chronic respiratory failure, was unaware of treatment discussions. The CNO admitted to not communicating with the family, and the Social Worker confirmed the family's exclusion from IDT meetings. The facility's failure to maintain regular contact with the family and update them on significant changes led to this deficiency.
The facility failed to submit staffing information to CMS for two quarters in 2024 due to the absence of the responsible staff member and the departure of key personnel with access to the reporting portal. This resulted in incomplete staffing data for the 3rd and 4th quarters.
The facility failed to develop comprehensive care plans for three residents, leading to potential inadequate care. A resident with a stroke did not have a care plan for their RNA program, while two residents on antibiotic therapy lacked care plans to monitor adverse reactions. This failure to adhere to care planning policies could result in unaddressed complications.
The facility failed to involve residents or their representatives in IDT care conferences, affecting the development of resident-centered care plans. Additionally, a resident's care plan was not updated after the removal of an indwelling catheter, leading to inaccurate medical records and potential care issues.
The facility failed to implement necessary safety measures for three residents, leading to potential injury risks. Two residents with seizure disorders were found without required padded side rails, and a third resident had a broken wheelchair with a malfunctioning hand brake and footrest. Staff acknowledged the deficiencies, which were contrary to physician orders and care plan directives.
The facility failed to manage G-tube administration properly, leading to potential health risks. An LVN did not check a resident's stomach residual before administering medication, risking aspiration pneumonia. Another resident's feeding bottle lacked labeling, risking infection from spoiled formula. Additionally, a feeding syringe was not labeled, risking cross-contamination, and another resident's feeding formula was not labeled with the time and date, risking adverse reactions.
A facility failed to ensure physician orders were signed and dated for three residents, leading to potential delays in care. One resident with respiratory failure had unsigned orders for physical therapy and nursing assistance. Another resident with diabetes and anemia had undated medication and lab orders. A third resident had an undated lab order for iron levels. Interviews confirmed the orders were not properly documented, violating facility policy.
A resident admitted with complex medical conditions did not receive a social service assessment within the required 48 hours due to the social worker being overwhelmed with other assignments. The facility's policy mandates timely assessments to address psychosocial needs and assist with adjustment, which was not adhered to, placing the resident at risk.
The facility failed to ensure proper documentation of controlled drug administration and timely replacement of emergency kits. Two residents had discrepancies between the Controlled Drug Record and Medication Administration Records, while three residents experienced delays in e-Kit replacement after Ativan was used. Staff interviews revealed non-compliance with facility policies, potentially leading to medication errors and service delays.
The facility failed to properly label and store medications, risking the administration of expired or discontinued drugs. An open potassium chloride solution lacked an open date, and a discontinued chlorhexidine solution was stored without a physician's order. Additionally, a Vitamin A and D ointment was undated, violating facility policy on medication shelf life.
The facility failed to label food stored in its freezers with the date they were placed, as observed by a registered dietician. Unlabeled frozen pork chops and fish sticks were found, contrary to the facility's policy requiring labeling for easy identification. This practice potentially risked 17 out of 58 residents receiving food from the facility's kitchen.
The facility failed to maintain infection control practices, as observed in three separate incidents involving staff not wearing protective gowns when required. A housekeeper entered a contact isolation room without a gown and failed to perform hand hygiene. An LPN administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without a gown, acknowledging the oversight. Another LPN administered enteral feeding and medication without a gown, unaware of the requirement. These lapses in PPE usage could lead to cross-contamination and infection spread.
A facility failed to keep a call light within reach of a resident who was totally dependent on staff for all ADLs and had intact cognition. The resident's care plan required the call light to be easily accessible, but it was observed out of reach. Staff confirmed the deficiency, acknowledging it could prevent the resident from requesting assistance, contrary to facility policy.
The facility failed to follow its advance directive policies for two residents. One resident was not provided with information about their right to create an advance directive upon admission, despite having intact cognitive skills. Another resident's advance directive was not maintained in their clinical record, despite severe cognitive impairment and total dependence on staff. These deficiencies were confirmed through staff interviews and record reviews.
A resident with complex medical needs was discharged from an LTC facility without a proper care plan or discharge planning assessment. The resident, who required significant assistance and had severe cognitive impairments, did not have a discharge plan developed or documented by the social worker, who was on medical leave. The Director of Nursing confirmed the discharge planning was incomplete, as no interdisciplinary team conference was held to address the resident's needs.
A facility failed to monitor a resident for orthostatic hypotension as per physician's orders on two occasions. The resident, with a history of dysphagia, bipolar disorder, and schizophrenia, was at high risk for falls. Despite the physician's order to monitor from 7:00 a.m. to 7:00 p.m. weekly, documentation was missing for specific weeks in October and November. A nurse confirmed the importance of this monitoring to prevent falls, aligning with the facility's policy to monitor residents on certain medications for adverse effects.
The facility failed to document pain management for two residents, as pain assessments were not conducted before and after administering Norco. The MAR lacked entries for medication administration, and interviews with staff confirmed that the process of signing the MAR was not followed, leading to potential unmanaged pain.
The facility failed to act on a pharmacist's recommendations for two residents, leading to deficiencies in medication management. One resident's need for FeroSul was not reassessed, and another resident did not receive recommended blood testing for levetiracetam levels. The facility lacked a specific policy for addressing the monthly Medication Regimen Review, contributing to these deficiencies.
A facility failed to monitor a resident for side effects of Cymbalta, prescribed for depression. Despite the care plan's directive, there was no documentation of monitoring, confirmed by a nurse. The resident had a history of Guillain-Barre syndrome, diabetes, and hypertension, and required maximal assistance with ADLs. The DSD acknowledged the need for monitoring to adjust medication dosage, as per facility policy.
The facility failed to maintain safe room temperatures for 51 residents in the Sub-Acute Unit due to malfunctioning chillers and inadequate monitoring by engineering staff. Despite installing rental chillers, temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range. Staff interviews and observations confirmed the deficiency, highlighting a lack of adherence to facility policies for temperature monitoring.
Failure to Involve Conservator in Medical Appointment Cancellation
Penalty
Summary
The facility failed to ensure that a resident's conservator was included in the decision to cancel a scheduled dermatology appointment. The resident, who was admitted for long-term care following head trauma resulting in cerebral swelling and a right temporal contusion, had a dermatology consult scheduled for a skin lesion related to dermatitis. The appointment was canceled due to a lack of available staff to accompany the resident, and the conservator was not consulted prior to this decision. Instead, the conservator was only notified after the cancellation and informed of the need to reschedule. Interviews with facility staff confirmed that there was no communication with the conservator before the appointment was canceled, despite the conservator's legal authority to make medical decisions for the resident. The facility's own admission agreement and resident rights documentation indicated that residents and their representatives have the right to participate in care planning and to be informed about medical appointments. The Director of Staff Development acknowledged that the lack of communication with the conservator before canceling the appointment was a violation of the resident's rights.
Failure to Inform Family of Resident's Care Plan and Condition
Penalty
Summary
The facility failed to inform the family of a resident's plan of care and change of condition, leading to anxiety for the family due to their lack of input into the resident's treatment. During an observation, the resident was seen with a tracheostomy and was able to speak in short sentences. The resident mentioned that his mother visits daily, but he was unaware of the outcome of discussions regarding his treatment. The Chief Nursing Officer admitted to not having direct conversations with the resident's mother, despite the resident being a candidate for transfer to a lower level of care. The facility's Social Worker acknowledged that there was a delay in obtaining a neurosurgery consultation due to insurance issues and confirmed that the family had not been included in previous Inter-Disciplinary Team (IDT) meetings. The resident's medical records indicated a history of traumatic subdural hemorrhage and chronic respiratory failure, with a plan for transfer to a facility providing a lower level of care. However, the resident's mother was unable to care for him at home, and there was no record of communication with her regarding the resident's current medical condition. The Social Worker's job description emphasized the importance of maintaining regular contact with residents' families and updating them on significant changes or concerns. Despite this, the facility failed to include the family in the resident's care planning process, as evidenced by the lack of documentation of communication with the family and their exclusion from IDT meetings. This deficiency highlights a breakdown in communication and collaboration between the facility and the resident's family, impacting the resident's care and the family's involvement in decision-making.
Failure to Submit Staffing Data for Two Quarters
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for two fiscal quarters in 2024. Specifically, the facility did not submit the required Payroll-Based Journal Staffing Data Report (PBJ-SDR) for the 3rd quarter (April 1 to June 30) and the 4th quarter (July 1 to September 30) of 2024. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who revealed that the individual responsible for submitting the PBJ-SDR was on medical leave. Additionally, the previous facility Administrator and Director of Nursing (DON), who had access to the reporting portal, were no longer employed by the facility, which contributed to the failure to submit the data. The facility's policy, titled PBJ Data Submission Specifications, dated April 16, 2020, mandates that staffing and census information be reported electronically to CMS through the Payroll-Based Journal system in compliance with section 6106 of the Affordable Care Act. The policy specifies that staffing information should be collected daily and submitted for each fiscal quarter no later than 45 days after the end of the reporting quarter. The failure to adhere to this policy resulted in incomplete and inaccurate direct care staffing information being unavailable to the public for the specified quarters.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential inadequate care. For Resident 46, who was admitted with diagnoses including stroke, tracheostomy, gastrostomy, and seizure disorder, the facility did not create a care plan addressing the Restorative Nursing Assistant (RNA) program. Despite a physician's order for passive and active assistive range of motion exercises, no person-centered interventions were developed, which could result in inadequate monitoring and care for the resident's condition. For Resident 57, who was admitted with chronic renal failure and type 2 diabetes mellitus, the facility did not develop a short-term care plan for antibiotic therapy after a change in condition due to pneumonia. The absence of a care plan meant that adverse reactions to the prescribed antibiotic, Zosyn, could go unmonitored, potentially leading to complications such as dehydration. The facility's policy required a care plan to ensure timely intervention and effective treatment evaluation, which was not followed. Similarly, Resident 55, who was in a persistent vegetative state and diagnosed with dysphagia and hypertension, did not have a care plan developed for antibiotic therapy after a change in condition due to urosepsis. The lack of a care plan for monitoring adverse reactions to Zosyn could result in unaddressed complications. The facility's failure to adhere to its care planning policy, which mandates updates upon changes in condition, contributed to these deficiencies.
Failure to Involve Residents in Care Planning and Update Care Plans
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) invited residents or their representatives to participate in care conferences for three out of five sampled residents. This lack of involvement was observed in residents who were in a persistent vegetative state and totally dependent on staff for self-care. The facility's policy encourages the participation of residents or their representatives in IDT meetings to ensure the care plan is resident-centered. However, the facility did not extend invitations to the representatives of these residents during several IDT meetings, potentially leading to care plans that were not tailored to the residents' needs. Additionally, the facility failed to update and revise a resident's care plan after the removal of an indwelling catheter. The resident, who had a history of hemorrhagic stroke and recurrent urinary tract infections, had their catheter removed, but the care plan was not revised to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer applicable. This oversight was acknowledged by the MDS Nurse and the Director of Nursing, who stated that care plans should be updated immediately after such changes to ensure accurate medical records and appropriate care. The facility's policy on care planning requires that a coordinated and comprehensive written plan be developed based on the resident assessment instrument and updated upon any change of condition. However, the failure to revise the care plan after the catheter removal indicates a lapse in adhering to this policy. The Director of Nursing emphasized the importance of having care plans that reflect the current condition of residents to provide appropriate care and services.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to implement necessary accident risk and hazard interventions for three residents, leading to potential injury risks. Resident 30, who has a seizure disorder, was observed without the required padding on the bed side rails, despite physician orders and care plan interventions specifying the need for such precautions. The Licensed Vocational Nurse confirmed the absence of padding and acknowledged the risk of injury during a seizure. Similarly, Resident 34, also diagnosed with a seizure disorder, was found without padded side rails, contrary to physician orders and care plan directives. The Director of Nursing confirmed that the staff did not implement the required seizure precautions, which could result in injuries during seizure activity. Resident 18 experienced issues with a broken wheelchair, which had a malfunctioning hand brake and footrest. Despite the resident's intact cognitive skills and ability to voice concerns, the wheelchair remained unrepaired for two weeks, with the resident resorting to using a rubber band to hold the hand brake in place. The Registered Nurse acknowledged awareness of the broken wheelchair components and admitted to not following up on the repair status. The Director of Nursing confirmed that staff failed to ensure the wheelchair was functioning properly, posing a risk of falls and injuries. The facility's policies and procedures for seizure precautions and safety precautions were not adhered to, as evidenced by the lack of padded side rails for Residents 30 and 34 and the unresolved issues with Resident 18's wheelchair. These deficiencies highlight the facility's failure to provide a safe environment and adequate supervision to prevent accidents, as required by their own guidelines.
Deficiencies in G-Tube Management and Labeling
Penalty
Summary
The facility failed to properly manage the administration of medications and feeding through gastrostomy tubes for several residents, leading to potential health risks. In one instance, a Licensed Vocational Nurse (LVN) did not check the residual volume in the stomach of a resident in a persistent vegetative state before administering Tramadol via a G-tube. This oversight could have increased the risk of aspiration pneumonia, as the medication might have been delivered into the lungs if the tube was improperly placed. Another deficiency was observed with a resident whose G-tube feeding bottle was not labeled with the date and time it was started. This lack of labeling made it impossible to determine if the feeding formula had been used for more than 24 hours, posing a risk of infection from spoiled formula. The facility's policy requires that feeding bottles be labeled to ensure they are changed within the safe time frame. Additionally, the facility did not label a feeding syringe with the resident's name and the date it was last changed, which could lead to cross-contamination and increased risk of healthcare-acquired infections. Furthermore, another resident's feeding formula was not labeled with the time, date, and initials of the nurse who initiated it, potentially allowing the formula to exceed its safe hang-time, which could cause adverse reactions. These deficiencies highlight lapses in following established protocols for enteral feeding management.
Physician Orders Not Properly Signed and Dated
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders in the physical or electronic records during visits for three residents. Resident 4, who was admitted with respiratory failure and had severe cognitive impairment, had several telephone orders related to physical therapy and nursing assistance that were not signed, dated, or timed by a physician. These orders included evaluations and exercises for maintaining the resident's functioning, as well as the application of supportive devices. Resident 13, who was cognitively intact and had diagnoses of diabetes mellitus and anemia, had multiple medication and laboratory orders that lacked dates and times. These orders included medications for weight loss and allergies, as well as laboratory tests and imaging studies. Similarly, Resident 51, who was severely cognitively impaired and dependent on staff for daily activities, had an order for laboratory tests related to iron levels that was not dated or timed. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the orders were not properly signed, dated, or timed, which is against the facility's policy. The facility's policy requires that all medication orders be clear, complete, and signed by a licensed physician, with telephone orders countersigned within five days. The lack of proper documentation could lead to delays in the residents' care plans.
Failure to Conduct Timely Social Service Assessment
Penalty
Summary
The facility failed to implement its policy and procedure for conducting a social service assessment within 48 hours of admission for a resident. The resident, who was admitted with complex medical conditions including stroke, tracheostomy, gastrostomy, and seizure disorder, did not receive a timely social service assessment. Despite having intact cognitive skills and being dependent on staff for various daily activities, the resident reported not having seen a social worker since admission. The social worker confirmed that no assessment was conducted due to being overwhelmed with other assignments. The facility's policy requires social workers to meet with residents within 24 hours of admission and complete an initial assessment within 48 hours. This assessment is crucial for gathering psychosocial information pertinent to the resident's adjustment and well-being. The Director of Nursing acknowledged the lapse, emphasizing the importance of timely assessments to address psychosocial concerns and assist with the resident's adjustment to the facility. The failure to conduct the assessment as per policy placed the resident at risk of not receiving appropriate social services to meet their needs.
Medication Administration and e-Kit Replacement Deficiencies
Penalty
Summary
The facility failed to ensure that the Controlled Drug Record (CDR) coincided with the Medication Administration Records (MAR) for two residents, which could lead to medication errors or drug diversion. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had discrepancies in the administration of Norco and lorazepam. The CDR indicated that these medications were removed on specific dates, but there were no corresponding entries in the MAR. Similarly, Resident 42, who was cognitively intact but required assistance with daily activities, had a discrepancy with the administration of Norco. The CDR showed that Norco was removed, but the MAR did not reflect this administration. The facility also failed to replace the refrigerator emergency kit (e-Kit) within 72 hours after medications were removed for three residents. Resident 4, who was severely impaired in cognition and had a diagnosis of seizures, received Ativan from the e-Kit, but the kit was not replaced in a timely manner. Resident 27, also severely impaired in cognition and with a seizure diagnosis, had a similar issue with the e-Kit not being replaced after Ativan was administered. Additionally, Resident 14, who had a seizure disorder and was totally dependent on staff, had an e-Kit opened for Ativan, but the replacement process was not followed, and the log for usage was missing. Interviews with staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), revealed that the process for documenting medication administration and replacing the e-Kit was not followed. The facility's policies and procedures required immediate documentation on the MAR after administering controlled drugs and prompt replacement of the e-Kit within 72 hours. However, these protocols were not adhered to, leading to potential delays in pharmaceutical services and inadequate documentation of medication administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks of administering expired or discontinued drugs. In one instance, an open potassium chloride solution used for a resident with severe cognitive impairment and total dependency on staff was found without an open date, making it difficult to determine its beyond use date. This oversight was confirmed by a registered nurse during an observation of the medication cart. Another deficiency involved the storage of an open and discontinued chlorhexidine solution in the medication cart for a resident who had no physician's order for this medication. The solution was not labeled with an open date, and the Director of Staff Development acknowledged that medications without orders should be removed promptly to prevent medication errors. The facility's policy mandates the removal of outdated or discontinued medications, which was not adhered to in this case. Additionally, a container of Vitamin A and D ointment was found in a medication cart without an open date. The Director of Staff Development confirmed that all opened medications should be dated to track their shelf life. The facility's policy requires that floor stock medications not be maintained beyond the manufacturer's expiration date or 180 days after opening, which was not followed in this instance.
Improper Food Storage Practices in Facility Freezers
Penalty
Summary
The facility failed to ensure proper food storage practices by not labeling food stored in the facility's freezers with the date they were placed in the freezer. This deficiency was observed during a survey when a registered dietician found an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1 and an unlabeled bag of frozen fish sticks in Freezer 2. Both the registered dietician and the dietary supervisor confirmed that all food items in the freezer are required to be labeled with the date they were placed in the freezer. The facility's policy and procedure for Food and Nutrition Services, last reviewed in March 2021, also indicated that frozen foods should be labeled with the name of the item and date of delivery for easy identification. This practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to potential cross-contamination and infection spread. In one case, a housekeeper entered a resident's room, which was under contact isolation due to Carbapenem-resistant Enterobacterales (CRE) and Extended-Spectrum Beta-Lactamases (ESBL) in the urine, without donning a gown. After collecting trash, the housekeeper exited the room, removed gloves, and failed to perform hand hygiene. This was observed by a Licensed Vocational Nurse (LVN), who confirmed that all staff entering such rooms are required to wear gloves and gowns and perform hand hygiene to prevent infection spread. In another instance, a Licensed Vocational Nurse (LVN) administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a protective gown. The LVN acknowledged the oversight and recognized that wearing a gown is necessary to prevent cross-contamination, as staff clothing can become contaminated when caring for multiple residents. The facility's policy requires staff to don personal protective equipment, including gowns, during high-contact resident care activities. A third incident involved another LVN who administered enteral feeding and medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a gown. The LVN was unaware of the requirement to wear a gown during such procedures. The Director of Staff Development and the Infection Preventionist confirmed that the facility's policies mandate the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. These deficiencies highlight lapses in adherence to infection control protocols, potentially compromising resident and staff safety.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach of Resident 11, who was totally dependent on staff for all activities of daily living and had intact cognition. Resident 11 was admitted with diagnoses including Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension. The resident's care plan specifically indicated that the call light should be placed within easy reach at the bedside. However, during an observation, it was noted that the adaptive call light was positioned on the left side of the head of the bed, out of reach for the resident, who could only move his head. Interviews with Registered Nurse 3 and the Director of Staff Development confirmed that the call light was not within reach, which contradicted the facility's policy and procedure. The policy required that call cords be placed within the resident's reach at all times. The staff acknowledged that the deficient practice could prevent the resident from requesting assistance and potentially lead to falls. The facility's policy emphasized the importance of ensuring that call lights are always accessible to residents.
Failure to Follow Advance Directive Policies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for two residents, Resident 46 and Resident 35. For Resident 46, the facility did not provide written information about the right to refuse or accept medical or surgical treatments and to formulate an advance directive upon admission. This was confirmed during interviews with Registered Nurse 1 and Social Worker 1, who acknowledged that the Advance Directive Acknowledgment form was not completed for Resident 46 upon admission, which is a violation of the resident's right to be informed about advance directives. Resident 46 was admitted with several medical conditions, including a stroke, tracheostomy, gastrostomy, and seizure disorder. Despite having intact cognitive skills for daily decision-making, the facility did not ensure that Resident 46 was informed about the option to create an advance directive, as required by the facility's policy. The policy mandates that residents be provided with written information about their rights concerning medical treatment and advance directives upon admission. For Resident 35, the facility failed to maintain a current copy of the resident's advance directives in the clinical record. Although the Advance Directive acknowledgment form indicated that Resident 35 had an advance directive, it was not present in the resident's chart. This oversight was confirmed by Social Worker 1 and the Director of Staff Development, who both stated that a copy of the advance directive should have been kept in the resident's chart to ensure the resident's wishes would be carried out. Resident 35 had severe cognitive impairment and was totally dependent on staff for all activities of daily living, making it crucial for the facility to have the advance directive readily available to guide care decisions.
Failure in Discharge Planning for a Resident with Complex Needs
Penalty
Summary
The facility failed to adhere to its discharge planning policy and procedure for a resident, identified as Resident 60, who was discharged without a proper care plan or discharge planning assessment. The resident, who had significant medical needs including a tracheostomy, gastrostomy, and seizure disorder, was admitted to the facility with severely impaired cognitive skills and was dependent on staff for various daily activities. Despite these needs, the facility did not develop a care plan addressing the resident's discharge plan or initiate a discharge planning assessment prior to the resident's discharge. The review of the resident's records revealed that the interdisciplinary team (IDT) conference notes lacked documentation for psychosocial and discharge planning sections. The social worker, who was responsible for the discharge planning, was on medical leave during the last IDT conference and did not document any discharge planning notes or develop a care plan for the resident's discharge. The social worker acknowledged the oversight and stated that it was important to comply with the facility's discharge policy by documenting all necessary discharge information and conducting required assessments. The Director of Nursing confirmed that the discharge planning for Resident 60 was incomplete, as there was no care plan developed for the resident's discharge needs, and no IDT conference was held to discuss these needs. The facility's policy required the social worker to document the level of care required for discharge within seven days of admission and to update it as needed. However, this was not done, and the discharge planning assessment was not initiated, leading to a lack of provision of necessary discharge care and services for the resident.
Failure to Monitor Orthostatic Hypotension
Penalty
Summary
The facility failed to adhere to a physician's order by not monitoring a resident for orthostatic hypotension on two specific dates, 10/23/2024 and 11/27/2024. This oversight involved a resident who had been admitted to the facility on 8/17/2021 and had a history of dysphagia, bipolar disorder, and schizophrenia. The resident's Minimum Data Set (MDS) indicated intact cognitive skills for daily decision-making and a requirement for supervision in certain activities. The resident was also identified as high risk for falls according to a Fall Risk Assessment. The physician's order, dated 2/3/2023, required monitoring for orthostatic hypotension from 7:00 a.m. to 7:00 p.m. weekly, which was not documented in the Medication Administration Records (MAR) for the specified weeks in October and November 2024. During an interview, a registered nurse confirmed the importance of monitoring for orthostatic hypotension, especially for residents on medications like Zoloft, to prevent potential falls and injuries. The facility's policy emphasized monitoring residents on certain medications for adverse effects, but this was not followed in the case of the resident in question.
Failure to Document Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure proper pain management for two residents, Resident 6 and Resident 42, by not assessing their pain before and after administering pain medication. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had orders for Norco to be administered via G-Tube for severe pain. However, the Medication Administration Record (MAR) did not reflect the administration of Norco on several dates, and there was no documentation of pain assessment for those times. Similarly, Resident 42, who was cognitively intact and required assistance with daily activities, had orders for Norco to be administered orally for severe pain. The Controlled Drug Record (CDR) indicated that Norco was removed from the blister pack, but the MAR did not show any record of administration or pain assessment on the specified date. Interviews with the Director of Staff Development (DSD) and the Director of Nurses (DON) confirmed that the process of signing the MAR after administering medication was not followed, which is crucial for assessing the effectiveness of pain relief. The facility's policies and procedures for controlled drug management and medication administration were not adhered to, as the licensed nurses failed to document the administration of pain medication on the MAR. This lack of documentation meant that there was no assessment or reassessment of the residents' pain levels, potentially leaving their pain unmanaged. The DON stated that the absence of documentation on the MAR indicated that pain was not assessed, which could result in the residents' pain not being relieved.
Failure to Act on Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents, leading to deficiencies in medication management. For Resident 17, who was admitted with respiratory failure and was cognitively intact, the facility did not reassess the need for the medication FeroSul, which had been prescribed since admission. Despite the consultant pharmacist's recommendation to reassess the necessity of this medication, there was no documentation indicating that the physician had been contacted to address this concern. Similarly, for Resident 35, who had severe cognitive impairment and was dependent on staff for all activities of daily living, the facility did not follow the consultant pharmacist's recommendation to order blood testing for levetiracetam, a medication used to treat seizures. The recommendation was made to ensure the medication levels were within a safe range, but no Keppra level test was conducted. This oversight was acknowledged by the nursing staff, who recognized the increased risk of medication side effects due to the lack of monitoring. The facility's policies and procedures for medication administration and pharmaceutical services were reviewed, highlighting the requirement for medications to be administered according to physician orders and for any concerns about medication orders to be clarified with the pharmacy. However, the facility lacked a specific policy for addressing the monthly Medication Regimen Review (MRR) and the timeframe for addressing issues raised in the report, contributing to the deficiencies observed.
Failure to Monitor Side Effects of Cymbalta
Penalty
Summary
The facility failed to monitor a resident for side effects associated with the use of Cymbalta, a medication prescribed for depression. The resident, who had a history of Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension, was admitted to the facility with intact cognition but required maximal assistance with activities of daily living. Despite the care plan's directive to monitor for adverse side effects every shift, there was no documentation indicating that the licensed nurses were performing this monitoring. During an interview, a registered nurse confirmed the administration of Cymbalta to the resident over several consecutive days but could not provide evidence of side effect monitoring. The Director of Staff Development acknowledged the necessity of monitoring for adverse side effects to inform the physician and adjust the medication dosage if needed. The facility's policy on psychoactive drug monitoring also required documentation of monitoring for adverse consequences, which was not adhered to in this case.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 51 residents in the Sub-Acute Unit. This deficiency was identified through observations, interviews, and record reviews. The facility's chillers, which are essential for the air conditioning system, were not functioning properly, and the temporary rental chillers installed as replacements were also not working correctly. The engineering staff did not monitor or record the room temperatures as required by the facility's policies, leading to unsafe conditions for the residents. Interviews with various staff members, including the Chief Nursing Officer, House Supervisor, and engineering staff, revealed that the chillers had malfunctioned, and the rental chillers were installed incorrectly by the vendor. Despite the installation of rental chillers, the engineering staff failed to verify the room temperatures, and no temperature logs were maintained. Observations confirmed that the room temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range and creating a hot environment in the Sub-Acute Unit. The facility's policies and procedures required daily monitoring and documentation of room temperatures, but these were not followed. The engineering department was expected to have a contingency plan for air conditioning failures, but this was not effectively implemented. The lack of proper monitoring and maintenance of the air conditioning system placed the residents at risk, as confirmed by staff interviews and temperature readings.
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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