Park View Nursing And Subacute
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 6740 Wilbur Ave Opco, Llc, Reseda, California 91335
- CMS Provider Number
- 555716
- Inspections on file
- 72
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Park View Nursing And Subacute during CMS and state inspections, most recent first.
A resident with DM, stroke, and HTN had an order for SQ insulin lispro per sliding scale before meals and at bedtime. Review of the MAR showed that a RN repeatedly documented insulin doses at times significantly later than the scheduled administration times. In interview, the RN stated insulin was given around mealtime as ordered but documentation on the MAR was completed late rather than immediately after administration. The DON and facility policy both indicated that licensed nurses must document medication administration directly after giving medications and that medication times must follow established timing guidelines.
A resident with a history of stroke, DM, and HTN, and intact cognition, had family concerns about care submitted by email to the ADM. Although the ADM acknowledged receipt, the concern was never entered on a grievance form, logged in the grievance binder, or investigated as required by the facility’s grievance P&P. The SSD and DON confirmed that no grievance was recorded for this resident, despite facility policy requiring staff to initiate a grievance/concern form and log upon receipt of any complaint. This failure violated the resident’s right to voice grievances and have the facility respond.
A resident admitted with stroke, DM, and HTN, who had intact cognition and required moderate assistance with ADLs, did not receive a written summary of the baseline care plan. ICC documentation showed the section indicating that a copy of the care plan was provided was left blank, and the CM and DON could not locate any record that a written baseline care plan summary had been given. Review of the facility’s baseline care plan policy confirmed requirements for timely development of a baseline care plan but did not clearly address providing a written summary to the resident or representative.
A resident with a sacrococcygeal stage III PI was admitted with orders and a care plan for use of a low air loss mattress (LALM) to support wound management, including monitoring for proper settings and functionality. During observation, the resident was found on the LALM with an incontinence brief, a flat sheet, and a cloth incontinence pad, creating four linen layers between the resident and the mattress, contrary to staff statements that only one to two layers should be used for the LALM to work properly. The DSD and DON confirmed that excess linen layers interfere with LALM function and acknowledged there was no specific facility P&P for LALM use, while the existing pressure ulcer protocol only generally referenced physician orders for pressure reduction surfaces.
Surveyors found that multiple residents with orders for low air loss mattresses (LALM) for PU/PI prevention and wound healing were using these specialty beds without any facility policy or procedure in place to guide their use. The DON confirmed there was no written P&P for LALM, including no direction on linen use, and that staff relied on manufacturer guidelines, which did not address linen. The administrator acknowledged that a P&P for LALM should exist to guide care for the many residents using these mattresses, despite job descriptions assigning responsibility for developing and implementing such policies.
A resident with severe cognitive impairment, functional quadriplegia, and multiple comorbidities was observed lying in bed with the call light placed on a bedside table out of reach, despite needing staff assistance for incontinence care and other ADLs. An LVN confirmed the call light was not within reach as required, and a CNA later stated he typically checks call light placement at the start of his shift but had forgotten to do so for this resident. The DON acknowledged that call lights must be within reach so residents can request assistance and that lack of access can lead to delayed care and negatively affect dignity. Facility policies on the call system and dignity require that residents have a means to call staff from bed and be cared for in a way that promotes self-worth and self-esteem.
A resident with traumatic brain injury, seizures, hydrocephalus, type 2 DM, and limited decision-making capacity had a physician order for bilateral AFOs to be applied to the lower extremities several times per week for specified hours with skin checks. During observation, the resident was found in bed with the right AFO rotated to the side and not providing proper support. The DOR confirmed the device was improperly applied, and the RNA who applied it stated he was unaware it was incorrect, while acknowledging it should remain correctly positioned. The DON stated staff should monitor AFO placement and skin condition. Facility policies required trained, competent staff to maintain and supervise assistive devices and to provide appropriate services and equipment to maintain or improve mobility, but the improper AFO application showed these requirements were not followed.
Three residents were placed at increased risk for injury when staff failed to ensure bed siderails were fully padded as ordered for two residents with seizure disorders, and did not provide a required floor mat, adequate lighting, or open curtains for a resident with impaired mobility. Nursing staff confirmed these safety measures were necessary, and facility policies required their implementation.
A licensed nurse failed to measure and document a resident's apical pulse before administering Flecainide, as required by a physician's order for a resident with atrial fibrillation. The nurse relied only on blood pressure and radial pulse checks, was unaware of the specific order, and did not follow established medication administration protocols, resulting in repeated administration of the medication without the necessary assessment.
The facility did not ensure timely replacement or proper documentation of emergency medication kits (E-kits) in two medication rooms after they were opened, and failed to notify the pharmacy as required by policy. A resident with sepsis and severe cognitive impairment was involved, and staff interviews confirmed lapses in following procedures for E-kit management and documentation.
A nurse failed to check a resident's apical pulse before administering Flecainide, as required by the physician's order for a resident with atrial fibrillation. The medication was given multiple times without the necessary pulse check, and the electronic medical record did not prompt for this parameter. The facility's policy and pharmacy recommendations to follow physician orders and monitor vital signs were not followed.
Seven residents on a puree diet were served a lemon crisp dessert that was too thick and did not meet IDDSI Level 4 standards, as confirmed by dietary staff during a test tray observation. The dessert failed the required spoon tilt test, indicating it was not prepared in the appropriate form for residents with dysphagia.
Surveyors found that kitchen staff failed to label and date stored bell peppers, did not check temperatures for several food items on the tray line, and a dietary aide touched his face and glasses with gloved hands without immediately washing hands or changing gloves. These actions were not in accordance with facility policies for food safety and staff hygiene.
A resident with a tracheostomy and ventilator dependence did not have an individualized care plan for oral care, resulting in observed dry, cracked lips and lack of staff intervention. Another resident, with multiple serious diagnoses, was found on the floor without a required floor mat in place, despite an active order and care plan intervention for fall prevention. Both deficiencies were confirmed through observation, staff interviews, and record review.
A resident with an enteral tube did not receive the full dose of crushed medications when an LVN left excess medication in the cups after administration and failed to flush the tube with the physician-ordered amount of water between medications. Both the LVN and DON confirmed that the full dose and proper flush volume were required by orders and facility policy.
A resident who was fully dependent on staff for all ADLs, including oral care, was found with severely dry, cracked lips and a thick layer of dried saliva and skin. The resident, who had multiple complex medical conditions and was on a ventilator and feeding tube, did not receive necessary oral hygiene, as confirmed by a nurse and facility policy review.
A resident with a history of neurogenic bladder and urinary retention, who was dependent on staff for care, was observed with a urinary catheter that had a long dependent loop, coils, and a kink, with visible sediment in the tubing. Staff and policy confirmed that catheter tubing should remain straight and unobstructed, but this was not maintained, contributing to improper catheter care and increased risk of UTI.
A resident with end stage renal disease and severe cognitive impairment did not have their post-dialysis weight documented by the dialysis center, and facility staff did not follow up as required by policy. This resulted in incomplete post-dialysis assessment documentation for the resident's hemodialysis care.
A deficiency was found when an LVN discovered an unlabeled, unpackaged tablet in a medication cart drawer. The LVN and DON both confirmed that all medications should be properly packaged and labeled to ensure correct administration and compliance with facility policy, which requires medications to be stored in legally compliant containers and contaminated medications to be removed immediately.
A resident with multiple diagnoses and unable to provide informed consent was incorrectly documented as having an Advance Directive in their medical record, despite confirmation from both the responsible party and facility staff that no such document existed. This resulted in inaccurate medical recordkeeping regarding the resident's Advance Directive status.
A facility failed to create a comprehensive care plan for a resident who preferred to keep food at their bedside. Despite the resident's diagnoses and preference, the care plan lacked specific interventions to address this, as confirmed by the DON. The facility's policy requires individualized care plans, but this was not implemented, potentially affecting the resident's quality of life and care.
A facility failed to complete a discharge summary for a resident who was readmitted with cervical disc degeneration and other conditions. Despite the resident having intact cognition, no discharge summary was documented upon their discharge, as confirmed by the Medical Records Director and DON. This oversight was against the facility's policy, which requires a discharge summary to be completed within 30 days of discharge.
A facility failed to document a resident's fluid intake, contrary to its hydration policy, placing the resident at risk for dehydration. The resident, with severe cognitive impairment and chronic conditions, required assistance with daily activities. Staff interviews revealed that CNAs did not document fluid intake in milliliters, and the Director of Nursing confirmed that intake was not documented unless ordered. This oversight could lead to dehydration and medical complications.
A facility failed to follow its policy on preventing foodborne illness by not discarding cooked eggs left on a resident's bedside table for over 24 hours. The resident, with COPD and functional quadriplegia, confirmed the eggs were not refrigerated. The Dietary Supervisor acknowledged the eggs should have been discarded after two hours, as per facility policy, to prevent bacterial growth.
A facility failed to implement its Enhanced Barrier Precautions and Hand Hygiene policies, leading to a deficiency in infection control. A CNA did not wear a gown while changing bed linen for a resident on EBP and did not perform hand hygiene after removing gloves. The resident had conditions including diabetes with a skin ulcer and cellulitis, requiring enhanced precautions. Staff interviews confirmed the failure to adhere to policies requiring gowns and gloves during high-contact activities and hand hygiene after removing PPE.
The facility failed to maintain room temperatures between 71-81°F, affecting a resident who reported discomfort due to cold conditions. Observations showed two rooms with temperatures below the required range, and the Maintenance Supervisor acknowledged the need for thermostat adjustments. The resident, with multiple health issues, used an extra blanket to stay warm, highlighting the deficiency in maintaining a homelike environment.
The facility failed to follow its policy on the safe placement of power strips, leading to potential hazards. During a tour, a power strip was found on the floor next to a resident's bed, and another was improperly secured to a bed rail with plastic gloves. Both residents involved had intact cognition. The facility's policy requires power strips to be stored safely to prevent tripping hazards.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to conduct the required neurological assessment as per its policy. Despite the protocol mandating a 72-hour post-fall assessment, it was not completed, and the assessment was not resumed after the resident returned from the hospital. The DON incorrectly believed a physician's order was needed to continue the assessment, leading to incomplete monitoring and documentation.
A resident with multiple health conditions experienced unrelieved pain due to the facility's failure to ensure timely physician notification for additional pain medication. The LVN faced technical difficulties contacting the on-call physician and did not escalate the issue, instead passing it to the next shift. The facility's pain management policy requires timely physician notification to maintain resident comfort.
The facility did not complete food preference assessments within 48 hours of admission for four residents, as required by policy. This delay, acknowledged by the Dietary Supervisor and Dietician, could lead to residents being served unwanted food, potentially decreasing meal intake and causing weight loss.
The facility failed to ensure call lights were within reach for three residents, potentially delaying care. A resident with dementia had the call light on the floor, another with spinal stenosis had it hanging off the bed, and a third dependent resident had it wrapped around side rails. Staff confirmed these observations, highlighting the importance of accessible call lights for timely assistance.
The facility failed to maintain current copies of advance directives for four residents, risking unwanted treatments. Despite having executed advance directives, the documents were missing from the medical records of residents with various medical conditions, including sepsis, multiple sclerosis, and dementia. The Social Service Director acknowledged the lack of follow-up with families to obtain these critical documents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident receiving antibiotics for a UTI lacked a care plan for antibiotic use, risking delayed healing. Another resident's care plan did not reflect physician's orders for RNA exercises, risking functional decline. A third resident with urinary retention had no care plan, impacting care monitoring. These deficiencies highlight a failure to adhere to the facility's policy requiring timely development of care plans.
Three residents in an LTC facility were at increased risk of pressure ulcers due to incorrect settings on their low air loss (LAL) mattresses. The mattresses were not adjusted according to the residents' weights, leading to improper pressure distribution. Staff confirmed and corrected the settings, acknowledging the potential harm caused by the initial errors.
A facility failed to ensure that nurses attempted non-pharmacological interventions before administering prn opioid pain medication to a resident with acute respiratory failure, tracheostomy, and gastrostomy status. The resident, who had moderately impaired cognition and required maximum assistance, was prescribed hydrocodone-acetaminophen for severe pain. However, documentation showed that non-pharmacological interventions were not attempted on several occasions, contrary to the facility's pain management policy.
The facility failed to properly document and administer medications, including antibiotics and controlled drugs, for several residents. Discrepancies between the MAR and CDR were found, raising concerns about medication errors and potential drug diversion. The DON confirmed these issues, emphasizing the importance of proper procedures to prevent errors.
The facility failed to properly label insulin and eye drop medications, risking their effectiveness, and allowed unauthorized access to a medication room. Two residents had insulin without open dates, and another resident's eye drops were used past the expiration period. Additionally, a Dietary Supervisor accessed a medication room, contrary to policy.
The facility failed to maintain infection control practices for three residents, including allowing a nasal cannula to touch the floor, not labeling urinals, and not labeling an IV administration set. These actions increased the risk of infection due to potential contamination and cross-contamination.
A facility failed to cover a resident's urinary catheter collection bag with a dignity bag, compromising the resident's dignity. The resident, with intact cognition and decision-making capacity, was observed with a visible urine bag. The Infection Preventionist confirmed the absence of a dignity bag, which is required by the facility's policy to ensure resident privacy and dignity.
A facility failed to timely collect and follow up on a STAT fecal occult blood test for a resident with Guillain-Barre syndrome and myasthenia gravis. Despite a STAT order placed after the resident's family reported black stool, the specimen was not collected during a bowel movement, and the order was delayed. The resident's hemoglobin levels dropped significantly, and a positive FOBT was only noted days later, leading to an emergency hospital transfer. Interviews revealed the facility's policy required STAT orders to be completed within 4 to 6 hours, highlighting a failure to adhere to protocols.
The facility failed to honor the food preferences of two residents, violating their rights to self-determination. One resident, recovering from knee surgery and gastric bypass, was denied cereal for dinner, while another resident with acute kidney failure was denied hard-boiled eggs. Both requests were feasible, as confirmed by the Dietary Supervisor, but were not fulfilled by the staff member responsible.
A resident's POLST form was found incomplete, missing the date of signature, signee relationship, and physician's documentation and signature. This oversight was confirmed by the Medical Records Director, RN, and DON, posing a risk of treating the resident as full code in emergencies, contrary to their wishes. The resident, with COPD and intact cognition, had their rights potentially violated due to this documentation lapse.
A facility failed to prevent insects and flies from entering a resident's room, who was dependent on staff and had a tracheostomy. Insects were observed crawling from wall cracks, and a fly was seen over the resident's head, increasing infection risk. The Maintenance Supervisor noted broken window screens and a door gap as entry points for pests, contrary to the facility's pest control policy.
A resident with multiple serious medical conditions requested lighter food, more fruits, and milk with every meal. Despite these requests being documented and recommended by the Registered Dietician, the facility failed to communicate and implement these preferences, as confirmed by interviews and record reviews.
A Nurse Practitioner at the facility falsified progress notes for a resident on three occasions, documenting assessments and vital signs despite the resident not being present in the facility. The Director of Nursing confirmed the resident's absence, and the NP admitted to the false documentation, attributing it to a mistake made during a busy period.
The facility failed to update a resident's care plan to include their food preferences for milk and more fruits with each meal, despite these preferences being documented and recommended by the Registered Dietician. The resident had serious medical conditions and required limited assistance with eating, but the care plan was not updated to reflect their nutritional needs.
The facility failed to provide a safe environment when a stranger entered and stole food from the employee breakroom. Staff interviews revealed that the entrance door is locked at night but unlocked early in the morning, which may have allowed the entry. The Administrator acknowledged the incident and the potential risk to residents and staff.
A facility failed to ensure a skin assessment was accurately completed for a resident with multiple medical conditions. The resident had redness and small red bumps on her back and left shoulder, which were not identified during a weekly summary assessment. The issue was discovered during an interview and physical examination, leading to a diagnosis of dermatitis by a dermatologist.
Late Documentation of Insulin Administration on MAR
Penalty
Summary
The deficiency involves the failure of a registered nurse to document insulin administration on the Medication Administration Record (MAR) immediately after giving the medication. The resident involved was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition, was independent with eating and oral hygiene, and required moderate assistance with some activities of daily living. The resident had an order for insulin lispro to be administered subcutaneously per sliding scale before meals and at bedtime for diabetes management. Review of the MAR for the month showed multiple instances where insulin lispro doses scheduled for specific times were documented as administered significantly later than the scheduled times. During interviews and concurrent record reviews, the RN who documented the insulin administrations stated that insulin was actually given at the scheduled times but that documentation was completed late. The RN explained that blood sugar was typically checked about 30 minutes before dinner and insulin lispro was administered right before the resident ate, but the MAR entries were made after the fact rather than immediately following administration. The DON confirmed that licensed nurses are expected to document medication administration right after giving all medications. The facility’s medication administration policy specified that medications are to be administered within 60 minutes of the scheduled time, except for before- or after-meal orders, and that the person administering the medication must record the administration on the MAR directly after the medication is given and review the MAR at the end of each pass to ensure doses were administered and documented.
Failure to Document and Investigate Family Grievance per Facility Policy
Penalty
Summary
The facility failed to follow its grievance policy and procedure by not documenting and investigating a grievance submitted on behalf of a resident’s family member. The resident was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition per the MDS, requiring varying levels of assistance with activities of daily living. Review of the grievance binder for the relevant period showed no grievance filed for this resident. The Social Services Director stated that any concerns or complaints received from staff or residents should result in completion of a grievance form, communication with social services for follow-up and documentation, and logging into the grievance binder. The DON similarly stated that all complaints should be documented in the grievance binder and that the Administrator, DON, and Social Services Director were designated grievance coordinators who should be informed so an investigation could be started right away. The family member reported sending an email to the facility outlining concerns about the resident’s care and receiving an email response from the Administrator acknowledging receipt the same day. The family member stated that no one from the facility informed the family about what had been done to address their concerns. The Administrator later confirmed receiving the email regarding the family’s concerns but acknowledged that the concerns were not placed on a grievance form and that no investigation was initiated at that time. Review of the facility’s grievance/concern policy indicated that upon receipt of a grievance or concern, a grievance/concern form must be initiated by the staff member receiving the concern and documented on the grievance/concern log. The resident rights policy stated that residents have the right to voice grievances without discrimination or reprisal and to have the facility respond to their grievances. These required steps were not followed for the grievance submitted on behalf of this resident’s family member.
Failure to Provide Written Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a written summary of a baseline care plan to a resident and/or the resident’s representative following admission. A resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, and hypertension. The resident’s MDS assessment showed intact cognition, independence with eating and oral hygiene, and a need for moderate assistance with toileting, showering, and dressing. An Interdisciplinary Care Conference (ICC) note dated shortly after admission documented that the checkbox indicating a copy of the care plan was provided to the resident or representative was left blank. During an interview and concurrent record review, the Case Manager was unable to recall whether a written baseline care plan summary had been provided and could not locate any documentation confirming that it had been given to the resident or family. In a subsequent interview and record review, the DON confirmed that the facility’s practice was to develop a baseline care plan within 48 hours of admission and to provide a written summary of that plan to the resident and/or family. The DON reviewed the ICC notes and clinical record for the resident and was unable to find any indication that a written baseline care plan summary had been provided. Review of the facility’s baseline care plan policy, last revised for 1/2026–1/2027, showed that it required development and implementation of a baseline care plan within 48 hours of admission but did not specify the requirement to provide a written summary to the resident or family, even though the DON stated that copies of the baseline care plan summary should be provided. The absence of documentation and the unmarked ICC checkbox demonstrated that the resident and/or representative did not receive the required written baseline care plan summary.
Improper Use of Low Air Loss Mattress for Resident With Stage III Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper use of a low air loss mattress (LALM) for a resident with a sacrococcygeal stage III pressure injury. The resident was admitted with osteoarthritis of the left knee, a left artificial knee joint, and a stage III sacral pressure ulcer, and had intact cognition per the MDS. The physician’s orders and the care plan included use of a LALM with settings based on the resident’s comfort and/or weight, and monitoring for proper settings and functionality, with the goal that the resident would not have further skin breakdown by monitoring the LALM in the correct setting. During observation, the resident was found lying on a LALM while wearing an incontinence brief, with a flat sheet and a cloth incontinence linen pad underneath, resulting in four layers of linen between the resident and the mattress. During interviews, CNA staff stated that the resident was on the LALM due to an open wound on the resident’s bottom and acknowledged that there were four layers of linen under the resident, while indicating there should only be one layer between the resident’s skin and the LALM. The DSD stated that for residents on a LALM, only flat sheets should be used and staff should use either disposable pads or an incontinence brief, but not both at the same time, and that there should be no more than two layers of linen between the bed and the resident for the LALM to function appropriately. The DON stated that LALMs are used primarily for skin management and that using more than two layers of linen would defeat the purpose of the LALM and delay wound healing. The DON also stated the facility did not have a policy and procedure specific to LALM use, and the existing pressure ulcer/skin breakdown protocol only generally referenced physician orders for pressure reduction surfaces without detailing LALM application or linen use.
Lack of Policies and Procedures for Low Air Loss Mattress Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement policies and procedures for the use of low air loss mattresses (LALM) for all 12 sampled residents who were using these specialty beds for pressure ulcer/injury (PU/PI) prevention and treatment. Record review of the facility’s Order Listing Report showed that each of the 12 residents had active physician orders for LALM, with start dates ranging from the prior year to the current month. During observation, all 12 residents were confirmed to be on LALM, and the treatment nurse stated that the mattresses were being used to prevent pressure ulcers and promote wound healing for residents with existing pressure ulcers. In interviews, the DON acknowledged that the facility did not have any written policy or procedure governing LALM use, including guidance on linen use with the mattresses, and stated that the facility followed the manufacturer’s guidelines. However, the manufacturer’s guidelines provided did not address linen use with LALM. The administrator also stated that the facility should have a policy and procedure for LALM use to guide management of residents on these mattresses and noted that many residents were using them. Review of the DON and administrator job descriptions showed that both positions were responsible for developing, maintaining, and ensuring implementation of facility policies and procedures, including nursing policies that conform to current standards and regulations.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted with multiple diagnoses, including metabolic encephalopathy, functional quadriplegia, type 2 diabetes, hypertension, and difficulty swallowing. The resident’s History and Physical documented that the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The MDS further showed the resident required supervision with eating and oral hygiene, moderate assistance with upper body dressing and personal hygiene, and maximal assistance with toileting hygiene, lower body dressing, and footwear. During an observation and interview in the resident’s room, the resident was found lying in bed, stating they required staff assistance with changing soiled briefs, and the call light was observed on the bedside table out of the resident’s reach. In a concurrent observation and interview, an LVN confirmed that the call light was out of reach and acknowledged it should be within the resident’s reach at all times. Later, a CNA reported that at the start of the shift he ensures residents’ call lights are within reach but stated he must have forgotten to check this resident’s call light position, and reiterated that all call lights should remain within residents’ reach so they can call for assistance when needed. The DON stated that call lights need to be within reach of all residents to enable them to call for assistance when needed and acknowledged that when a call light is out of reach there is a potential for delayed care, increased risk of falls, and decreased feelings of self-worth, self-esteem, and dignity. Review of the facility’s Call System policy indicated each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and the floor, and the Dignity policy stated residents are to be treated with dignity and respect in a manner that promotes individuality, well-being, satisfaction with life, self-worth, and self-esteem.
Improper Application and Monitoring of AFO for Resident With Limited Mobility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper application and monitoring of an ankle foot orthosis (AFO) as ordered by the physician for a resident with significant neurological and medical conditions. The resident had a history of traumatic brain injury, seizures, hydrocephalus, type 2 DM, and difficulty swallowing, and the H&P documented that the resident lacked capacity to understand and make decisions. A physician order dated 6/9/2025 directed that bilateral AFOs be placed on the resident’s lower extremities five times per week for 4–6 hours as tolerated, with skin checks. During an observation in the resident’s room, the resident was found lying in bed with an AFO on the right foot and ankle that was rotated to the side and not providing the intended support. During a concurrent observation and interview at the bedside, the Director of Rehabilitation confirmed that the right AFO was not applied properly and stated that the brace should be supporting the right foot and ankle to prevent further foot drop. Later, the RNA reported that he had applied the right AFO that morning in accordance with the physician’s order but was unaware that it was not correctly positioned, and acknowledged that the AFO should remain in the correct position on the foot and ankle. The DON also stated that the AFO should remain correctly positioned at all times and that staff should monitor both the placement of the AFO and the resident’s skin condition while it is in place. Facility policies on assistive devices and on resident mobility and ROM required that staff be trained and competent in the use of devices and that residents with limited mobility receive appropriate services and equipment based on professional standards of practice, but the observed improper application of the AFO demonstrated noncompliance with these requirements.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For two residents with seizure disorders and severely impaired cognitive skills, the facility did not ensure that bed siderails were fully covered with padding as ordered by their physicians and outlined in their care plans. Observations revealed that one resident's bed rail padding had slipped, leaving hard rails exposed, and another resident's bed rail had no padding on one side. In both cases, nursing staff confirmed that the padding was necessary to protect the residents from injury during seizures, in accordance with physician orders and care plans. Additionally, the facility did not provide a required floor mat for a resident with impaired mobility and multiple medical conditions, including respiratory failure and cancer. This resident was found on the floor without a floor mat in place, despite a physician order and care plan intervention indicating its necessity for injury prevention. The resident's bed was positioned against the wall, and the room had low lighting with curtains drawn, making it difficult to see the resident from the hallway. Nursing staff acknowledged that the floor mat should have been present and that the room should have been better lit with curtains open for visibility. The facility's own policies and procedures require the prevention or reduction of hazards associated with bed rails, the provision of a safe and homelike environment, and adequate lighting to promote safety. The failure to follow these policies, physician orders, and care plan interventions resulted in an environment that placed the affected residents at increased risk for injury.
Failure to Follow Physician's Order for Apical Pulse Prior to Heart Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) failed to follow a physician's order requiring the measurement of a resident's apical pulse prior to administering Flecainide, a heart medication. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a physician's order specifying that Flecainide should be held if the apical pulse was less than 60 beats per minute. Despite this, the LVN did not take the apical pulse before administering the medication on multiple occasions, as evidenced by the Medication Administration Records (MAR) for March, April, and May, which showed no documentation of the apical pulse being taken prior to administration. During a medication pass observation, the LVN was seen taking only the resident's blood pressure and radial pulse before giving Flecainide, and stated there was no need to check anything else. When questioned, the LVN indicated he was unaware of the order to check the apical pulse and had never done so for this resident before administering the medication. The LVN also stated that the electronic medical record system did not prompt for an apical pulse entry, and believed that the order should have been entered with a parameter requiring this check. The Director of Nursing (DON) and the facility's Pharmacist Consultant both confirmed that the apical pulse should have been checked and documented prior to each administration of Flecainide, as per the physician's order and pharmacy recommendations. The DON verified that the medication was given without the required apical pulse check on multiple occasions. The LVN's competency records indicated training on following medication parameters, but this was not adhered to in practice. The facility's policy required medications to be administered according to physician orders, which was not followed in this instance.
Failure to Timely Replace and Document Emergency Medication Kits
Penalty
Summary
The facility failed to ensure timely replacement and proper documentation of emergency medication kits (E-kits) in both the Subacute and Skilled Nursing Facility Medication Rooms, as required by facility policy. In the Subacute Nursing Station, documentation indicated that two vials of Ceftazidime were removed from the E-kit for a resident with sepsis, but subsequent interviews revealed that the medication was not actually removed and the documentation was incorrect. Additionally, the E-kit was not exchanged within the required 72-hour timeframe after being opened, and the pharmacy was not notified promptly for replacement. In the Skilled Nursing Facility Medication Room, the E-kit was found to be opened without the appropriate yellow zip tie or documentation indicating medication removal, and the pharmacy was not notified for replacement as per policy. A resident involved had been admitted with sepsis and was severely cognitively impaired, requiring total assistance for daily activities. Physician orders indicated the need for intravenous antibiotics, and the facility's failure to follow procedures for E-kit management had the potential to delay access to critical medications. Staff interviews confirmed lapses in following the established process for E-kit documentation, notification, and replacement, as outlined in the facility's policy and procedure.
Failure to Check Apical Pulse Before Administering Heart Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to check a resident's apical pulse prior to administering Flecainide, a heart medication, as required by the physician's order. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a specific order to hold the medication if the apical pulse was less than 60 beats per minute. Despite this, the LVN administered the medication without taking the apical pulse, relying only on the radial pulse and blood pressure measurements. Review of the Medication Administration Records (MAR) for three consecutive months showed that the apical pulse was not taken before administering Flecainide on multiple occasions. The MARs for March, April, and May indicated repeated failures to document the apical pulse prior to medication administration, confirming that this was an ongoing issue rather than an isolated incident. The resident's care plan also specified the need to assess and monitor vital signs as ordered, which was not followed in practice. Interviews with the LVN and the Director of Nursing (DON) revealed that the LVN was unaware of the requirement to check the apical pulse and that the electronic medical record system did not prompt for this parameter. The facility's policy required medications to be administered according to physician orders, but this was not adhered to in the case of this resident. The facility pharmacist had also recommended that the apical pulse be checked before administering Flecainide, but this recommendation was not implemented prior to the survey.
Puree Diet Food Served with Incorrect Consistency
Penalty
Summary
Seven of eight residents on a puree diet were served a puree lemon crisp dessert that was too thick in consistency. During a test tray observation, the Dietary Supervisor (DS) and Regional Dietary Supervisor (RDS) confirmed that the dessert did not meet the required texture for a puree diet, as it was too thick and failed the spoon tilt test, which is used to assess the appropriateness of food texture for individuals with dysphagia. The DS stated that the dessert should be smooth, similar to mashed potatoes, and should slide off the spoon easily, but the observed dessert did not meet these criteria. A review of the facility's diet manual for the Dysphagia Diet, Puree IDDSI Level 4, indicated that all puree foods should be lump-free, not firm or sticky, and should pass both the fork drip and spoon tilt tests before being served. The manual also specified that all prepared recipes should be tested prior to service to ensure they meet IDDSI guidelines. The DS acknowledged that the dessert served did not comply with these requirements, which could result in residents having difficulty swallowing.
Deficient Food Storage, Temperature Monitoring, and Staff Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and staff hygiene. Bell peppers stored in the walk-in refrigerator were not labeled with the date they were placed inside, contrary to facility policy requiring all foods to be labeled and dated to prevent cross contamination. Additionally, during a tray line observation, staff failed to check the temperatures of several food items, including mashed potatoes, gravy, various modified diet potatoes, chicken, pasta, and carrots. Both the Dietary Supervisor and the staff member acknowledged that all food temperatures should have been taken to ensure proper hot and cold holding, as outlined in facility policy. Further, a Dietary Aide was observed touching his face and eyeglasses with a gloved hand during food service and did not immediately wash hands or change gloves until prompted by the Dietary Supervisor. Both the Dietary Supervisor and the aide confirmed that hand washing and glove changes are required after touching the face, in accordance with facility policy. These deficiencies were identified during observations and interviews, and the facility's policies were reviewed to confirm the requirements that were not followed.
Failure to Implement Individualized Care Plans for Oral Care and Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized oral care interventions for a resident with a tracheostomy who was dependent on a ventilator. The resident was observed with very dry, cracked lips and a thick layer of dry crust, and was seen rubbing her lips with her hand. During interviews and record reviews, nursing staff confirmed that there was no care plan or intervention in place for oral care, despite the resident's dependence on staff for all activities of daily living and the facility's own policies requiring individualized care plans and oral hygiene support for residents unable to perform these tasks independently. Additionally, the facility failed to implement a care plan intervention for another resident who required a floor mat for injury prevention as ordered. The resident, who had diagnoses including respiratory failure, cancer of the larynx, and dysphagia, was found on the floor without a floor mat in place, despite an active order for one to be provided on the left side of the bed. Nursing staff confirmed that the floor mat was not present, and the care plan indicated the intervention should be in place if indicated. Both deficiencies were identified through direct observation, interviews with nursing staff, and review of facility policies and resident records. The facility's policies require ongoing assessment and revision of care plans to meet residents' medical, physical, and psychosocial needs, including specific protocols for oral care and fall prevention, which were not followed in these cases.
Improper Enteral Medication Administration and Inadequate Tube Flushing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow proper technique during medication administration through an enteral tube for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The LVN crushed magnesium oxide and zinc tablets, placed them in separate medication cups with water, and administered them via the resident's enteral tube. After administration, excess crushed medication remained in both cups, indicating the resident did not receive the full prescribed dose. Additionally, the LVN flushed the enteral tube with only 10 milliliters of water between medications, despite a physician's order specifying a 15 milliliter flush between each medication. The resident's medical records confirmed the presence of an enteral tube and orders for medication administration, including the required flush volume. Both the LVN and the Director of Nursing acknowledged during interviews that the full dose of medication should be administered and the tube should be flushed with the ordered amount of water to ensure proper delivery and prevent tube clogging. Facility policies also required adherence to prescriber orders for medication administration and flushing volumes.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary oral hygiene services to a resident who was completely dependent on staff for all activities of daily living. The resident, who had diagnoses including hemiplegia, respiratory failure with hypoxia, dysphagia, and was dependent on a ventilator and feeding tube, was observed lying in bed with very dry, cracked lips covered by a thick layer of dried saliva and skin. The resident was unable to communicate effectively and required total assistance for hygiene and movement. During the observation, a registered nurse acknowledged the resident's lips were very dry and in need of oral care, noting the potential for bleeding or pain and the possible impact on the resident's feelings. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive appropriate care, including oral care, and that care should promote well-being and dignity. However, the observed condition of the resident's lips demonstrated that these services were not provided as required.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, neuromuscular bladder dysfunction, and urinary retention was admitted with an indwelling urinary catheter. The resident was dependent on staff for all activities of daily living, including hygiene and toileting, and had documented episodes of confusion. The resident had a physician order for a urinary catheter due to retention and neurogenic bladder, and had experienced urinary tract infections (UTIs) on two separate occasions during their stay. During an observation, the resident was found lying in bed with the urinary catheter bag improperly positioned and the catheter tubing exhibiting a long dependent loop, two coils, and a kink. The tubing contained yellow liquid with white sediments. Both the Minimum Data Set Coordinator and a registered nurse confirmed that the catheter tubing should not be looped, coiled, or kinked, as this can impede urine flow and increase infection risk. Facility policy required catheter tubing to be kept free of kinks to maintain unobstructed urine flow, but this was not followed in the resident's care.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident with end stage renal disease who required hemodialysis. Specifically, on 5/15/2025, the dialysis center did not record the resident's post-dialysis weight on the Dialysis Communication Record. This omission was verified during record reviews and interviews with both a registered nurse and the Director of Nursing, who confirmed that the post-dialysis weight was missing and that the facility's protocol required staff to contact the dialysis center to obtain this information if it was not documented. The resident involved was severely cognitively impaired and dependent on staff for daily activities, as indicated by the Minimum Data Set. The resident's care plan required pre- and post-dialysis weights to be taken at the dialysis center to help avoid fluid overload. Facility policy and licensed nurse competency guidelines both specified that missing post-dialysis weights should be immediately followed up with the dialysis center, but this was not done, resulting in incomplete documentation for the resident's dialysis care on the specified date.
Unlabeled and Unpackaged Tablet Found in Medication Cart
Penalty
Summary
A deficiency was identified when, during an observation and interview with an LVN at one of the medication carts, a white, round, unlabeled and unpackaged tablet was found in the bottom of a cart drawer. The LVN confirmed that medications should be packaged and labeled when stored in the cart to ensure the correct medication is administered and to verify expiration dates. The DON also stated that all medications should be packaged and labeled to prevent accidental administration to the wrong resident and to reduce medication errors. Review of the facility's policy indicated that medications are to be kept in containers that meet legal requirements and that contaminated medications are to be immediately removed and disposed of.
Inaccurate Documentation of Advance Directive Status
Penalty
Summary
The facility failed to ensure the accuracy of a medical record for one resident when the Advance Directive Acknowledgement form incorrectly indicated that the resident had an Advance Directive, despite no such document existing. The resident in question was admitted with diagnoses including pneumonia, bipolar disorder, and schizophrenia, and was noted to be deaf and non-speaking. The Minimum Data Set assessment indicated that no Advance Directive was completed for this resident. Additionally, a letter from the regional center clarified that the resident was not capable of providing informed consent, had no court-appointed conservator or guardian, and that a regional center designee would provide consent for medical treatments. During interviews, the responsible party from the regional center confirmed there was no Advance Directive for the resident, and the Social Services Director acknowledged that the Advance Directive Acknowledgement form was incorrect. The facility's policy required staff to inquire about the existence of an Advance Directive upon admission and to document its presence or offer the opportunity to create one if it did not exist. However, the documentation in the resident's medical record inaccurately reflected the existence of an Advance Directive, resulting in a deficiency related to the maintenance of accurate medical records.
Failure to Develop Comprehensive Care Plan for Resident's Food Preference
Penalty
Summary
The facility failed to develop a comprehensive care plan with resident-centered interventions for a resident who preferred to keep food at their bedside. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, noncompliance with medical treatment, and functional quadriplegia, was observed to have two eggs wrapped in plastic on their bedside table. The resident expressed a preference for keeping food at their bedside, which was confirmed by the Dietary Supervisor. The Director of Nursing acknowledged that the resident's care plan, revised on 2/6/2025, did not include specific interventions related to the resident's preference for keeping food at the bedside. The facility's policy requires the Interdisciplinary Team to develop individualized comprehensive care plans, but this was not done in this case. The lack of specific interventions in the care plan had the potential to negatively affect the resident's quality of life and care.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, identified as Resident 3, upon their discharge. Resident 3 was readmitted to the facility with diagnoses including cervical disc degeneration, a laceration on the head, and a history of falling. The Minimum Data Set (MDS) indicated that the resident had intact cognition. Despite these details, there was no documented evidence of a discharge summary being completed when Resident 3 was discharged from the facility. Interviews with the Medical Records Director and the Director of Nursing revealed that a discharge summary should have been documented upon the resident's discharge, as per the facility's policy. The discharge summary is intended to provide a summary of the services provided and the resident's condition during their stay, and it is crucial for ensuring consistent care coordination. The facility's policy mandates that a discharge summary be completed within 30 days of discharge, but this was not adhered to in the case of Resident 3.
Failure to Document Resident's Fluid Intake
Penalty
Summary
The facility failed to implement its hydration and prevention of dehydration policy by not ensuring that a resident's fluid intake was documented in the medical record. This deficiency was identified for a resident who was admitted with osteomyelitis, low back pain, and chronic kidney disease, and who had severely impaired cognition requiring assistance with daily activities. The facility's policy required that intake be documented in medical records and that aides report intake of less than 1,200 mL/day to nursing staff. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not document residents' fluid intake in milliliters, and there was no specific area in the medical records for such documentation. The Director of Nursing confirmed that unless there was an intake and output order or fluid restrictions, fluid intake was not documented. This lack of documentation had the potential to place the resident at risk for dehydration and related medical complications.
Failure to Discard Perishable Food Puts Resident at Risk
Penalty
Summary
The facility failed to adhere to its policy on preventing foodborne illness by not ensuring that cooked eggs found on a resident's bedside table were discarded after being left out for over 24 hours. The resident, who was readmitted to the facility with chronic obstructive pulmonary disease and functional quadriplegia, was observed to have two hard-boiled eggs wrapped in plastic on their bedside table. These eggs were labeled with a date indicating they had been there since the previous day. The resident confirmed that the eggs had not been refrigerated and had been at their bedside since the previous day. The Dietary Supervisor acknowledged that the resident receives cooked eggs as a snack upon request and confirmed that cooked eggs should be refrigerated if not consumed immediately. The facility's policy, reviewed in July 2024, states that food served without temperature controls should be discarded if not eaten within two hours to minimize the risk of foodborne illness. The Dietary Supervisor reiterated that cooked eggs are perishable and should be discarded after two hours if not refrigerated, as they could lead to bacterial growth. This oversight placed the resident at risk for foodborne illnesses.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) and Hand Hygiene (HH) policies, leading to a deficiency in infection control practices. Certified Nurse Assistant 1 (CNA 1) did not don a gown while changing the bed linen for a resident on EBP, despite the signage on the resident's door indicating the requirement to wear a gown and gloves for such tasks. Additionally, CNA 1 did not perform hand hygiene after removing gloves, which is a critical step in preventing the spread of infections. The resident involved was admitted with diagnoses including idiopathic peripheral autonomic neuropathy, diabetes mellitus with a skin ulcer, and cellulitis of the lower limb. The resident's Minimum Data Set indicated intact cognition and a need for maximum assistance with personal hygiene and moderate assistance with bed mobility. Physician orders specified enhanced barrier precautions due to the resident's risk of infection from wounds. Interviews with facility staff, including CNA 1, Licensed Vocational Nurse 2 (LVN 2), the Infection Prevention Nurse (IP), and the Director of Nursing (DON), confirmed the failure to adhere to the facility's policies. The facility's policy required staff to wear gowns and gloves during high-contact activities, such as changing bed linens, to prevent the transmission of multidrug-resistant organisms. The policy also mandated hand hygiene after removing personal protective equipment, which was not followed in this instance.
Failure to Maintain Required Room Temperature
Penalty
Summary
The facility failed to maintain the required room temperature levels between 71-81 degrees Fahrenheit for residents, as observed in two rooms and affecting one resident. During an observation, Room A was found to have a temperature of 65 degrees F, and Room B had a temperature of 69.5 degrees F. The Maintenance Supervisor confirmed that the resident rooms are required to be within the specified temperature range and acknowledged the need to adjust the thermostat to meet these requirements. Resident 3, who was admitted with diagnoses including a left pelvic fracture, left hip fracture, heart failure, and insomnia, reported discomfort due to the cold room temperature. The resident was observed using an extra blanket to keep warm, indicating the room's temperature was below the required level. The facility's policy on providing a homelike environment also specifies maintaining a comfortable and safe temperature range, which was not adhered to in this instance.
Improper Placement of Power Strips Creates Hazards
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the safe placement of power strips, leading to potential hazards for residents, visitors, and staff. During a facility tour, it was observed that a power strip was placed on the floor next to a resident's bed, creating a tripping hazard. Additionally, another power strip was improperly secured to a bed rail using plastic gloves, which was acknowledged by the Maintenance Supervisor as not being secured properly. These observations were made in the rooms of two residents, both of whom had intact cognition and the capacity to understand and make decisions. The facility's policy, revised in July 2024, clearly states that power strips should not be mounted to any permanent structure and must be stored in a manner that does not create a tripping hazard. Despite this, the power strips were not stored safely, posing an increased risk of falls, trips, and occupational hazards. The Administrator confirmed that the power strips should not be lying on the floor or tied to bed rails with plastic gloves, indicating a lapse in following the established guidelines for maintaining a safe environment.
Failure to Conduct Neurological Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its policy and procedure on Fall Management and Neurological Evaluation by not completing a neurological assessment after an unwitnessed fall involving a resident. The resident, who had been admitted with diagnoses including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, experienced an unwitnessed fall on 8/17/2024. Despite the facility's protocol requiring a neurological assessment for 72 hours post-fall, this was not conducted, potentially leading to a delay in care and placing the resident at risk. Interviews and record reviews revealed that the MDS Nurse acknowledged the requirement for a neurological assessment following an unwitnessed fall, which should be performed by licensed nurses without needing a physician's order. However, the assessment was not completed, and the resident was transferred to the hospital for evaluation. Upon the resident's return to the facility, the neurological assessment was not resumed, as the Director of Nursing incorrectly believed that a physician's order was necessary to continue the assessment. The facility's policies on Fall Management and Neurological Evaluation clearly state the need for immediate and ongoing neurological checks following an unwitnessed fall. Despite this, the Neurological Flow Sheet for the resident was not completed, and the Director of Nursing maintained that the facility staff did not err, citing the absence of a physician's order as the reason for not continuing the assessment. This oversight resulted in incomplete documentation and monitoring of the resident's condition post-fall.
Failure to Ensure Timely Pain Management for a Resident
Penalty
Summary
The facility failed to implement its pain management policy by not ensuring timely notification of the physician to obtain orders for treating a resident's pain. The resident, who was admitted with conditions including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, required substantial assistance with daily activities. Despite having orders for pain medications such as Acetaminophen, Gabapentin, and Tramadol, the resident continued to experience pain. On a specific day, the resident complained of pain, and the Licensed Vocational Nurse (LVN) attempted to contact the on-call physician for additional pain medication but faced technical difficulties with the phone service. The LVN did not take further action to resolve the issue, such as contacting the medical director, and instead endorsed the situation to the next shift. The Director of Nursing later stated that the LVN should have informed them, so they could have contacted the medical director. The facility's pain management policy, last reviewed in July 2024, emphasizes maintaining the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain, which includes notifying the physician and obtaining treatment orders as needed.
Delayed Food Preference Assessments for New Residents
Penalty
Summary
The facility failed to complete food preference assessments within 48 hours of admission for four out of five sampled residents, as required by their policy and protocol. This deficiency was identified through observation, interviews, and record reviews. The residents involved had various medical conditions, including diabetes mellitus, cerebral infarction, right hemiplegia, displaced intertrochanteric fracture, depression, and osteoarthritis. Despite having intact cognition or mild cognitive impairment, their food preference interviews were delayed, being conducted on the same date, well beyond the 48-hour requirement. During interviews, both the Dietary Supervisor and the Dietician acknowledged the failure to adhere to the facility's policy, which mandates that food preference interviews be completed within 48 hours of a resident's admission. They recognized that this oversight could lead to residents being served food they do not prefer, potentially resulting in decreased meal intake and weight loss. The facility's policy, reviewed in July 2024, clearly states the necessity of identifying individual dining, food, and beverage preferences promptly upon admission.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for three residents, which could potentially delay care and leave residents' needs unmet. Resident 2, who was admitted with dementia and heart failure, was observed with the call light on the floor, out of reach. The Infection Preventionist confirmed that the resident would be unable to call for assistance, increasing the risk of accidents if the resident attempted to go to the bathroom unassisted. Resident 7, admitted with spinal stenosis and difficulty walking, was found asleep in bed with the call light hanging off the back of the bed, out of reach. A Certified Nursing Assistant verified this observation. The Director of Nursing stated that staff are trained to ensure call lights are within reach, emphasizing the importance of timely response to emergencies to prevent accidents. Resident 70, who was totally dependent on assistance for mobility and personal hygiene, was observed waving to get attention as the call light was wrapped around the side rails and not within reach. A Registered Nurse and a Certified Nursing Assistant confirmed the situation, noting the importance of the call light being accessible to prevent skin problems from prolonged soiling and resident frustration.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that the clinical records of four residents were updated with their advance directives, which are crucial documents outlining a person's medical treatment preferences in situations where they cannot communicate their wishes. Resident 26, who was admitted with a diagnosis of sepsis and had moderate cognitive impairment, had executed an advance directive, but the facility was still waiting for the family to provide a copy. The Social Service Director (SSD) acknowledged that no follow-up had been conducted with the family to obtain the document. Similarly, Resident 58, who had intact cognition and was admitted with multiple sclerosis and benign prostatic hyperplasia, had also executed an advance directive. However, the facility had not received a copy from the family, and no follow-up was done. The SSD reiterated the importance of having advance directives to ensure residents' wishes are honored, especially in emergencies. Resident 29, with severely impaired cognition and a history of rhabdomyolysis, bipolar disorder, and dementia, had an advance directive executed by a surrogate decision maker, but it was missing from the medical record. Resident 82, with intact cognition and a diagnosis of chronic obstructive pulmonary disease, also had an advance directive that was not present in their medical chart. The SSD and Medical Records Director confirmed the absence of these documents, emphasizing the dignity issue and the necessity of honoring residents' wishes as per the facility's policy.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident 82, who was admitted with chronic obstructive pulmonary disease, was receiving antibiotics for a urinary tract infection but did not have a care plan in place for the antibiotic use. This lack of a care plan meant there were no specified goals, interventions, or monitoring processes to ensure the effectiveness of the treatment, potentially delaying the resident's healing process. Resident 30, who had diagnoses including abnormalities of gait and mobility, did not have a care plan that accurately reflected the physician's orders for Restorative Nursing Assistant exercises. Although the resident had orders for active range of motion exercises for both upper and lower extremities, the care plan only included exercises for the lower extremities. This discrepancy could lead to missed interventions by the interdisciplinary team, risking functional decline for the resident. Resident 32, admitted with obstructive and reflux uropathy, did not have a care plan for urinary retention despite having a diagnosis and physician's orders for medication to manage the condition. The absence of a care plan meant there was no structured approach to monitor urinary retention or ensure normal urination, which could impact the resident's care and well-being. The facility's policy requires comprehensive care plans to be developed within seven days of the resident's assessment, but this was not adhered to in these cases.
Incorrect LAL Mattress Settings Increase Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that the low air loss (LAL) mattresses were set correctly for three residents, which increased their risk of skin breakdown and pressure ulcers. Resident 29, who was readmitted with conditions including rhabdomyolysis, bipolar disorder, and dementia, had a sacral pressure ulcer classified as stage four. Observations revealed that the LAL mattress was set to static mode and at an incorrect weight setting, which was not adjusted according to the resident's weight and comfort. Treatment Nurse 1 and Treatment Nurse 2 confirmed the incorrect settings and adjusted them accordingly, noting that the static mode and incorrect weight setting could hinder wound healing. Resident 48, admitted with a tracheostomy and traumatic brain injury, was dependent on staff for self-care and mobility and at risk of developing pressure ulcers. The LAL mattress for this resident was observed to be set at the maximum weight setting, which was significantly higher than the resident's actual weight. Treatment Nurse 3 confirmed the incorrect setting and adjusted it to match the resident's weight, acknowledging that the previous setting could increase the risk of pressure ulcers due to the mattress's firmness. Resident 62, who had severely impaired cognition and was dependent on staff for all activities of daily living, was also at severe risk of developing pressure ulcers. The LAL mattress for this resident was set at a weight significantly higher than the resident's actual weight, as indicated by a sticker on the mattress. Registered Nurse 1 confirmed the discrepancy and adjusted the setting to the correct weight. The Director of Nursing stated that incorrect settings on the LAL mattress would defeat its purpose of preventing pressure injuries.
Failure to Attempt Non-Pharmacological Interventions Before Administering Opioid Pain Medication
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed opioid pain medication to a resident on multiple occasions. This deficiency was identified for a resident who had been admitted with acute respiratory failure, tracheostomy status, and gastrostomy status. The resident had moderately impaired cognition and required maximum assistance for most activities of daily living. The resident's physician had prescribed hydrocodone-acetaminophen to be administered via gastrostomy tube for severe pain, but there was no documentation of non-pharmacological interventions being attempted prior to administering the medication on several dates in April and May 2024. During interviews, both the MDS Nurse and the Director of Nursing acknowledged the importance of attempting non-pharmacological interventions before administering prn pain medication to potentially avoid unnecessary medication and its adverse side effects. The facility's policy on pain management emphasized the need for an individualized care plan that includes both non-pharmacological and pharmacological approaches, and required documentation of non-pharmacological interventions and their effectiveness. However, the lack of documentation indicated that this policy was not followed, leading to the deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and administration of Zosyn, an antibiotic, for a resident diagnosed with cellulitis. The resident was admitted with conditions including dementia, heart failure, and cellulitis of the left lower limb. The physician's orders required Zosyn to be administered intravenously every eight hours for seven days. However, the Medication Administration Record (MAR) lacked documentation for several doses, and there was no indication of refusal by the resident. This lack of documentation raised concerns about whether the medication was administered as prescribed. Additionally, the facility did not maintain accurate records for controlled drugs for several residents. For one resident with epileptic seizures, there was a discrepancy between the Controlled Drug Record (CDR) and the MAR for lacosamide, a medication administered via PEG tube. The nurse responsible admitted to forgetting to sign the CDR, which is a critical step in the medication administration process. This oversight could lead to medication errors, such as double dosing. Similar discrepancies were found for other residents receiving controlled medications like Norco, morphine sulfate, and tramadol. In each case, the CDR indicated that medications were removed from the bubble pack, but corresponding entries were missing from the MAR. The Director of Nursing confirmed these discrepancies and emphasized the importance of the 'pour, pass, and sign' procedure to prevent medication errors. These lapses in documentation and procedure adherence posed risks of medication errors and potential drug diversion.
Medication Labeling and Access Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which led to several deficiencies. For two residents, insulin medications were not dated when opened, which is crucial to ensure the medication is not used beyond its effective period of 28 days. Resident 12, who was cognitively intact, had a Lantus insulin pen without an open date, and Resident 387, who was severely impaired in cognition, had a lispro insulin vial also lacking an open date. Both instances were observed by a registered nurse, who acknowledged the importance of labeling to maintain medication effectiveness. Additionally, the facility did not ensure that an eye drop medication for Resident 33 was used within its effective period. The latanoprost ophthalmic solution, prescribed for glaucoma, was observed with an open date indicating it was used past the 28-day period. The registered nurse involved was under the impression that the eye drops could be used for 30 days, contrary to the facility's policy, which mandates discarding after 28 days to ensure effectiveness. Furthermore, the facility allowed unauthorized access to a medication room, which could lead to drug diversion. The Dietary Supervisor was observed entering the medication room using an access code, despite facility policies stating that only licensed nurses or staff accompanied by licensed nurses should have access. The Director of Nursing confirmed that unauthorized personnel should not have access to the medication room, as it increases the risk of unauthorized access to medications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for three residents, leading to potential health risks. For Resident 187, the nasal cannula tubing was observed touching the floor, which was confirmed by a Certified Nursing Assistant (CNA) and acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON) as a potential source of contamination. The facility's policy and CDC guidelines emphasize the importance of keeping medical equipment off the floor to prevent bacterial contamination. Additionally, the facility did not label urinals for Residents 187 and 188, which could lead to cross-contamination. During observations, both residents were found with unlabeled urinals, and staff confirmed that labeling is necessary to prevent the use of the same equipment by different residents. The IP and DON both acknowledged the increased risk of infection due to the lack of labeling, and the Administrator admitted there was no specific policy addressing this issue. For Resident 337, the intravenous administration set used to deliver antibiotics was not labeled, which could result in contamination and infection. The Registered Nurse (RN) responsible for administering the medication admitted to dropping the label and not replacing it. The IP confirmed that labeling is crucial for tracking the administration schedule and preventing bacterial transmission. The facility's policy requires labeling of IV sets with specific information, including the date, time, and initials of the administering nurse.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter collection bag was covered with a privacy bag for a resident, which compromised the resident's dignity. The resident, who was admitted with diagnoses of multiple sclerosis and benign prostatic hyperplasia, had the capacity to make decisions and intact cognition. Despite these considerations, the resident's urinary catheter bag was observed without a dignity bag, making the urine visible. During an observation and interview with the Infection Preventionist, it was confirmed that the resident's drainage bag lacked a dignity bag, which is necessary for maintaining resident dignity and infection control. The facility's policy on Quality of Life - Dignity, last reviewed in July 2023, mandates that residents be cared for in a manner that promotes their well-being and self-esteem, including maintaining privacy during personal care and treatment procedures.
Failure to Timely Collect and Follow-Up on STAT Fecal Occult Blood Test
Penalty
Summary
The facility failed to ensure timely collection and follow-up of a STAT fecal occult blood test (FOBT) for Resident 25, who was admitted with Guillain-Barre syndrome and myasthenia gravis. On 6/5/2024, a STAT order for a complete blood count (CBC), basic metabolic panel (BMP), and FOBT was placed after the family reported the resident had a soft black stool, indicating potential internal bleeding. However, the stool specimen was not collected during the resident's bowel movement at 9:32 p.m. on the same day, and the order was marked as incomplete and rescheduled for 6/7/2024. The stool specimen was eventually collected on 6/7/2024, but there was no documentation of follow-up on the FOBT result until 6/10/2024. During this period, the resident's hemoglobin levels dropped significantly, indicating worsening anemia. On 6/10/2024, the resident was found to have a positive FOBT and critically low hemoglobin, prompting an emergency transfer to the hospital. The delay in collecting the stool specimen and following up on the test results contributed to the resident's deteriorating condition. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) revealed that the facility's policy required STAT orders to be completed within a 4 to 6-hour timeframe. The DON emphasized the importance of timely specimen collection and result follow-up to prevent complications such as hypovolemic shock. The failure to adhere to these protocols resulted in a delay in necessary medical intervention for Resident 25.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, which violated their rights to self-determination and choice. Resident 44, who was admitted for orthopedic aftercare following knee surgery and had undergone gastric bypass surgery, requested cereal for dinner due to a lack of appetite. However, the staff member, [NAME] 1, denied this request, mistakenly believing there was no cereal available. This led to Resident 44 not eating that night as she did not like the alternative meal offered. Similarly, Resident 57, admitted for acute kidney failure, requested hard-boiled eggs for dinner, which was denied by [NAME] 1, who thought there were no eggs available. Instead, [NAME] 1 offered a hamburger from the alternate menu, which Resident 57 declined. The Dietary Supervisor confirmed that both cereal and eggs were available and should have been provided to the residents. The Director of Nursing emphasized the importance of accommodating residents' preferences, especially when dietary restrictions do not prevent it.
Incomplete POLST Documentation for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the sampled residents, identified as Resident 82. The deficiency was identified during a review of Resident 82's Physician's Order for Life-Sustaining Treatment (POLST) form, which was found to be incomplete. The POLST form, which is crucial for specifying the types of medical treatment a resident wishes to receive during serious illness, was missing the date of the resident's signature, the relationship of the signee, and the physician's documentation of discussion and signature. This incomplete documentation was confirmed during interviews with the Medical Records Director, Registered Nurse 2, and the Director of Nursing, all of whom acknowledged the missing information on the POLST form. Resident 82 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease (COPD) and had intact cognition as per the Minimum Data Set assessment. The incomplete POLST form posed a risk of violating the resident's rights and preferences regarding treatment, as it would be deemed invalid in an emergency situation, leading to the resident being treated as full code status. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, which was not adhered to in this case.
Inadequate Pest Control Measures Lead to Insect Presence in Resident's Room
Penalty
Summary
The facility failed to prevent the presence of insects and flies in the room of a resident who was admitted with cerebral infarction, hemiplegia, and hemiparesis, and was dependent on staff for daily activities. During a visit, a family member observed insects crawling out from small cracks in the walls and reported it to the registered nurse. Additionally, a fly was observed flying over the resident's head during a concurrent observation and interview, posing a risk of infection due to the resident's tracheostomy. The Maintenance Supervisor acknowledged that some windows had bent and broken screens, allowing insects to enter the facility. The pest control company had also noted a door with a gap that could allow insects to enter. The facility's policy indicated that windows should be screened to prevent insect entry, but this was not consistently implemented, contributing to the presence of pests in the resident's room.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, specifically for milk and more fruits with each meal. The resident, who had multiple serious medical conditions including respiratory failure, diabetes mellitus, and bipolar disorder, had requested lighter food, more fruits, and milk with every meal. Despite these requests being documented in the resident's Nutritional Care Assessment and recommended by the Registered Dietician, there was no evidence that these preferences were communicated to or implemented by the dietary department. The lack of documentation and follow-through was confirmed through interviews with the Registered Dietician, Licensed Vocational Nurse, and Dietary Supervisor, who were unable to locate any diet communication slips or records indicating that the resident's food preferences were accommodated. The resident's Minimum Data Set indicated that their cognition was intact, and they required limited assistance with eating. The resident had experienced a 5% weight loss over 90 days, which could be attributed to inadequate oral intake. The facility's policy on Resident Food Preferences required that individual food preferences be assessed upon admission and communicated to the interdisciplinary team, with modifications to the diet ordered with the resident's consent. However, the facility failed to follow this policy, resulting in the resident's food preferences not being met, which had the potential to decrease meal intake and lead to weight loss.
Falsification of Resident Progress Notes by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) did not willfully falsify progress notes for a resident on three separate occasions. The resident, who had been admitted with serious conditions including respiratory failure, diabetes mellitus, and bipolar disorder, was not present in the facility on the dates the progress notes were documented. Despite this, the NP recorded detailed assessments and vital signs for the resident on those dates, creating a fraudulent clinical record that inaccurately reflected the care provided. During an interview, the Director of Nursing (DON) confirmed that the resident had been transferred to a General Acute Care Hospital and was not in the facility on the dates the progress notes were made. The DON could not explain how the NP was able to document assessments for the resident during their absence. The NP admitted to completing the progress notes despite the resident not being present and attributed the false documentation to a mistake, stating that the assessments were done from memory after returning home. The facility's policies and procedures require that all services provided to residents and any changes in their condition be accurately documented in their medical records. The NP's actions violated these policies, as the progress notes did not reflect the resident's actual status or care provided. The Primary Care Provider (PCP) also acknowledged that the progress notes were mistakenly completed during a busy period, further highlighting the issue of inaccurate documentation.
Failure to Update Care Plan for Resident's Food Preferences
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address and accommodate a resident's food preferences for milk and more fruits with each meal. The resident, who had intact cognition and required limited assistance with eating, had requested lighter food, more fruits, and milk with every meal. Despite these requests being documented in the resident's Nutritional Care Assessment and recommended by the Registered Dietician, the care plan was not updated to reflect these preferences. This oversight was confirmed during interviews with the Registered Dietician, Licensed Vocational Nurse, and Minimum Data Set Nurse, who all acknowledged the absence of an updated care plan addressing the resident's food preferences. The resident's medical history included serious conditions such as respiratory failure with hypoxia, tracheostomy, dependence on a respirator, diabetes mellitus, and bipolar disorder. The facility's policy required that any changes in diet, including food preferences, be documented in the care plan and communicated to the resident's physician. However, the facility did not adhere to this policy, resulting in a failure to implement a comprehensive care plan that met the resident's nutritional needs and preferences.
Stranger Enters Facility and Steals Food
Penalty
Summary
The facility failed to provide a safe and comfortable environment for residents, staff, and the public when a stranger was able to enter the facility and steal food from the employee breakroom. On 1/7/2023, at approximately 1:40 a.m., a suspect entered the break room, took chicken from the refrigerator, ate it, and then left the location. The incident was reported to the police department at 8:20 a.m. the same day. Interviews with staff revealed that the entrance door is locked between 11 p.m. and 11:30 p.m. daily and then unlocked around 3 a.m. for incoming staff, which may have allowed the stranger to enter the facility undetected. During an interview, a Licensed Vocational Nurse (LVN) stated that they found a stranger in the breakroom looking for food but were unsure how the individual gained entry. The Administrator confirmed that the incident should not have occurred and acknowledged the potential risk to residents and staff. A review of the facility's policy on safety and supervision indicated a commitment to making the environment as free from accident hazards as possible, highlighting a failure in the facility's security measures.
Failure to Accurately Complete Skin Assessment
Penalty
Summary
The facility failed to ensure a skin assessment was accurately completed during a weekly summary assessment for Resident 2. Resident 2, who has a medical history including type 2 diabetes, chronic obstructive pulmonary disease, major depressive disorder, hypertension, and difficulty in walking, was admitted from a General Acute Care Hospital. The Minimum Data Set indicated that Resident 2 had moderately impaired cognitive skills and required assistance for daily activities. On a weekly summary assessment, LVN 1 documented that Resident 2 had no skin issues without actually assessing the resident's skin condition. This led to the failure to identify redness and small red bumps on Resident 2's back and left shoulder, which were later observed during an interview and physical examination on 4/10/2024. During interviews, it was revealed that Resident 2 had been experiencing itching on her back but was unsure of the duration. CNA 1 mentioned that Resident 2 preferred bed baths over showers and would notify the charge nurse if a rash was observed. The Director of Nursing was unaware of the skin condition until the interview and subsequently arranged for a dermatologist consultation. The dermatologist diagnosed Resident 2 with dermatitis and prescribed a treatment plan. LVN 1 admitted to not assessing Resident 2's skin during the weekly summary assessment, which was against the facility's policy and procedure for skin integrity management.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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