Palazzo Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5400 Fountain Ave, Los Angeles, California 90029
- CMS Provider Number
- 056456
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Palazzo Post Acute during CMS and state inspections, most recent first.
A CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, in violation of federal nurse aide registry requirements and the facility’s job description requiring a valid CNA license. The DON had a personnel file printout indicating the CNA’s status was active and employable, but a concurrent CDPH registry search showed no matching data. Review of assignment and attendance sheets confirmed the CNA worked the shift after being called in by a Charge Nurse who did not realize the CNA had been removed from the schedule for lapsed certification. The DSD reported that CNAs with expired certifications are taken off the schedule and payroll and that this CNA had been informed of her limitations, yet she still worked the shift without valid certification.
A resident with a history of severe psychiatric disorders exhibited aggressive behavior requiring 1:1 supervision, but the facility did not update the care plan to reflect this intervention after significant behavioral changes and hospital readmission. Staff interviews and record reviews confirmed that the care plan was not revised as required by facility policy, leaving the resident's current needs and interventions undocumented.
A resident with multiple health conditions, including blindness and psychiatric diagnoses, became agitated after being denied a request to smoke. A CNA attempted to prevent the resident from getting up, but did not notify the RN of the agitation. Another resident, believing the CNA was at risk, struck the agitated resident on the jaw, causing pain and requiring an x-ray. Facility policies required staff to prevent and report abuse, but these were not followed, resulting in physical harm.
Two residents, both with significant medical and behavioral histories, were involved in a physical altercation after one became agitated over smoking restrictions and the other intervened, believing staff were at risk. Staff failed to notify the RN of escalating agitation and did not provide adequate supervision, resulting in one resident being struck and requiring medical evaluation.
A resident with impaired mobility and a high risk for falls was not properly positioned in a wheelchair after a toilet transfer, resulting in a fall. Despite a care plan requiring assistance and safety interventions, staff failed to ensure correct seating before moving the wheelchair, leading to the incident. The resident did not sustain injuries.
The facility failed to properly manage emergency drug supplies, resulting in the absence of a narcotic E-kit for about 24 hours, did not replace E-kits within the required timeframe, and left several drug disposition forms incomplete. Additionally, staff did not adequately follow up or document actions regarding a resident's pending Norco opioid order, leading to delays in medication availability.
Surveyors found that kitchen staff did not keep the ice scooper holder clean, stored personal perishable food in the facility refrigerator, and left personal items in non-designated kitchen areas. The Dietary Food Nutrition Supervisor confirmed these actions violated facility policies for food safety and sanitation.
Surveyors observed that staff failed to follow infection prevention protocols, including not wearing required gowns during direct care for a resident on enhanced barrier precautions and not disinfecting IV injection ports during medication administration. Additionally, the facility's water management plan lacked critical details, such as building and water system descriptions, control measures, and verification steps, as confirmed by facility leadership.
A resident with severe cognitive impairment and multiple mental health diagnoses was allowed to sign medical consent forms and an Advance Health Care Directive without the involvement of a legal representative, despite documentation and staff acknowledgment of the resident's incapacity. Staff obtained verbal consent and witnessed signatures instead of following procedures for residents lacking decision-making capacity.
A resident with a history of falls and neurological conditions experienced a fall, but the care plan was not updated to reflect this incident or to add new interventions. Despite facility policy and staff acknowledgment that care plans should be revised after such events, the last update had occurred months earlier, resulting in a deficiency related to care plan management.
A resident with severe cognitive impairment, dysphagia, and a g-tube was observed with poor oral hygiene, including a tan substance on teeth, dry lips, and a reddened, swollen tongue. Staff interviews revealed oral care was not provided as frequently as care plans required, and the resident's mouth had been in poor condition for some time. The DON confirmed that the observed oral condition was unacceptable and not in line with facility policy.
Staff failed to lock both the bed and the Hoyer lift before placing a sling under a resident with significant mobility impairments and a history of falls. This action was inconsistent with the resident's care plan and facility policy, as confirmed by staff interviews and direct observation.
A resident with multiple medical conditions and frequent incontinence did not receive a quarterly bowel and bladder assessment as required by their care plan. Documentation and staff interviews confirmed that the last assessment was completed several months prior, and facility policy requiring regular continence assessments was not followed.
A resident dependent on g-tube feeding due to dysphagia and malnutrition was found to have an unlabeled flush bag attached to their feeding pump, despite the care plan requiring labeling with date, time, and nurse's initials. Both nursing staff and the DON acknowledged the omission and the associated risk of infection.
A resident with a history of fibromyalgia and skin sensation disturbances experienced facial itching due to a possible allergic reaction. Although a physician ordered Benadryl 25 mg to be given as needed, review of the MAR showed the medication was not documented as administered, and the resident reported not receiving it. Interviews with nursing staff and review of facility policy confirmed the lack of required documentation for medication administration.
The facility did not post the actual hours worked by staff, as required by federal regulations. On the observed day, only projected hours were displayed, and the previous day's actual hours were missing. Interviews with the DSD and DON revealed a misunderstanding of the posting requirements, which were clarified upon reviewing the facility's policy.
A resident with multiple myeloma missed two doses of Pomalyst due to the facility's failure to implement a consistent medication reconciliation system. The resident, who also had type 2 diabetes and end-stage renal disease, was aware of the prescription but reported not receiving the medication as ordered. The DON confirmed the missed doses, and an LVN admitted to not administering the medication due to its unavailability in the medication cart. The facility's policy required medications to be administered safely and as prescribed, which was not followed.
The facility failed to uphold resident dignity and respect, as evidenced by two residents reporting incidents of staff yelling. One resident, with conditions including hypertension and cellulitis, was yelled at by a CNA after assisting another resident. Another resident, with osteoarthritis and reduced mobility, confirmed hearing an argument involving staff. Both residents had intact cognition and required assistance for daily activities, highlighting a breach in the facility's policy on resident rights.
A resident with an amputation site, acute respiratory failure, and an arterial ulcer did not receive necessary care and services. The facility failed to assess and document the ulcer upon admission, did not develop a comprehensive care plan, and did not follow the physician's treatment order. Additionally, the resident's respiratory status was not adequately monitored, leading to their transfer to a hospital where they were diagnosed with further complications and subsequently passed away.
A resident at risk for malnutrition did not receive 17 doses of Megestrol Acetate Suspension due to the medication not being in stock, leading to significant weight loss. The facility failed to maintain accurate medication administration records, marking the medication as administered when it was not available. Interviews with staff revealed a lack of adherence to documentation practices, contributing to the deficiency.
The facility failed to label and date food stored in the kitchen, including bread and various frozen vegetables, as observed during a kitchen tour. Both the Dietary staff and the DON acknowledged that all food should be labeled and dated to prevent food-borne illnesses, in accordance with the facility's policy.
A resident with Type II diabetes and other conditions experienced a significant change in health status with elevated blood sugar levels. The LTC facility failed to develop an individualized care plan to address hyperglycemia, as required by policy, leading to inadequate care and monitoring. Interviews with staff confirmed the oversight in care planning.
A resident with a right heel deep tissue injury did not receive necessary care and services as per their care plan, which included monitoring and documenting changes in the wound's condition. For 16 days, there was no documentation of the wound's status, despite facility policies requiring detailed recording of treatment and assessment data. This oversight was confirmed by staff interviews and posed a risk of infection or worsening of the wound.
A resident with a history of falls did not receive the necessary fall prevention interventions as outlined in their care plan. The facility failed to implement the required measures, such as a yellow star on the wall, a fall risk wristband, and non-skid socks. Additionally, the care plan was not updated following a fall that resulted in a skin abrasion. The facility's policies on fall risk management and care plan updates were not followed.
A resident with acute respiratory failure was not provided with proper respiratory care as their nasal cannula tubing was neither labeled nor stored in a plastic bag, contrary to facility policy. Staff interviews confirmed the tubing should have been labeled and stored correctly to prevent infection, as per the care plan and facility guidelines.
A resident continued to receive Effexor for depression without documented justification beyond 30 days. Despite the absence of verbalized sadness, the Consultant Pharmacist's Medication Regimen Review lacked recommendations or rationale for the medication's continued use. The facility's policy required monthly reviews and reporting of medication irregularities, but no Gradual Dose Reduction was documented.
A resident experienced significant weight loss due to the unavailability of Megestrol Acetate Oral Suspension for 17 days. The medication, intended to stimulate appetite, was inaccurately documented as administered by multiple nurses. The resident's weight dropped from 182 to 156 pounds, and the facility's policies on medication administration and documentation were not adhered to.
A facility failed to store Dorzolamide-Timolol Ophthalmic Solution correctly, as it was found in a refrigerator instead of being stored at room temperature as per manufacturer's guidelines. This improper storage was acknowledged by an LVN and confirmed by the DON, who noted that it could render the medication ineffective for treating a resident's eye condition.
A resident with multiple medical conditions, including dependence on renal dialysis, was inappropriately administered MiraLAX despite experiencing frequent loose stools. The facility failed to notify the physician of the resident's condition change, continuing the laxative treatment without adjustment. Staff interviews revealed a lack of awareness and communication regarding the resident's diarrhea, and the DON acknowledged the oversight. The facility's policies on notifying changes in condition were not followed, posing a risk of dehydration and other complications.
A facility failed to review transfer records for a resident admitted with multiple medical conditions, resulting in missed critical appointments for vascular diagnostics, chemotherapy, and specialist consultations. The oversight occurred because the admitting nurse only reviewed medication pages, leading to a delay in the resident's treatment.
A facility failed to safeguard a resident's personal funds by improperly storing $800 in a narcotic box instead of transferring it to the business office the next business day, as required by policy. The delay and improper storage posed a risk of theft or misuse.
CNA Allowed to Work Overnight Shift Without Active Certification
Penalty
Summary
Surveyors identified that one CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, contrary to federal nurse aide registry requirements and the facility’s own job description, which requires a valid CNA certification. During interview and record review with the DON, the CNA’s Licensing & Certification Verification Detail Page in the personnel file showed an active, employable status with a future expiration date, which the DON had relied upon. However, when the DON searched the California Department of Public Health (CDPH) website during the same review, no data was found for the CNA, confirming that the CNA did not have an active certification on the registry at the time she worked the shift. Further review of the nursing assignment and attendance sign‑in sheets for the overnight shift confirmed that the CNA had signed in and worked that shift. The DON stated that the situation occurred because the evening shift Charge Nurse, attempting to cover a CNA call‑off, contacted this CNA, who was known for helping cover shifts, and did not recognize that she had been removed from the schedule due to lapsed certification. In a separate telephone interview, the DSD explained that CNAs with lapsed certifications are removed from the monthly schedule and payroll until their certification is valid, and that this CNA had been informed of what she could and could not do with an expired certification. The DSD also noted that the CNA should have known her status when the system would not allow her to clock in, yet she knowingly worked the shift without a valid CNA certification.
Failure to Update Care Plan for Aggressive Behavior and 1:1 Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's aggressive behavior and need for 1:1 supervision following significant changes in the resident's condition. On one occasion, the resident exhibited aggressive behavior, including spitting at a nurse, which resulted in a physician's order for 1:1 supervision. Despite this, a care plan reflecting the new intervention was not created or updated on the same day. Documentation and interviews confirmed that the care plan did not include the required interventions for aggressive behavior or 1:1 supervision at that time. Subsequently, the resident was transferred to a general acute care hospital for further evaluation due to increased agitation and aggression. Upon readmission to the facility, the care plan still lacked updates to address the resident's aggressive behavior and the need for 1:1 supervision. Multiple staff interviews, including those with LVNs, an RN, and the DON, confirmed that the care plan was not revised to reflect the resident's current needs and interventions after these significant events. Record reviews and staff statements indicated that the facility's policies and job descriptions required care plans to be updated with any significant change in a resident's condition or upon readmission from a hospital stay. However, these procedures were not followed, resulting in the absence of an accurate and current care plan for the resident during periods of behavioral escalation and after hospital readmission.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place when a resident, who was blind and had a history of schizophrenia, bipolar disorder, and nicotine dependence, became agitated after being told by a CNA that it was not time to smoke. The CNA attempted to prevent the resident from getting up due to fall risk, but did not notify the RN of the resident's agitation. Another resident, who had type 2 diabetes, blindness in one eye, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident struck the first resident on the jaw, causing pain that required an x-ray to rule out a fracture. The facility's records and interviews confirmed that the agitated resident was attempting to get up from bed to smoke outside of designated hours, and the CNA intervened to prevent a fall. The second resident, witnessing the interaction, interpreted the agitated resident's behavior as threatening toward the CNA and decided to intervene physically. The staff responded to the incident after hearing a commotion, separated the residents, and later moved the aggressor to another room. The injured resident reported pain and anger following the incident, and the x-ray showed no fracture. Review of facility policies indicated that staff are expected to identify and prevent all forms of abuse, including resident-to-resident abuse, and to notify the charge nurse immediately if there are concerns about resident behavior or policy violations. The policies also require staff training in abuse prevention and management of aggressive resident behavior. In this case, the failure to notify the RN of the resident's agitation and the lack of effective intervention allowed the physical altercation to occur, resulting in harm to a resident.
Failure to Prevent Resident-to-Resident Physical Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for two residents, resulting in one resident being struck by another. On the night of the incident, a resident with a history of blindness, schizophrenia, bipolar disorder, and nicotine dependence became agitated after being denied the opportunity to smoke outside of designated hours. The certified nursing assistant (CNA) attempted to calm the resident and prevent him from getting up due to his fall risk, but did not notify the registered nurse (RN) of the resident's escalating agitation. Another resident, who had blindness in one eye, diabetes, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident moved in his wheelchair and struck the agitated resident on the jaw. The incident was witnessed by staff, and the two residents were separated. The struck resident experienced jaw pain and required an x-ray, which showed no fracture. Interviews and record reviews confirmed that the facility's staff did not provide adequate supervision to prevent the altercation. The care plan for the agitated resident required monitoring for unsafe smoking practices and immediate notification of the charge nurse if the smoking policy was violated, but this was not followed. The facility's policies also required staff to protect residents from abuse, including resident-to-resident physical aggression, but these measures were not effectively implemented during the incident.
Failure to Implement Fall Prevention Care Plan During Transfer
Penalty
Summary
The facility failed to implement care plan interventions designed to prevent falls for a resident with a history of impaired gait, balance issues, and a high risk for falls. The resident, who was cognitively intact and required substantial assistance with transfers, was admitted with diagnoses including abnormalities of gait and mobility, lack of coordination, and a need for assistance with personal care. The care plan for this resident included interventions such as adapting the environment for safety, anticipating and meeting the resident's needs, and assisting with all transfers or ambulation. Despite these interventions, on the date of the incident, the resident was not properly positioned in the wheelchair after being transferred from the toilet by a CNA, which resulted in the resident sliding off the wheelchair and falling to the floor. Interviews and documentation confirmed that the CNA did not ensure the resident was seated properly in the wheelchair before moving it, and both the LVN and DON acknowledged that the resident was sitting close to the edge of the seat at the time of the fall. The facility's policies emphasized the importance of individualized, resident-centered safety interventions and the implementation of care plan measures to prevent accidents. However, these measures were not followed during the transfer, directly leading to the fall event. The resident did not sustain injuries as confirmed by subsequent x-rays.
Deficient Management and Documentation of Emergency Drug Supplies and Medication Orders
Penalty
Summary
The facility failed to ensure proper management and documentation of emergency drug supplies (E-kits), resulting in several deficiencies. Upon delivery from the pharmacy, the facility did not receive the correct narcotic E-kit and instead received a C-II E-kit, leaving the facility without a narcotic E-kit for approximately 24 hours. Staff interviews and observations revealed that the narcotic E-kit was missing from its designated location, and only C-II E-kits were present. The facility's policy required staff to check medications against pharmacy order sheets and retain a signed delivery receipt, but this process was not followed, leading to the absence of the required narcotic E-kit. Additionally, the facility did not replace the E-kit within 72 hours of first use, as required by policy. Review of the narcotic E-kit logbook showed entries for medication use that were several weeks apart, indicating that the kit was not replaced in a timely manner. The Director of Nursing confirmed that the dates on the log should not be more than 72 hours apart, but this standard was not met. Furthermore, the facility failed to ensure that drug disposition forms were properly completed; seven forms were found with missing dates and nurse signatures, and some lacked a witnessing nurse's signature altogether. The facility also did not adequately follow up on a resident's order for Norco 10-325 mg, a potent opioid, which was pending authorization from the pharmacy. The medication was not available in the resident's medication drawer, and there was no documentation of follow-up with the pharmacy until prompted by the surveyor. The facility's policy required documentation of non-delivery and follow-up, but this was not done for the resident's Norco order.
Failure to Maintain Sanitary Food Storage and Staff Practices in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Specifically, the ice scooper holder was found to be dirty during an inspection, despite cleaning logs indicating it had been cleaned. The Dietary Food Nutrition Supervisor (DFNS) confirmed the ice scooper holder should always be kept clean to prevent contamination, and acknowledged that a dirty holder could lead to a break in infection control. Facility policy required all containers used with ice to be kept clean and stored in a sanitary manner. Additionally, staff were found to be storing personal perishable food in the facility's refrigerator and placing personal items, such as a tumbler, in non-designated areas within the kitchen. The DFNS confirmed that personal food and belongings are not allowed in the kitchen or food service production areas, as outlined in the facility's policies. These actions were observed during a kitchen inspection and were acknowledged by the DFNS as violations of facility policy.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program in several key areas. During medication administration observations, a nurse did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy when providing direct care to a resident identified as needing enhanced precautions. The nurse acknowledged forgetting to wear the gown, and both the infection preventionist and another nurse confirmed that medication administration and taking vital signs are considered direct care activities that require the use of gowns and gloves under EBP. The facility's policy specified that EBP is used to prevent the spread of multi-drug-resistant organisms and requires targeted gown and glove use in addition to standard precautions. Additionally, another nurse failed to disinfect the vial top and injection ports with alcohol swabs during the preparation and administration of intravenous vancomycin for a resident. The nurse stated that disinfection was not necessary, which was contradicted by the infection preventionist and the facility's policy. The policy required strict aseptic technique, including disinfecting all injection ports with a sterile alcohol swab for at least 30 seconds before access. The facility's water management plan was also found to be insufficient. The plan lacked essential details such as a description of the building, the population it housed, and a comprehensive description of the water system. It did not identify areas where Legionella could grow and spread, nor did it include control measures or verification steps to ensure the plan was being followed. Interviews with facility leadership confirmed that the water management plan was not personalized or adequate for the facility's needs, and did not meet the requirements outlined in the facility's own policy and procedures.
Failure to Obtain Legal Representative for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident who was severely cognitively impaired and lacked decision-making capacity had a legal representative to assist with medical decisions. The resident, who had diagnoses including major depressive disorder, schizophrenia, cataracts, and anxiety disorder, was documented in both the Minimum Data Set and History & Physical as being unable to understand or make decisions. Despite this, the facility obtained verbal consent from the resident for psychotropic medication and had the resident sign an Advance Health Care Directive and other documents, with staff acting as witnesses, rather than involving a legal representative. Interviews with staff confirmed that the resident had periods of confusion and limited vision, and that staff were aware of the resident's lack of capacity. The Social Services Assistant acknowledged not knowing the facility's advance directives policy, and the DON confirmed the resident's incapacity. The Medical Director stated that in cases of cognitive decline, a bioethics meeting and possible appointment of a conservator should occur. The facility's policy indicated residents have the right to appoint a legal representative, but this was not followed for the resident in question.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall incident. The resident, who had a history of Parkinson's disease, encephalopathy, unsteadiness on feet, lack of coordination, and previous falls, was admitted with these diagnoses and was identified as being at risk for falls. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living, but had not experienced any falls since admission until the incident in question. On the date of the incident, the resident experienced a fall and was found sitting on the floor holding onto his walker. The assessment following the fall noted no injuries, and the physician was notified, resulting in an order for an x-ray. Despite this event, a review of the resident's care plan revealed that it had not been updated or revised to reflect the fall or to include any new interventions. The last revision to the care plan had occurred several months prior to the fall. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan should have been updated after the fall to include additional interventions and ensure staff were aware of the necessary care. The facility's policy also required care plans to be reviewed and updated after significant changes in a resident's condition, such as a fall. The failure to update the care plan after the resident's fall constituted the deficiency identified in the report.
Failure to Provide Effective Oral Hygiene Care for Dependent Resident
Penalty
Summary
The facility failed to provide effective oral hygiene care for a resident who was dependent on staff for all activities of daily living, including oral care. The resident had significant medical conditions, including dysphagia, a gastrostomy tube, and malnutrition, and was assessed as having severely impaired cognitive skills and poor memory. The care plan specified that oral care should be provided three times daily, but observations revealed the resident had a tan substance on her teeth, dry lips, and a substance on her reddened, swollen tongue. Interviews with staff indicated that oral care was being performed only twice daily, and the CNA acknowledged that the resident's mouth had appeared in poor condition for some time. The RN confirmed the poor state of the resident's mouth and indicated that such a condition would warrant notifying a physician and seeking further interventions. The dental hygienist, who had seen the resident recently, noted difficulty in providing care due to the resident's lack of cooperation and was unable to confirm whether consistent oral care was being provided. Subsequent observations showed some improvement in the resident's oral condition, but documentation and interviews confirmed that the facility's policy of maintaining moist lips and oral tissues and preventing oral infection was not consistently followed. The DON stated that daily oral care is especially important for residents with g-tubes and acknowledged that the observed condition of the resident's mouth was unacceptable.
Failure to Lock Bed and Hoyer Lift During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNA2 and CNA3) failed to lock both the bed and the Hoyer lift before placing the sling under a resident with a history of hemiplegia, hemiparesis, cerebral infarction, aphasia, and previous falls. The resident's care plan specifically required a safe environment with bed wheels locked and assistance with all transfers due to impaired gait, balance, and mobility. During the observed transfer, neither the bed nor the Hoyer lift was locked, contrary to the care plan and facility policy. Interviews with the involved CNAs, a Licensed Vocational Nurse, and a Registered Nurse confirmed that both the bed and the Hoyer lift should have been locked to ensure safety and prevent accidents. The facility's policy on using mechanical lifts also required staff to ensure the lift was stable and locked before use. The failure to follow these procedures was directly observed and acknowledged by staff, representing a lapse in implementing required safety measures for the resident.
Failure to Complete Required Bowel and Bladder Assessments
Penalty
Summary
The facility failed to perform a quarterly bowel and bladder assessment for a resident as required by the resident's care plan. The care plan specified that assessments should be completed on admission, quarterly, and as needed, but documentation showed that the last assessment was performed on 2/14/2025, with no subsequent assessments recorded. This omission was confirmed during interviews with both a registered nurse and the Director of Nursing, who acknowledged that the quarterly assessment had not been completed as required. The resident involved had multiple medical diagnoses, including congestive heart failure, cirrhosis of the liver, reduced mobility, and adult failure to thrive. The resident was cognitively intact, able to make needs known, and required substantial assistance with toileting hygiene. The resident was frequently incontinent of both bowel and bladder, and the care plan included a goal to prevent complications from incontinence, such as skin breakdown or infection. Despite these needs, the required ongoing assessments to monitor and manage the resident's continence status were not performed according to the care plan schedule. Facility policy and procedure documents indicated that comprehensive, person-centered care plans should be developed and implemented for each resident, including measurable objectives and timeframes. The policies also required ongoing assessment and management of urinary continence and incontinence, with regular documentation and review. The failure to follow these policies and the resident's care plan resulted in a deficiency related to the lack of timely bowel and bladder assessments.
Failure to Label G-Tube Flush Bag for Resident Receiving Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of aphasia, dysphagia, and malnutrition, who was dependent on gastrostomy tube (g-tube) feeding, was observed to have a flush bag attached to their g-tube pump that was not labeled with the date, time, and nurse's initials. The resident's care plan specifically required that the formula container, syringe, and administration set be labeled with the resident's name, date, time, and nurse's initials. During observation and interview, both the treatment nurse and an LVN confirmed that the flush bag was not labeled as required. Further interviews with the LVN and the Director of Nursing confirmed that the lack of labeling on the flush bag could result in not knowing when the flush was hung and could pose a risk of infection. Review of the facility's policy indicated requirements for labeling the formula but did not specifically address labeling of the flush bag. The failure to label the flush bag as outlined in the resident's care plan constituted the deficiency.
Failure to Administer and Document Physician-Ordered Medication for Allergic Reaction
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who was admitted with diagnoses including fibromyalgia and disturbances of skin sensation, experienced facial itching due to a possible allergic reaction. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the date of the incident, the resident complained of facial itching, and a Change in Condition Evaluation was completed. The primary physician was notified and gave an order to administer Benadryl 25 mg orally every six hours for 14 days as needed for itching. This order was documented in the resident's physician order and care plan, which included the intervention to administer Benadryl as needed for itching. However, review of the Medication Administration Record (MAR) showed that the Benadryl was not signed as given on the date of the incident. The resident later stated in a telephone interview that she did not receive the Benadryl. The LVN involved stated she administered the medication, but there was no documentation to support this. Both the registered nurse supervisor and the director of nursing confirmed during interviews and record reviews that the MAR was not signed and there was no other documentation indicating the medication was given. Facility policy requires that the individual administering medication must document the administration on the MAR, including date, time, dosage, route, symptoms, results, and signature. The lack of documentation and failure to administer or record the administration of Benadryl as ordered constituted the deficiency.
Failure to Post Actual Staff Hours as Required
Penalty
Summary
The facility failed to comply with the federal requirement to post the actual hours worked by staff daily in an area accessible to the public. On the observed day, the Direct Care Services Hours Per Patient Day (DHPPD) actual hours were not posted, only the projected hours were displayed. This deficiency was identified during an observation on 11/12/2024, where it was noted that the DHPPD for the previous day (11/11/2024) was also missing. Interviews with the Director of Staff and Development (DSD) and the Director of Nursing (DON) revealed a misunderstanding of the posting requirements. The DSD was unsure if actual hours needed to be included, while the DON initially believed only projected hours were necessary. However, upon reviewing the facility's policy, the DON acknowledged that actual hours for the previous day should have been posted alongside the current day's projected hours. The facility's policy clearly stated that shift staffing information, including actual hours worked, must be recorded and maintained for 24 hours in a single location.
Failure to Administer Pomalyst as Prescribed
Penalty
Summary
The facility failed to implement a consistent and accurate system for reconciling the administration of Pomalyst, an oral chemotherapeutic capsule prescribed for a resident with multiple myeloma. This failure resulted in the resident missing two doses of the medication on specified dates. The resident, who was admitted with multiple diagnoses including multiple myeloma, type 2 diabetes mellitus, and end-stage renal disease, was prescribed Pomalyst to be taken on specific days. However, the medication was not administered as ordered, leading to missed doses. During interviews, it was revealed that the resident was aware of the prescription but reported not receiving the medication as prescribed. The Director of Nursing confirmed the missed doses upon reviewing the Medication Administration Record. An LVN admitted to not administering the medication on one occasion due to being unable to locate it in the medication cart. The pharmacist emphasized the importance of administering Pomalyst as prescribed to avoid potential side effects. The facility's policy indicated that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure dignity and respect for two residents, resulting in a deficiency related to resident rights. Resident 2, who was admitted with conditions including hypertension, low back pain, anemia, and cellulitis, reported an incident where a CNA yelled at them and another resident for questioning the care provided. This incident occurred after Resident 2 assisted another resident who was cold and uncovered. Resident 2 expressed that staff frequently yelled during the night shift, which was inappropriate behavior. Resident 7, who was admitted with osteoarthritis, anemia, reduced mobility, and lack of coordination, corroborated the occurrence of yelling, having heard an argument involving multiple people around the same time as Resident 2's incident. Both residents had intact cognition and required varying levels of assistance from staff for daily activities. The facility's policy on resident rights, revised in 2016, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to a resident with multiple medical conditions, including an amputation site, acute respiratory failure with hypoxia, and an arterial ulcer on the right lower leg. The facility did not assess or document the condition of the resident's arterial ulcer upon admission, nor did they develop a comprehensive care plan that included the physician's order for treatment of the ulcer. The treatment order, which required daily care for 21 days, was not followed, resulting in the resident not receiving treatment for over two weeks. Additionally, the facility did not adequately monitor the resident's respiratory status as per the continuous oxygen therapy care plan. There were discrepancies in the documentation of the resident's oxygen saturation levels, and the facility failed to administer the correct amount of oxygen as required. This lack of proper monitoring and treatment contributed to the resident's transfer to a general acute care hospital, where they presented with altered levels of consciousness, shortness of breath, and right ankle pain. The resident's condition deteriorated further at the hospital, where they were diagnosed with soft tissue ulceration with underlying osteomyelitis, pulmonary edema, and adjacent atelectasis. Despite the hospital's efforts, the resident passed away three days after the transfer. Interviews with facility staff revealed that the treatment order was incorrectly documented, and the care plan was not initiated upon admission, leading to a lack of interventions for the resident's wounds.
Failure to Administer Medication Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 78, who was at risk for malnutrition. Resident 78 did not receive 17 doses of Megestrol Acetate Suspension, an appetite stimulant, as ordered by the physician. This failure was due to the medication not being available in stock, and the facility did not maintain accurate medication administration records. The medication was marked as administered on multiple occasions when it was not available, leading to significant weight loss for the resident. Resident 78 was admitted with several diagnoses, including an intracranial abscess, hearing loss, and gastroesophageal reflux disease. The resident had intact cognition and required assistance with activities of daily living. Despite being at risk for malnutrition, as indicated by a Mini Nutrition Evaluation score, the facility's interventions to administer the appetite stimulant were not followed. The medication administration records inaccurately reflected that the medication was given, even though it was not in stock, as confirmed by interviews with the nursing staff and the Director of Nursing. The facility's policies and procedures required that medications be administered according to prescriber orders and documented immediately after administration. However, the facility failed to adhere to these policies, resulting in Resident 78 experiencing more than a five percent weight loss in one month. The Registered Pharmacist confirmed that the medication was requested but not delivered until a later date. Interviews with the nursing staff revealed a lack of awareness and adherence to proper documentation practices, contributing to the deficiency.
Failure to Label and Date Stored Food
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was properly labeled and dated, which could potentially lead to food-borne illnesses for all residents receiving food from the kitchen. During an initial kitchen tour, surveyors observed several items in the walk-in refrigerator that were unlabeled and undated, including unopened and opened bags of whole wheat bread, hamburger buns, and various frozen vegetables such as broccoli, spinach, mixed vegetables, peas, carrots, and cauliflower. The Dietary staff confirmed that these items were not labeled or dated, acknowledging that all food stored in the kitchen should be labeled and dated to track their usability and prevent food-borne illnesses. The Director of Nurses also confirmed that all food stored in the kitchen should be labeled and dated to ensure the safety of the residents. A review of the facility's policy and procedure on labeling and dating foods indicated that all food items in storage areas, including the storeroom, refrigerator, and freezer, need to be labeled and dated. The policy specifies that food delivered to the facility should be marked with a received date, and newly opened food items should be labeled with an open date and a use-by date according to various storage guidelines. This deficiency highlights a failure to adhere to the facility's established procedures for food safety.
Failure to Develop Individualized Care Plan for Resident with Diabetes
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for a resident, identified as Resident 40, who was admitted with diagnoses including Type II diabetes, unsteadiness on feet, and major depressive disorder. Despite the resident's condition requiring specific interventions, the facility did not create a care plan addressing hyperglycemia after a significant change in the resident's condition was noted. On 3/7/2024, Resident 40 experienced an elevated and uncontrolled blood sugar level of 495 mg/dl, yet no care plan was developed to manage this condition. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that licensed staff were required to develop and implement care plans with appropriate interventions following a change in a resident's condition. However, this was not done for Resident 40, leading to a lack of care and monitoring. The facility's policy indicated that care plans should be revised as residents' conditions change, but this was not adhered to in this case, resulting in the deficiency.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a right heel deep tissue injury (DTI) as per the comprehensive assessment and professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with a diagnosis of pressure-induced deep tissue damage. The care plan for the resident, initiated shortly after admission, included interventions to monitor and document changes in the wound's condition, such as color, drainage, odor, sensation, and pain, as well as weekly measurements of the wound. However, these interventions were not implemented for a period of 16 days. During this period, there was no documentation in the resident's medical record or the Treatment Administration Record (TAR) regarding the condition of the right heel DTI. This lack of documentation included essential details such as the wound's color, drainage, odor, sensation, and measurements, which were required by the care plan. Observations and interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of documentation and highlighted the potential risk of infection or worsening of the wound due to this oversight. The facility's policies and procedures for charting, documentation, and wound care required detailed recording of treatment and assessment data, including the date and time of procedures, assessment findings, and the resident's response to treatment. Despite these requirements, the facility did not adhere to its own policies, resulting in a failure to track the resident's progress and potentially compromising the resident's care.
Failure to Implement and Update Fall Prevention Plan
Penalty
Summary
The facility failed to implement and update the Risk for Falls Care Plan for a resident with a history of falls, identified as Resident 64. The care plan, dated 12/5/2023, included interventions such as a yellow star on the wall above the headboard, a gold star on the name plate, a yellow fall risk wristband, yellow non-skid socks, and a yellow star on the wheelchair. These interventions were not implemented, as observed on 5/8/2024, when the resident was seen without the required fall prevention items. Additionally, the care plan was not revised following a fall on 2/16/2024, which resulted in a skin abrasion on the resident's right anterior forearm. The facility's policy on Falls and Fall Risk Management, revised in 3/2018, requires a resident-centered fall prevention plan to be implemented and updated as needed. However, the care plan for Resident 64 was not updated after the fall, and the interventions were not in place, as confirmed by the Director of Nursing during an interview. The facility's policy on comprehensive person-centered care plans, revised in 7/2017, also mandates that care plans be revised when there is a significant change in a resident's condition, which was not adhered to in this case.
Failure to Properly Label and Store Nasal Cannula Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring the nasal cannula (NC) tubing was labeled and stored in a plastic bag. The resident, who was admitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, had a care plan that required continuous oxygen therapy at two liters per minute via NC to maintain oxygen saturation above 93%. Observations revealed that the NC tubing was not labeled and was improperly stored, either hanging over a tube feeding machine or placed inside a bedside drawer. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the NC tubing should have been labeled with the date and stored in a plastic bag to prevent contamination and infection. The facility's policy indicated that the oxygen cannula and tubing should be changed every seven days or as needed and stored in a plastic bag when not in use. The failure to adhere to these protocols put the resident at risk for infection and complications associated with oxygen therapy.
Lack of Justification for Continued Antidepressant Use
Penalty
Summary
The facility failed to provide documented justification for the continuation of the antidepressant medication Effexor beyond 30 days for a resident diagnosed with major depressive disorder, among other conditions. The resident was admitted with diagnoses including major depressive disorder, osteoarthritis, and difficulty in walking. The care plan for the resident included administering medications as ordered and monitoring for side effects and effectiveness, but there was no review date indicated for the goal of being free of depression symptoms. The resident received Effexor daily, and there were no episodes of verbalization of sadness recorded during this period. The Consultant Pharmacist's Medication Regimen Review (MRR) from January to April did not include any recommendations, actions, or rationale for the continued administration of Effexor. The facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and report any non-life-threatening medication irregularities to the attending physicians. However, there was no documentation of a Gradual Dose Reduction (GDR) for the resident, which the Director of Nurses acknowledged as important to ensure the necessity of the prescribed medications.
Medication Error Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically by not having the medication Megestrol Acetate Oral Suspension available for administration for 17 days. This medication was prescribed to stimulate the resident's appetite, and its absence led to significant weight loss. The resident, who was admitted with various medical conditions including intracranial abscess and gastroesophageal reflux disease, was at risk for malnutrition due to the lack of medication. During a medication pass observation, it was noted that the medication was not available in the medication cart, and the Licensed Vocational Nurse (LVN) inaccurately marked the medication as administered. This error was repeated by multiple nurses over the course of several days, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that the medication was not delivered until much later, and the Registered Pharmacist corroborated that the medication was requested but not delivered until a later date. Interviews with staff and the resident's representative revealed that the resident had not been eating well and experienced a significant weight loss from 182 pounds to 156 pounds. The Registered Dietician noted that the resident's oral intake was initially stable but declined due to the lack of the appetite stimulant and ongoing antibiotic treatment. The facility's policies on medication administration and documentation were not followed, contributing to the deficiency.
Improper Storage of Ophthalmic Solution
Penalty
Summary
The facility failed to ensure the safe storage of Dorzolamide-Timolol Ophthalmic Solution, a medication used to treat high pressure in the eyes, for a resident. During an observation and interview, it was found that the medication was stored in a refrigerator at 40 degrees Fahrenheit, contrary to the manufacturer's requirement of storing it between 68 to 77 degrees Fahrenheit. The Licensed Vocational Nurse (LVN) acknowledged the improper storage and indicated that the medication should not have been refrigerated, as this could render it ineffective. The Director of Nursing (DON) confirmed that the Dorzolamide-Timolol should not have been stored in the refrigerator, as improper storage could lead to the medication being ineffective in treating elevated eye pressure. The facility's policy on medication storage, dated April 2019, requires that drugs and biologicals be stored under proper temperature, light, and humidity controls, which was not adhered to in this instance.
Failure to Adjust Laxative Administration for Resident with Loose Stools
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident experiencing a change in bowel condition, specifically frequent loose stools. The resident, who was admitted with multiple medical conditions including multiple myeloma, malnutrition, and dependence on renal dialysis, was prescribed MiraLAX, a laxative, to be taken every 12 hours for constipation. Despite the resident experiencing frequent loose stools, the facility continued administering the laxative without notifying the physician or adjusting the treatment plan. The resident's medical records indicated frequent loose bowel movements over several weeks, yet there was no documentation of the physician being informed of this change in condition until much later. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's diarrhea, with some staff members unaware of the resident's condition or the need to adjust the laxative dosage. The Director of Nursing acknowledged that the resident should not have been given MiraLAX with loose stools and that the physician should have been notified sooner. The facility's policies required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The resident's diarrhea was eventually linked to chemotherapy and dialysis, and the laxative was deemed unnecessary. The failure to address the resident's change in condition in a timely manner posed a risk of dehydration and other complications, highlighting a deficiency in the facility's care and communication processes.
Failure to Review Transfer Records Leads to Missed Appointments
Penalty
Summary
The facility failed to thoroughly review the transfer records from the general acute hospital (GACH 1) for a resident admitted on 3/16/24. The resident had multiple follow-up appointments arranged by GACH 1 for vascular diagnostics, chemotherapy, and consultations with a hematologist and pulmonologist. However, the facility did not review the inpatient progress notes that contained these appointments. Instead, the admitting registered nurse (RNS) only reviewed the medication pages to transcribe the admission orders and verify them with the resident's primary physician. This oversight resulted in the resident missing several critical medical appointments scheduled between 3/18/24 and 4/25/24. Interviews with the director of nursing (DON) and RNS 1 revealed that GACH 1 did not inform the facility about the resident's appointments during the pre-admission report. The facility's policies on charting, documentation, and admission were reviewed, indicating that documentation should be complete and accurate, and preliminary resident information should be documented upon admission. Despite these policies, the failure to review the transfer records thoroughly led to a delay in the resident's treatment for multiple myeloma, anemia, and other conditions requiring substantial assistance with daily activities.
Failure to Safeguard Resident's Personal Funds
Penalty
Summary
The facility failed to safeguard personal funds for one resident. The Licensed Vocational Nurse (LVN) retrieved $800 from the resident and placed the money in the narcotic box instead of following the proper procedure. The resident, who was cognitively intact and required maximum assistance with daily activities, had been admitted with $900, of which $100 was kept in their wallet and $800 was stored in the medication cart by staff. The Social Services staff observed the $800 in the medication cart the following day, but it was not removed and placed in the business office until two days later. The facility's policy required that the money be transferred to the business office on the next available business day, with the transaction requiring two signatures. The delay in transferring the funds and improper initial storage in the narcotic box led to the potential risk of the resident's personal funds being stolen or misused.
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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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