Park Regency Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Habra, California.
- Location
- 1770 W. La Habra Blvd., La Habra, California 90631
- CMS Provider Number
- 555536
- Inspections on file
- 25
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Park Regency Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were not provided with timely, individualized care plans after assessments identified wandering and elopement risks. In both cases, care plans addressing these risks were not initiated until days after the behaviors or risks were documented, as confirmed by RN and DON review.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility after staff failed to complete an elopement risk assessment and did not respond promptly to a door alarm. Staff interviews confirmed lapses in supervision and failure to follow protocols, resulting in the resident being found outside the facility by police.
A resident with a Stage 3 pressure injury did not receive a low air loss (LAL) mattress as required by the facility's care plan and protocol. Staff confirmed the absence of a LAL mattress and lack of a physician's order for one, despite the care plan specifying this intervention for wound management. This deficiency was identified through observation, staff interviews, and medical record review.
The facility failed to provide necessary care for three residents, with care plans not addressing floor mat use and incomplete post-fall neurological assessments. Floor mats were observed but not documented in care plans, and neurological flowsheets lacked required assessments, as confirmed by the DON.
The facility failed to assess and supervise two residents' ability to handle hot liquids, leading to an incident where a resident spilled hot chocolate on herself, causing injury. Despite the facility's policy requiring such assessments, they were not conducted, and the resident was left unsupervised while consuming the hot beverage. This posed a risk of injury to residents consuming hot liquids.
The facility failed to maintain sanitary conditions in the kitchen, with observations of chipped and discolored utensils, unclean equipment with food residue, and improper drying of blenders. The kitchen hood also had dirt residue, posing contamination and fire risks. The DSS confirmed these issues, acknowledging the potential hazards.
The facility failed to conduct complete entrapment assessments for residents using side rails, impacting 15 residents. Observations and interviews revealed that the Bed System Measurement Device Test Results Worksheets lacked documentation for critical zones, posing potential risks. Despite physician orders for side rails, the facility's maintenance staff did not assess all necessary zones, which was confirmed by the Maintenance Director and acknowledged by the administration.
The facility failed to ensure call lights and bed controls were accessible for several residents, including one with a non-functional call light. Observations revealed call lights on the floor or out of reach, and a bed control on the floor. These residents had cognitive impairments or required substantial assistance, highlighting the importance of accessibility.
The facility failed to maintain a clean and homelike environment for several residents. A resident was observed entering a shower room with a soiled towel and unpackaged adult briefs, raising infection control concerns. Another resident's room had scratches, unpainted areas, and stained curtains, leading to dissatisfaction. Additional residents' rooms had similar maintenance issues, indicating a risk for unsanitary conditions and potential impact on residents' quality of life.
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. One resident, diagnosed with psychosis and major depressive disorder, was inaccurately screened as having no mental illness, despite being prescribed Seroquel. Another resident with a depressive disorder was also incorrectly screened, missing a potential Level II evaluation. The MDS Coordinator and DON acknowledged these discrepancies.
A resident with severe cognitive impairment and high fall risk was found without the required floor mattresses on both sides of their bed, as ordered by the physician and outlined in the care plan. This deficiency was observed during a facility tour and confirmed by both an LVN and the DON, highlighting a failure to follow the facility's Fall Prevention Program policy.
The facility failed to maintain proper care and documentation for PICC lines for two residents. Upon admission, required measurements and documentation were not completed, and care plans did not address the PICC lines. Dressings were not changed weekly as per policy, and there was no physician's order for one resident's PICC line care. These failures were confirmed by staff interviews and medical record reviews.
A resident with a history of central cord syndrome and other conditions was not administered the correct dosage of oxycodone for severe pain levels, as per physician's orders. Despite the facility's policy to manage pain according to comprehensive assessments, the resident received a lower dosage than prescribed for pain levels recorded as 8. Interviews with staff confirmed the oversight, highlighting a potential for ineffective pain management.
A facility failed to monitor and document the fluid intake and output for a resident with end-stage renal disease requiring dialysis. Despite a physician's order for a strict fluid restriction, the facility did not record the resident's fluid intake, as confirmed by staff interviews and medical record reviews. This oversight risked the resident's health due to their impaired kidney function.
The facility failed to ensure proper documentation and informed consent for bed rail use, affecting multiple residents. Observations and interviews revealed incomplete consent forms, missing physician orders, and absent care plans, posing potential risks to resident safety.
The facility failed to ensure informed consent and proper monitoring for residents prescribed psychotropic medications. Several residents were given antipsychotic drugs without signed consent forms, and there was inadequate monitoring for side effects and behavior manifestations. The facility's administration acknowledged these deficiencies.
The facility failed to ensure proper storage, labeling, and disposal of medications. Expired medications were found in Medication Room A and Treatment Cart A, while improper storage practices were observed in Medication Carts A and C. Medications were not stored separately according to their routes of administration, and some lacked proper labeling with open dates. These deficiencies were verified by LVNs and acknowledged by the DON.
The facility failed to ensure safe storage and handling of food brought by family or visitors, as it lacked a designated refrigerator for residents. The policy required food to be consumed within two hours, but did not address storage for later consumption, leading to potential food safety risks.
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies in advance directives, treatment documentation, and informed consents. A resident's POLST was incomplete, while two others had conflicting advance directive information. Another resident's TAR lacked documentation of wound care treatments. Additionally, informed consents for side rails and medications were incomplete or missing physician signatures.
The facility failed to provide information on formulating advance directives and maintain documentation for three residents. One resident was not informed about advance directives despite having the cognitive ability to understand, while another's POLST was incomplete, and a third's advance directive was not documented. The DON and SSD confirmed these deficiencies.
The facility failed to ensure accurate documentation and reconciliation of controlled medications for several residents, leading to discrepancies in the Medication Administration Record (MAR) and Controlled Drug Record. Staff interviews confirmed the lapses, and the Director of Nursing acknowledged the issues.
A resident did not receive a dose of either Keppra or metformin due to a leaking medication cup during administration via enteral tube. The LVN could not identify which medication was not given, and the DON confirmed the error but was unable to determine which medication was missed. The resident, who cannot make medical decisions, was prescribed these medications for seizures and diabetes management.
The facility failed to assess and offer the COVID-19 vaccine to two residents as per its policy. One resident's medical record lacked documentation of vaccination status or an offer of the vaccine. Another resident, who was on antibiotics, had consented to vaccination but was not re-offered the vaccine after completing treatment. These deficiencies were confirmed during a review with the IP.
The facility failed to ensure glucometer quality control tests were accurately documented, with discrepancies found between recorded and observed results for two medication carts. LVNs confirmed that night shift nurses were responsible for these tests, and the DON acknowledged the expectation for nightly completion. This failure had the potential to result in inaccurate glucose readings for residents.
A resident's privacy was compromised during ADL care when a CNA left the door open, exposing the resident to passersby. Additionally, an LVN left a computer monitor displaying the resident's medical information unattended at the nurses' station, violating confidentiality policies.
The facility failed to maintain a pest-free environment as cockroaches were observed in the conference room, posing a potential infection risk. The facility's Pest Control Program requires effective eradication of pests, but observations on multiple occasions confirmed the presence of cockroaches. The QA RN, Social Services Director, and Maintenance Director all acknowledged the infestation and its associated risks.
Failure to Timely Develop Care Plans for Wandering and Elopement Risks
Penalty
Summary
The facility failed to develop and implement timely, individualized care plans for two residents with identified behavioral and safety risks. For one resident with severe cognitive impairment, documentation showed the resident exhibited wandering behavior by attempting to enter other female rooms, as noted on an assessment dated 8/13/25. Despite this, there was no evidence that a care plan addressing this behavior was developed prior to the resident's elopement on 8/17/25. Both the RN and DON confirmed that the care plan should have been initiated as soon as the wandering behavior was observed, but it was not started until after the elopement occurred. For a second resident with moderate cognitive impairment, an assessment identified the resident as being at risk for elopement. However, the medical record did not show that a care plan addressing this risk was developed until several days after the risk was identified. The RN and DON both acknowledged that the care plan should have been created immediately upon identification of the elopement risk. These failures were confirmed through interviews and medical record reviews, and were acknowledged by facility leadership.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to provide necessary care and services to prevent accident hazards for a resident with severe cognitive impairment, resulting in an elopement incident. The resident, who had a documented history of wandering and attempting to enter other residents' rooms, was not assessed for elopement risk following a change in condition. Despite facility policy requiring elopement risk assessments and timely staff response to alarms, there was no documented evidence that the required assessment was completed after the resident exhibited wandering behavior. On the day of the incident, the resident was able to leave the facility in a wheelchair without staff noticing, and the door alarm was not responded to promptly by staff members present. Interviews with staff revealed that the CNA did not hear the door alarm due to being busy, and another staff member, who heard the alarm during a lunch break, did not investigate, assuming someone else would respond. The lapse in supervision and failure to follow established protocols allowed the resident to exit the facility unsupervised. The resident was later found by police outside the facility. Facility leadership acknowledged that the elopement risk assessment should have been completed and that staff should have responded immediately to the door alarm.
Failure to Provide LAL Mattress for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure injury for one resident with a Stage 3 pressure injury. Despite the facility's policy and care plan indicating that a low air loss (LAL) mattress should be used for wound management in such cases, the resident was observed using a regular mattress. Multiple staff interviews confirmed that the resident did not have a LAL mattress upon admission and that there was no physician's order for one, even though it was facility protocol for residents with Stage 3 pressure injuries to have this intervention. Medical record review showed the resident was admitted with a Stage 3 pressure injury measuring 3 cm by 2 cm, and the care plan included an intervention for a LAL mattress. However, this intervention was not implemented, as verified by staff and direct observation. The failure to provide the LAL mattress as required by both the care plan and facility policy constituted a deficiency in the provision of necessary care and services for the resident's pressure injury.
Deficiencies in Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services were provided for three residents, leading to deficiencies in fall prevention and post-fall assessments. For two residents, the care plans did not properly address the use of floor mats, which were observed by their beds but not documented in their care plans. Interviews with the LVN and DON revealed that the floor mats were intended as a nursing intervention for fall risk residents, but the care plans were not updated to reflect this intervention. This oversight occurred despite the residents having experienced unwitnessed falls that required hospital evaluation. Additionally, the facility did not complete post-fall neurological assessments for two residents who had unwitnessed falls. The neurological flowsheets for these residents were missing several assessment items, which were supposed to be documented according to the facility's policy. The DON confirmed that the neurological assessments were incomplete, indicating a failure to adhere to the facility's fall prevention program and documentation requirements.
Failure to Assess and Supervise Residents Handling Hot Liquids
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 1 and 3, were free from accident hazards related to the consumption of hot liquids. The facility's policy required an assessment of residents' ability to handle containers and consume hot liquids, but this was not completed for either resident. Resident 1 experienced an incident where she spilled hot chocolate on herself, resulting in redness and blisters on her left shoulder and upper back. The incident occurred while Resident 1 was lying in bed, not in an upright position, and without adequate supervision. Resident 1 had a history of cognitive loss, forgetfulness, and required partial to moderate assistance with eating due to impairments in both upper extremities. Despite these needs, there was no documented assessment of her ability to handle hot liquids. On the day of the incident, Resident 1 was given hot chocolate by a CNA, who then left to attend to another resident. Resident 1 attempted to drink the hot chocolate but spilled it on herself, causing injury. Interviews with staff confirmed that Resident 1 needed cuing and supervision during meals, and no specific assessment for handling hot liquids was conducted. Similarly, Resident 3's medical records showed no evidence of an assessment for handling hot liquids, as required by the facility's policy. Interviews with the RN confirmed the lack of such assessments for both residents. The facility's failure to conduct these assessments and provide adequate supervision posed a risk of injury to residents consuming hot liquids, as evidenced by the incident involving Resident 1.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a survey. Kitchen utensils were found to be in poor condition, with chipped, discolored, and partially melted surfaces, which did not comply with the USDA Food Code 2022 requirements for utensils to have a smooth, cleanable surface. The Dietary Services Supervisor (DSS) confirmed these findings, acknowledging that such utensils should not be used as they pose a hazard and could contaminate food. Additionally, the facility did not ensure that kitchen utensils were clean and free of food particles or residue. Several stainless steel utensils, including tongs, measuring cups, and serving spoons, were observed with dry and crusted residue. The DSS confirmed that these items should not be used and should be properly cleaned and sanitized to prevent cross-contamination. The facility also failed to adhere to proper drying procedures for kitchen equipment. Heavy-duty blenders used for puree preparation were found to be wet and not air-dried before storage, contrary to the facility's policy and USDA Food Code requirements. Furthermore, the kitchen hood was observed with black dirt residue, indicating inadequate cleaning, which the DSS acknowledged. This lack of maintenance could lead to contamination of food with pathogenic organisms and poses a fire hazard.
Incomplete Entrapment Assessments for Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using side rails, impacting 15 residents. The assessments did not include measurements for Zones 1, 6, and 7, which are critical areas for potential entrapment. This oversight was confirmed through observations, interviews, and document reviews, revealing that the Bed System Measurement Device Test Results Worksheets consistently lacked documentation for these zones. Several residents, including those with cognitive impairments and mobility issues, were observed using side rails for assistance with bed mobility and transfers. Despite physician orders and documented needs for side rails, the facility's maintenance staff did not complete comprehensive entrapment assessments. Interviews with staff, including the Maintenance Director, confirmed that only Zones 2, 3, and 4 were assessed, leaving potential risks unaddressed. The deficiency was acknowledged by the facility's administration, including the Director of Nursing and the Administrator. The lack of complete assessments posed a risk of entrapment, which could lead to serious injury or death. The facility's policy required regular inspections and assessments, but these were not fully implemented, as evidenced by the missing documentation for critical zones.
Failure to Ensure Accessibility of Call Lights and Bed Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs of several residents, as observed during a survey. Specifically, the call lights for three residents were not within reach, with one resident's call light found on the floor, another on a floor mat, and a third clipped to the wall above the bed. Additionally, a resident's bed control was found on the floor, out of reach. These residents were noted to have no capacity to make medical decisions or had moderate cognitive impairment, which further emphasizes the importance of having these devices accessible. Another resident's call light button was found to be non-functional, as it was not plugged in correctly. This resident, who required substantial assistance for bed mobility and transfers, reported that the call light had not been working the previous night. The facility's policy requires that call lights be accessible to residents, but this was not adhered to, leading to potential delays in care and impacting the residents' well-being.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Resident 86 was seen entering a shower room that had a soiled towel on the floor and unpackaged clean adult briefs on the floor and shower chair, which was confirmed by RN 2 as an infection control concern. Resident 49's room was found with scratches, unpainted areas on the walls and bathroom door frame, and stained curtains. Resident 49 expressed dissatisfaction with the room's condition, stating he spent most of his time in bed and expected a clean and well-maintained environment. Additionally, Resident 27's room had scratches and unpainted areas on the walls, and she mentioned that painting the walls would make her room more livable. Resident 33's room was observed with scratches and chipped paint on the walls, and although she felt comfortable, she believed her room needed maintenance. These observations indicate a failure to provide a safe, clean, and homelike environment, posing a risk for unsanitary conditions and potentially impacting the residents' quality of life.
Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. Resident 77, diagnosed with unspecified psychosis and major depressive disorder, was prescribed Seroquel, an antipsychotic medication. However, the Level 1 PASRR screening inaccurately indicated no diagnosis of serious mental illness and no psychotropic medication prescriptions, resulting in a negative screening and no Level II evaluation. The MDS Coordinator confirmed the inaccuracies and acknowledged that a Level II evaluation might have been required. Similarly, Resident 53, diagnosed with depressive disorder, had a Level 1 PASRR screening that incorrectly showed no diagnosis of serious mental illness. This screening was completed at an acute care hospital before the resident's readmission to the facility. The MDS Coordinator verified the discrepancy between the PASRR screening and the resident's medical records, which documented the depressive disorder diagnosis. The MDS Coordinator stated that the resident required a PASRR resident review submission to inform the Department of Health Care Services about the diagnosis, potentially necessitating a Level II mental health evaluation. The facility's policy and procedure for coordinating assessments with the PASRR program were reviewed, indicating that all applicants should be screened for serious mental disorders or intellectual disabilities. A negative Level 1 screen permits admission without further PASRR process unless a serious mental disorder arises later, while a positive screen requires a Level II evaluation. The MDS Coordinator and DON acknowledged the findings, highlighting the failure to ensure accurate PASRR screenings and the potential need for Level II evaluations for the residents involved.
Failure to Implement Fall Risk Precautions
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 62, was free from accident hazards as per the physician's orders and the resident's care plan. The deficiency was observed during an initial tour and subsequent observation, where Resident 62 was found lying in a low bed without the required floor mattresses on both sides. This was contrary to the physician's order dated February 3, 2023, and the care plan interventions, which specified the use of floor mattresses as a precautionary measure due to the resident's high fall risk. Resident 62 had a history of severe cognitive impairment, lower extremity impairment, and was at risk for falls due to confusion, psychoactive drug use, psychosis, and dementia with behavioral disturbances. The facility's Fall Prevention Program policy required that residents be assessed for fall risk and receive appropriate interventions. However, the lack of floor mattresses, as confirmed by both an LVN and the DON during interviews, indicated a failure to adhere to the prescribed fall risk precautions, potentially exposing the resident to serious injury.
Deficiency in PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of PICC lines for two residents, Resident 63 and Resident 77. Upon admission, the facility did not complete or document the required measurements of the PICC line's external catheter length and arm circumference for both residents. Additionally, there was no physician's order obtained for the care and maintenance of Resident 77's PICC line, and the facility did not develop a care plan for the use of the PICC line for either resident. These omissions were contrary to the facility's policy and procedures, which require such measurements and documentation to be completed upon admission and weekly thereafter. For Resident 63, the medical record review showed that the PICC line dressing was not changed upon admission as per the physician's order, and the required measurements were not documented until several days later. The resident was receiving IV medications for sepsis and fungal prophylaxis, yet the care plan did not address the PICC line. An interview with RN 1 confirmed that the dressing change and measurements were not completed as required, and the nurse admitted to signing off on tasks that were not performed. Similarly, for Resident 77, the facility failed to document the necessary measurements and did not change the PICC line dressing weekly as required. The resident was receiving IV antibiotics for pneumonia, but the care plan did not include the PICC line. RN 1 confirmed that there was no order for the PICC line dressing change since admission, and the dressing had not been changed weekly. The Director of Nursing verified these findings, acknowledging the lack of documentation and care planning for the PICC lines.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to administer pain medication according to the physician's order for a resident, identified as Resident 87, who was reviewed for pain management. The facility's policy and procedure for pain management, revised on 12/19/22, emphasized managing or preventing pain consistent with the comprehensive assessment and plan of care. However, the medical record review revealed that Resident 87, who had a history of central cord syndrome, wedge compression fracture, multiple rib fractures, and malignant neoplasm of the prostate, was not administered the correct dosage of oxycodone as per the physician's orders. Specifically, on multiple occasions, Resident 87 was given a lower dosage of oxycodone for severe pain levels, which were recorded as 8 on the pain scale, instead of the prescribed higher dosage for such pain levels. Interviews conducted with LVN 7 and the DON confirmed the findings. LVN 7 acknowledged that Resident 87 should have received two tablets of oxycodone 5 mg for the reported pain level of 8, as per the physician's order. The DON stated that licensed nurses were expected to assess the resident's pain and administer medication according to the physician's orders. The failure to administer the correct dosage had the potential for ineffective pain management for Resident 87. The facility's administration, including the Administrator, DON, and Medical Records Assistant, were informed and acknowledged the findings.
Failure to Monitor and Document Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with end-stage renal disease who required dialysis. The resident, who was admitted with a diagnosis necessitating dialysis three times a week, had a physician's order for a strict fluid restriction of 1000 ml per 24 hours. This order specified the distribution of fluid intake across meals and nursing shifts. However, the facility did not monitor or document the resident's fluid intake and output as ordered, which is crucial for managing the resident's condition. Interviews and medical record reviews revealed that the facility staff, including RN 1 and the DON, acknowledged the lack of documentation regarding the resident's fluid intake. The Monitor Record for the resident showed that from late September to early October, there was no recorded evidence of the resident's fluid intake, with only 'X' marks noted in the documentation areas. This oversight had the potential to result in an excess of fluids, posing a risk to the resident's health due to their impaired kidney function.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure the safety of residents through proper documentation and informed consent regarding the use of bed rails. For Resident 83, the Physician's Documentation of Informed Consent was incomplete, lacking a physician's signature and date, despite the resident's diagnosis of Alzheimer's disease and inability to make decisions. Observations confirmed the use of bilateral half side rails without proper consent, and staff interviews acknowledged the oversight. Residents 77 and 80 were also affected by the facility's failure to obtain physician's orders and initiate care plans for the use of side rails. Both residents were observed using the rails for mobility and repositioning, yet their medical records did not reflect the necessary documentation or care plan problems addressing the use of these devices. Interviews with staff confirmed the absence of required orders and care plans, highlighting a systemic issue in the facility's management of side rail use. Additionally, Resident 24's records showed a physician's order for side rail use, but the informed consent documentation was incomplete, missing the physician's signature. Resident 53's case further illustrated the facility's deficiencies, as there was no documentation of informed consent for side rail use upon re-admission. These failures collectively posed a risk of injury to the residents, as acknowledged by the facility's administration and nursing staff.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that five residents were free from unnecessary psychotropic medications, as evidenced by the lack of signed and dated informed consent forms by physicians for the administration of these medications. Residents 13, 23, 77, 83, and 541 were all prescribed antipsychotic medications such as Seroquel and Risperdal without the necessary documentation of informed consent. This oversight was confirmed through interviews with licensed vocational nurses (LVNs) and the Director of Nursing (DON), who acknowledged the absence of physician signatures and dates on the consent forms. In addition to the lack of informed consent, the facility did not adequately monitor residents for adverse side effects associated with the use of psychotropic medications. For instance, Resident 541 was not monitored for orthostatic hypotension or the number of behavioral episodes, and there was no evidence of non-pharmacological interventions being implemented. Similarly, Resident 77's medical records did not show monitoring for orthostatic hypotension or adverse effects related to Seroquel use, despite the care plan indicating such monitoring should occur. Furthermore, the facility's documentation was inconsistent and incomplete regarding the behavior manifestations that warranted the use of psychotropic medications. For example, Resident 541's orders for Seroquel did not match the behavior monitoring orders, leading to discrepancies in the documented reasons for medication use. Additionally, Resident 23's records lacked documentation of behavioral monitoring and non-pharmacological interventions, which were supposed to be part of the care plan. These deficiencies were acknowledged by the facility's administration and nursing staff during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as observed during a survey. In Medication Room A, expired medications for a nonsampled resident were found in the refrigerator, with expiration dates that had already passed. Additionally, in Treatment Cart A, expired medications such as Bacitracin Zinc ointment, hydrocortisone cream, and triple antibiotic ointment were not removed from the current treatment supply. These expired medications were verified by the respective LVNs, who acknowledged that expired medications should not be administered due to potential adverse effects. Further inspection of Medication Cart A revealed improper storage practices, where orally administered medications were not stored separately from externally used medications and supplies. Items such as nitroglycerin tablets were stored with artificial tears, and stool softeners were stored with topical creams. Additionally, medication bottles and trays were found with sticky residues, and some opened medications lacked proper labeling with open dates. These findings were confirmed by the LVN present during the inspection. In Medication Cart C, similar issues were observed, including the improper storage of medications with different routes of administration. A bottle of shell calcium tablets was stored with suppositories and topical creams, and medications for two residents were found without open dates. The DON was informed of these findings and acknowledged the issues. These deficiencies in medication management had the potential to negatively impact residents' well-being and the effectiveness of the medications.
Deficiency in Safe Storage of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure the safe use and storage of food brought in by family members or visitors, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy and procedure (P&P) stated that residents have the right to receive food from outside sources, but it must be handled safely. The P&P required that all food items brought in must be approved by nursing staff to ensure they align with the resident's diet order, consumed within two hours, and any leftovers discarded. However, the facility did not have a designated refrigerator for residents, which was acknowledged by the Director of Social Services (DSS), Registered Dietitian (RD), and Director of Nursing (DON) during interviews. The DSS, RD, and DON confirmed that the facility lacked a refrigerator for residents and that food brought from outside was intended for immediate consumption within two hours. The DON further stated that they discouraged families from bringing perishable food due to concerns about mold and insects. The facility's P&P did not address the storage of food if a resident or their responsible party preferred to eat it later or beyond the two-hour window. This oversight in the facility's policy and lack of proper storage facilities contributed to the deficiency identified by the surveyors.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies and omissions in critical documentation. For Resident 541, the Physician Orders for Life-Sustaining Treatment (POLST) was incomplete, lacking advance directive information. Similarly, Residents 291 and 49 had conflicting information regarding their advance directives, with discrepancies between their POLST forms and Advance Directive Acknowledgment forms. These inconsistencies were verified by the Social Services Director (SSD) during interviews and record reviews. Resident 87's Treatment Administration Record (TAR) for October 2024 was found to be inaccurate. Although physician orders were in place for wound care treatments on the resident's heels, there was no documentation of these treatments being administered from October 3 to October 7, 2024. Licensed Vocational Nurse (LVN) 4 confirmed that the treatments were given but not signed off in the TAR, and there was no documentation in the progress notes to explain the omission. Additional deficiencies were noted in the informed consent documentation for Residents 12, 13, and 62. Resident 12's consent for side rail use was incomplete, lacking confirmation from the resident or responsible party. Resident 13's consent for bilateral half side rails was missing the physician's signature and date. For Resident 62, informed consents for multiple medications were not signed by the physician, despite verification that consent was obtained from the responsible party. These findings were acknowledged by the Director of Nursing (DON) and other staff members during interviews.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure that information on how to formulate an advance directive was provided to Resident 33, who had the cognitive capacity to understand and make decisions. Despite having an Advance Directive Acknowledgment form indicating that Resident 33 had executed an advance directive, the resident stated she did not have one and was not provided with information on how to formulate it. The facility's records showed conflicting information between the POLST and the Advance Directive Acknowledgment form, and the Director of Nursing (DON) confirmed that there was no advance directive in the medical record. For Resident 87, the facility did not maintain a copy of the advance directive in the medical record, despite the resident having executed one. The POLST form was incomplete, lacking information and signatures in Section D. The Social Services Department (SSD) acknowledged that there was no documentation showing follow-up to obtain a copy of the advance directive from the resident's representative, who had promised to fax it to the facility. Resident 23's medical record also lacked a copy of the advance directive, and the POLST form did not document whether the resident had an advance directive. The SSD confirmed that there was no follow-up to verify the presence of an advance directive, and RN 1 verified that the advance health care directive was not maintained in the medical record. These deficiencies indicate a failure to uphold residents' rights to have their treatment preferences documented and respected.
Controlled Medication Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate reconciliation and documentation of controlled medications for several residents. Specifically, the administration of hydrocodone/apap for Residents 54, 741, and 742 was not accurately documented in the Medication Administration Record (MAR), despite being signed out in the Controlled Drug Record. Additionally, Resident 48's hydrocodone/apap administration was not documented in the Controlled Drug Record, leading to discrepancies in the medication count. The facility's policies and procedures for medication administration and controlled substance accountability were not followed. The Controlled Substance Shift Count Log for Medication Cart C was also incomplete, with missing signatures from licensed nurses for specific shifts. These lapses in documentation and accountability posed a risk for medication diversion. Interviews with staff, including LVN 7, LVN 5, and RN 3, confirmed the discrepancies and acknowledged the failure to document medication administration as required. The Director of Nursing (DON) was informed of these findings and acknowledged the issues identified during the survey.
Medication Administration Error Due to Leaking Medication Cup
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 76, was free from significant medication errors. During a medication administration observation, it was noted that a liquid medication intended for Resident 76 leaked from the medication cup into the medication tray, resulting in the medication not being administered. The Licensed Vocational Nurse (LVN) involved was unable to identify which medication had leaked, as both Keppra, an anticonvulsant, and metformin, an antidiabetic medication, were prepared in unlabeled cups. This incident occurred despite the facility's policy and procedure for medication administration via enteral tube, which requires each medication to be administered separately and not combined. Resident 76, who lacks the capacity to make medical decisions, was prescribed Keppra to manage seizures and metformin for diabetes mellitus. The Director of Nursing (DON) confirmed the medication cup leakage and acknowledged that one of the medications was not administered, although it was unclear which one. The DON communicated with the physician's assistant (PA) on call, who ordered an additional dose of Keppra and instructed monitoring of the resident's blood glucose levels. However, the DON did not initially seek laboratory tests to assess the resident's condition following the medication error.
Failure to Assess and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 23 and 80, were assessed for their COVID-19 vaccination status or offered the COVID-19 vaccine, as per the facility's policy. The policy, revised on June 9, 2023, mandates that residents and staff be educated and offered the COVID-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. However, a review of Resident 23's medical record showed no documentation of the resident's COVID-19 vaccination status or any offer of the vaccine. For Resident 80, the medical record indicated that informed consent for the COVID-19 vaccination was obtained on July 1, 2024, but the resident was on antibiotics and chose to wait until the treatment was completed. The facility's records did not show any evidence that Resident 80 was re-offered or received the COVID-19 vaccine after completing the antibiotic treatment. These findings were verified during an interview and medical record review with the Infection Preventionist (IP) on October 9, 2024.
Failure to Maintain Accurate Glucometer Quality Control
Penalty
Summary
The facility failed to maintain essential equipment, specifically glucometers, in safe operating condition. During a review of the Assure Platinum Glucose Monitoring System's Quality Control Records for two medication carts, it was found that the quality control test results documented in the logs did not match the results observed on the glucometer devices. For Medication Cart A, discrepancies were noted on 10/8/24 and 10/9/24, where the normal and high control results were recorded as 88 mg/dL and 230 mg/dL, and 87 mg/dL and 226 mg/dL, respectively, but these results were not observed on the device. Similarly, for Medication Cart C, discrepancies were found for multiple dates, including 10/2/24 through 10/9/24, with recorded results not matching those on the glucometer. Licensed Vocational Nurses (LVNs) 7 and 5 verified these findings, acknowledging that the 11-7 shift licensed nurses were responsible for performing and documenting the glucometer quality control tests every night shift. The Director of Nursing (DON) confirmed that the facility's expectation was for these tests to be completed every night shift. However, the failure to ensure accurate documentation and observation of glucometer quality control results had the potential to lead to inaccurate glucose readings for residents requiring glucose checks.
Privacy and Confidentiality Breach
Penalty
Summary
The facility failed to ensure the privacy of a resident during activities of daily living (ADL) care. During an observation, it was noted that a certified nursing assistant (CNA) was providing ADL care to a resident in Room A with the door wide open. The resident was seated on a shower chair and covered with a blanket from the neck to the waist, leaving the legs and buttocks exposed to anyone passing by in the hallway. Interviews with the quality assurance registered nurse (QA RN), the CNA, and the director of nursing (DON) confirmed that the privacy curtain and door should have been closed to protect the resident's privacy. Additionally, the facility failed to maintain the confidentiality of the resident's medical information. An observation at the nurses' station revealed that a licensed vocational nurse (LVN) left a computer monitor on, displaying the resident's personal medical information. The LVN walked away from the station twice, leaving the information exposed. Upon returning, the LVN acknowledged the oversight. These actions were in direct violation of the facility's policies and procedures regarding patient privacy and confidentiality.
Cockroach Infestation in Conference Room
Penalty
Summary
The facility failed to ensure the environment was free of pests, specifically cockroaches, which were observed in the conference room. The facility's Pest Control Program, revised on 12/19/22, mandates maintaining an effective pest control program to eradicate and contain common household pests and rodents. On 9/13/24, during an observation and interview with the QA RN, a cockroach was seen crawling towards a trash bin in the conference room, and the QA RN confirmed the potential risk of infection spread due to the presence of cockroaches. Later the same day, another cockroach was observed in the conference room during an interview with the Social Services Director, who acknowledged its presence. The Maintenance Director also confirmed the presence of cockroaches in the conference room and recognized the risk of spreading infection.
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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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