Parkview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 1514 E. Lincoln Avenue, Anaheim, California 92805
- CMS Provider Number
- 055671
- Inspections on file
- 18
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Parkview Healthcare Center during CMS and state inspections, most recent first.
A resident's medical record was found to be incomplete, with sections of the Elopement Evaluation left blank and missing documentation of monitoring during a shift following a change in condition involving agitation and attempts to leave. The DON and administrator confirmed the omissions during record review.
A resident with lower extremity contractures did not receive consistent application of physician-ordered bilateral AFOs, and staff failed to document the times of application and removal or perform and record required skin assessments. The care plan and facility policy did not address skin assessment during AFO use, and multiple staff confirmed the lack of documentation and protocol.
A resident with severe cognitive impairment and high fall risk did not have a floor mat placed on the left side of the bed as ordered by the physician and outlined in the care plan. Staff confirmed the absence of the mat despite being aware of the order and facility policy, resulting in a deficiency in accident prevention.
Three residents receiving oxygen therapy did not receive care in accordance with physician orders, and their nasal cannula oxygen tubing was observed touching the floor. For two residents, the oxygen flow rate did not match the physician's order, and for all three, the tubing was not maintained in a sanitary manner, as confirmed by staff interviews and medical record review.
Two residents did not receive pharmaceutical services in accordance with facility policy: one resident's insulin injection sites were not documented on the MAR, and another resident was given crushed oral medications by an LVN without a physician's order. Both the DON and pharmacy consultant confirmed these actions were not consistent with required procedures.
Surveyors found that medication storage areas and carts were not maintained in a clean and sanitary manner, with personal and unrelated items stored alongside medications, oral and external medications stored together, and medication carts left unlocked and unattended. Additionally, some medications were not labeled with opened dates and discontinued medications were not properly disposed of, all in violation of facility policy.
Surveyors found that kitchen utensils, including scoops and measuring cups, were not properly cleaned and were stored while still wet, contrary to facility policy and USDA Food Code requirements. The kitchen hood was also observed with black, dirt residue, despite scheduled cleaning. The Dietary Services Supervisor confirmed these sanitation lapses, which affected food prepared for most residents.
The facility's Facility Assessment did not include active involvement from direct care staff, residents, or their representatives, and failed to address necessary resources for weekends, recruitment and retention of direct care staff, or a contingency plan for staffing needs. The Administrator confirmed the assessment was not updated per the latest CMS guidance.
Surveyors identified multiple infection control deficiencies, including inaccurate infection surveillance documentation, improper storage of personal items on clean linen carts, mishandling of clean linens by staff, and failure of a hospice aide to perform hand hygiene after handling soiled linens before providing care to a resident with cognitive impairment. These actions were acknowledged by facility leadership as not compliant with infection control policies.
Several residents using side rails had inaccurate or incomplete entrapment assessments, with discrepancies found between documented measurements and actual findings during surveyor re-assessment. Facility staff acknowledged that original assessments did not match current measurements, and in some cases, assessment forms were incomplete or based on similar rather than actual beds. These failures did not align with facility policy and had the potential to negatively impact resident safety.
A resident's care plan was not updated to reflect the current size of their suprapubic indwelling urinary catheter after a new catheter was inserted. Staff and leadership confirmed that the care plan still referenced outdated catheter information, contrary to facility policy requiring timely updates based on changes in a resident's condition.
The facility did not post daily nurse staffing information in a publicly accessible area. The DON confirmed that staffing records were kept in a binder at the nursing station and were not available for residents, staff, or visitors to view.
Surveyors observed that the facility's outside garbage dumpster had its lid partially propped open by garbage bags, preventing it from fully closing. This was confirmed by the Maintenance Supervisor, despite facility policy and FDA Food Code requirements for tight-fitting lids to prevent pest and rodent entry.
A resident's medical record was found to be incomplete, with missing documentation by licensed nurses for the administration of prescribed topical antifungal treatments and wound care. The DON confirmed the omissions during a review and stated that undocumented treatments are considered not completed, in accordance with facility policy requiring complete and accurate charting.
Surveyors found that Room A was occupied by five residents, exceeding the allowed maximum of four residents per room. The administrator confirmed the over-occupancy and acknowledged the room's insufficient square footage.
A five-bed room was found to provide only 78.4 square feet per resident, which is below the required 80 square feet. The Administrator confirmed the room's measurements and acknowledged the deficiency during an interview.
The facility failed to ensure the IP was knowledgeable about updated CDC guidelines for pneumococcal immunization and CMS guidelines for enhanced barrier precautions. The IP continued to administer only PPSV 23 vaccines and did not implement enhanced barrier precautions for residents with chronic wounds or indwelling medical devices, including a resident with a Stage 4 pressure ulcer and an infected surgical wound.
The facility failed to offer PCV 15/PCV 20 immunizations to 20 residents in accordance with updated CDC guidelines, only providing PPSV 23 due to outdated policies and lack of awareness. Medical records lacked documentation of offering the updated vaccines, and the facility did not have a tracking system for pneumococcal vaccine history.
The facility failed to notify five residents or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility lacked a specific bed hold notification form, relying only on a notice of transfer or discharge form, which did not fulfill the requirement for informing residents or their representatives about the bed hold policy.
The facility failed to ensure accurate MDS assessments for 11 residents regarding their pneumococcal vaccination status, leading to discrepancies in immunization records and improper documentation. Interviews and medical record reviews confirmed that residents were not offered the appropriate vaccines as per updated guidelines.
The facility failed to follow physician's orders for a resident's abduction pillow, knee immobilizer, and bowel management medication. Additionally, the facility did not ensure proper collaboration with hospice care teams for two residents, including participation in Quarterly IDT meetings and review of care plans.
The facility failed to ensure food safety and sanitary requirements in the kitchen, with unsanitary cutting boards and equipment, expired food items, improper food temperature checks, personal belongings stored in the kitchen, poor hand hygiene, uncovered food transportation, and incorrect diet texture for a resident. These failures posed a risk of foodborne illnesses to residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and gastrostomy tubes (GT), did not ensure proper hand hygiene practices, and improperly stored medical equipment. Staff interviews and observations confirmed these deficiencies, which were acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON).
The facility failed to ensure staff provided care and promoted dignity for three residents. Two CNAs were observed standing over residents while assisting with meals, and another CNA transported a resident from the shower room with her body partially uncovered, compromising her dignity.
The facility failed to inform two residents about the risks associated with the use of bed side rails, specifically regarding the entrapment assessment for Zone 6. Both residents had beds that failed the Zone 6 measurement, but there was no documentation showing that they were informed of this specific risk. The facility's policies require residents to be informed of their care and treatment options, but this was not adhered to in these cases.
The facility failed to ensure a resident's call light was within reach, as observed during an initial tour. The resident required dependent assistance for bed mobility and transfers, and the call light was found on the floor. The CNA admitted to not noticing the call light, and the DON confirmed that call lights should always be within reach.
The facility failed to honor a resident's documented food preferences by serving him rice, which he had not eaten for two years and explicitly disliked. This discrepancy was confirmed by the Social Services Director and acknowledged by the Director of Nursing.
The facility failed to inform and provide written information about advance directives to a resident and did not ensure that copies of advance directives were readily available in the medical records of two other residents. The Social Services Director confirmed these deficiencies, and the Director of Nursing acknowledged the findings.
The facility failed to provide a resident and/or their representative with the required written notification of a transfer to an acute care hospital, as mandated by the facility's policy. The resident, who had the capacity to understand and make decisions, was transferred without receiving the necessary written notice, including details and appeal rights.
A facility failed to provide a summary of the baseline care plan to a newly admitted resident. Despite discussing physical therapy, there was no documented evidence that the resident was informed or given a summary of her baseline care plan, contrary to the facility's policy.
The facility failed to develop a care plan to address a resident's noncompliance with a physician's order to use a hip abduction pillow while in bed. Despite the resident's capacity to understand and make decisions, and her expressed right to remove the pillow, the care plan did not reflect this issue, leading to inconsistent care.
The facility failed to provide an individualized and ongoing activity program for a resident with severe cognitive impairment, leading to potential social isolation and frustration. Despite the care plan requiring daily activities and sensory stimulation, the resident was often observed lying awake in bed without engagement, and the Activity Attendance Record showed significant gaps in activity provision.
The facility failed to provide necessary catheter care for two residents, leading to potential risks for UTIs. One resident's catheter care was not documented every shift, and another resident's catheter bag was changed weekly against CDC guidelines. Staff acknowledged these deficiencies.
The facility failed to meet the nutritional needs of a resident who consumed less than 50% of their meal tray. Despite the resident's history of weight fluctuations and a physician's order for a regular diet with a large protein portion, staff did not offer an alternative meal as required. This oversight was confirmed by both the DON and the RD.
The facility failed to ensure proper care for three residents with gastrostomy tubes (GT). A CNA was observed turning off a GT feeding machine, which is outside their scope of practice. Additionally, the GT tubing for three residents was not labeled, which is necessary to ensure daily changes. Both the DSD and DON confirmed these deficiencies.
The facility failed to provide necessary respiratory care services for two residents. One resident received incorrect oxygen therapy, and another had issues with the maintenance and availability of respiratory equipment. These deficiencies were confirmed by staff and acknowledged by the DON.
A facility failed to ensure ongoing assessment before, during, and after dialysis treatments for a resident. The dialysis communication forms on two dates were incomplete, lacking necessary documentation of the dialysis access site and post-dialysis assessments of bruit and thrill. The Infection Preventionist and Director of Nursing acknowledged the findings.
The facility failed to replace the emergency kit for oral medications in a timely manner. The kit, opened on 3/30/24, was not reported to the pharmacy until 4/3/24, delaying its replacement. The DON acknowledged the findings.
The facility failed to act on the Pharmacy Consultant's recommendations for two residents regarding the duration of therapy for enoxaparin (Lovenox). For one resident, there was no documentation that the physician was notified or that the recommendation was acted upon. For the other resident, although the physician was informed and responded to continue the same order, no rationale was provided for not following the recommendation.
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not conducting required AIMS assessments for two residents prescribed antipsychotic medications. Both the RN and the DON confirmed the lack of AIMS assessments and acknowledged the absence of a form for this assessment.
A facility failed to ensure medications were not left unattended on a medication cart. An LVN prepared medications for a resident and left them unattended in a hallway, contrary to the facility's policy. The DON acknowledged the deficiency.
The facility failed to follow puree recipes and renal and CCHO menus for several residents, leading to improper meal preparation and non-compliance with dietary requirements. The DSS and Dietary Aide did not adhere to standardized recipes and menu items, as confirmed by the RD and DON.
The facility failed to ensure that food served to residents was at an appetizing and safe temperature. During a test tray evaluation, food temperatures were found to be significantly below the recommended levels. Additionally, three residents complained about receiving cold food. The RD confirmed the temperatures were below the recommended levels and acknowledged the residents' complaints.
The facility failed to ensure complete and accurate medical records for three residents. One resident's physician's order for no weight bearing status and sling support was not discontinued, another resident's medication order was inaccurate, and a third resident's meal consumption was incorrectly documented. The DON acknowledged these deficiencies.
The facility failed to ensure collaboration between hospice and facility staff in the care plans for two hospice residents. There was no documented evidence that the hospice care teams reviewed or acknowledged the care plans, and they did not participate in IDT meetings. The DON acknowledged these findings.
The facility failed to follow up on bed entrapment assessments for two residents, leading to potential safety risks. Both residents' beds failed Zone 6 measurements, indicating a risk of entrapment, but no follow-up actions were taken to reassess or adjust the beds. The facility's policies and procedures for regular inspections and reassessments were not adhered to, resulting in potential safety hazards.
The facility failed to complete a resident's quarterly MDS assessment within 14 days of the ARD. The assessment, initiated but not completed, was confirmed by the MDS Nurse. The DON acknowledged the findings.
The facility failed to submit a resident's MDS Quarterly assessment within the required timeframe. The assessment, completed on 2/28/24, was not submitted until 3/28/24, exceeding the 14-day submission requirement. The MDS Nurse confirmed the late submission, and the DON acknowledged the finding.
The facility failed to ensure Room A did not accommodate more than four residents. During a tour, it was observed that Room A had five occupied beds, which was confirmed by the Administrator. The Administrator acknowledged the room's insufficient square footage and mentioned the facility's intention to continue with the room variance waiver.
The facility failed to ensure Room A met the required minimum of 80 square feet per resident. Room A, a five-bed room, measured 392 square feet in total, providing only 78.4 square feet per resident when fully occupied. The Administrator confirmed the room's measurements and acknowledged the deficiency.
Incomplete Medical Record Documentation for Resident with Change in Condition
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own policies and accepted professional standards. Specifically, the Elopement Evaluation form for the resident, dated 5/2/25, was found to have several sections left blank, including those addressing the pattern and impact of wandering behavior, risk identification, goals, interventions, and clinical suggestions. This incomplete documentation was confirmed during a review of the closed medical record with the Director of Nursing (DON), who acknowledged that the form should have been fully completed. Additionally, the resident experienced a change in condition, including agitation, physical aggression, striking out at staff, and attempts to leave the facility, as documented on the eINTERACT tool. However, there was no documentation in the medical record indicating that the resident was monitored for this change in condition during the 0700-1500 hours shift on 5/3/25. The DON verified that the required progress note for monitoring during this period was missing. The facility administrator also acknowledged these findings.
Failure to Document and Assess Skin During AFO Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion (ROM) for a resident with contractures in both lower extremities. Despite a physician's order for the application of bilateral ankle-foot orthoses (AFOs) for four hours daily, five times a week, the order was not consistently followed. Documentation was lacking regarding the exact times the AFOs were applied and removed, and there was no evidence that skin assessments were performed or recorded when the AFOs were in use. The resident's care plan addressed the use of AFOs to prevent decline in ROM, but did not include interventions for skin assessment during device application. Interviews with restorative nursing assistants (RNAs), a licensed vocational nurse (LVN), and an occupational therapist (OT) confirmed that while the AFOs were applied, there was no documentation of the timing or skin assessments. The facility's policy on restorative nursing care emphasized maintaining good body alignment and proper positioning, but did not specify skin assessment procedures. The director of nursing (DON) verified the findings, confirming the lack of documentation and absence of skin assessment protocols related to the use of AFOs for the resident.
Failure to Implement Fall Prevention Intervention as Ordered
Penalty
Summary
The facility failed to implement a physician's order to place a floor mat on the left side of a resident's bed, as part of fall prevention interventions. During an initial tour, the resident was observed in bed with the bed in the lowest position, but no floor mat was present on the left side. The resident's care plan, physician's order, and facility policy all indicated the need for a floor mat due to the resident's high risk for falls and tendency to lean to the left. The resident had severe cognitive impairment and was unable to make decisions, further emphasizing the need for adherence to safety interventions. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the physician's order and the absence of the floor mat at the time of observation. The LVN acknowledged that the floor mat should have been in place for safety reasons, and the DON verified the findings. The failure to follow the prescribed intervention constituted a deficiency in providing necessary care and services to prevent accidents.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for three residents who were receiving oxygen therapy. Observations revealed that the nasal cannula oxygen tubing for all three residents was touching the floor, which was confirmed by staff during interviews. Additionally, for two of the residents, the facility did not follow the physician's orders regarding the prescribed oxygen flow rates. Specifically, one resident was observed receiving oxygen at a rate different from the physician's order, and another resident's oxygen therapy was not administered as ordered for their respiratory condition. Medical record reviews indicated that the affected residents had care plans and physician orders specifying the need for continuous oxygen therapy due to conditions such as oxygen desaturation and respiratory acidosis. The care plans also included interventions to administer oxygen as ordered and to monitor oxygen saturation levels. Despite these documented needs and orders, the facility did not ensure that the oxygen therapy was provided according to the physician's instructions, nor did it maintain the cleanliness and safety of the oxygen delivery equipment as required by facility policy.
Failure to Document Insulin Injection Sites and Crush Medications Without Physician Order
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not ensuring proper medication administration and documentation. For one resident with moderate cognitive impairment and diabetes, the facility did not document the injection sites for multiple insulin orders, including Lantus Solostar and Novolog Flexpen, as required by facility policy. The Medication Administration Record (MAR) for the month reviewed did not show any documentation of injection sites for these insulin medications, and both the Director of Nursing (DON) and a registered nurse confirmed the absence of this documentation. The facility's policy required recording the injection site for medications administered by injection, but this was not followed. In a separate incident, another resident with moderate cognitive impairment was observed receiving crushed oral medications without a physician's order to do so. During a medication administration observation, a licensed vocational nurse (LVN) crushed and administered several oral medications to the resident, despite the resident's medical record lacking any physician's order permitting the medications to be crushed. The LVN confirmed that the medications were crushed based on the resident's preference, not on a physician's directive. The DON and the pharmacy consultant both acknowledged that crushing medications should require a physician's order, but this was not obtained in this case. These failures were identified through observation, interviews, and review of medical records and facility policies. The lack of documentation for insulin injection sites and the administration of crushed medications without a physician's order were both contrary to the facility's established policies and procedures, as well as standard pharmaceutical practices.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices. Medication Storage Room A was found to contain personal items such as a staff member's sweater, desk fans, a resident's box of candies, and a large stuffed toy, all stored alongside medication supplies. An opened diaper package was found near the sink, and both oral and external medications, such as bisacodyl suppositories and saline enema laxatives, were stored together with oral medications. In the medication refrigerator, latanoprost ophthalmic medication was stored with Tubersol injectable solution, and a collection of clear liquid was observed in the freezer basin. These findings were acknowledged and verified by the Director of Staff Development (DSD). Further inspection of Medication Carts A and B revealed additional issues. Medication Cart B was found unlocked and unattended, and contained items with dried residues, such as forceps and wound skin cleanser, as well as unsealed gauze sponges and a bottle of baby powder with dried residue. Medication Cart A contained both oral and external medications stored together, an opened bottle of latanoprost ophthalmic solution without an opened date, and discontinued medications stored in the narcotic locked drawer. The DSD and Director of Nursing (DON) confirmed these findings, which were not in accordance with the facility's policies for medication storage, labeling, and disposal.
Sanitation Deficiencies in Kitchen Utensil Cleaning and Hood Maintenance
Penalty
Summary
Surveyors identified multiple sanitation deficiencies in the facility's kitchen during an inspection. Observations revealed that kitchen utensils, including stainless steel scoops and measuring cups used for food portioning, were not properly cleaned and contained dry, crusted food residue, white residue, and watermarks. Additionally, some utensils and measuring cups were found stored while still wet, indicating they had not been air dried as required by facility policy and USDA Food Code standards. The Dietary Services Supervisor (DSS) confirmed these findings and acknowledged that the utensils should have been rewashed and air dried before storage. Further inspection of the kitchen revealed that the hood over the stove was not maintained in a sanitary condition, as it was observed with black, dirt residue. The DSS stated that the hood was supposed to be cleaned twice a week by dietary staff and serviced by an outside company, but acknowledged that grease residue should not be present due to the risk of contamination and fire hazard. These deficiencies were found in a kitchen that prepared food for the majority of the facility's residents, as indicated by the Diet Type Report.
Facility Assessment Lacks Required Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure that its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. Review of the Facility Assessment did not show evidence of participation from these groups in the assessment process. Additionally, the assessment did not address the resources necessary to care for residents during weekends or include a plan to maximize recruitment and retention of direct care staff. Furthermore, the Facility Assessment lacked a contingency plan for staffing needs, which is required to ensure adequate staffing during both routine operations and emergencies without activating the facility's emergency plan. During an interview and document review, the Administrator confirmed that the Facility Assessment was not updated to reflect the latest CMS guidance and acknowledged the absence of required involvement and planning elements.
Infection Control Deficiencies in Documentation, Linen Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection prevention and control practices as evidenced by multiple deficiencies in documentation, environmental services, linen handling, and hand hygiene. Review of the facility's monthly Infection Prevention and Control Surveillance Logs revealed discrepancies between the surveillance logs and the monthly summary reports for several months, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the numbers reported did not match and acknowledged the inaccuracy of the infection data, which is used for tracking and trending infections within the facility. In the laundry area, personal items such as a tumbler cup, bottled water, and lotion were found stored on a clean linen cart, contrary to facility policy requiring clean linens to be protected from environmental contamination. Staff members were observed mishandling clean linens by holding them against their bodies while delivering them to residents' rooms, which was acknowledged by the staff as improper practice. These actions were verified by the Maintenance Supervisor, Director of Nursing (DON), and IP as not compliant with infection control policies. Additionally, a hospice aide was observed providing care to a resident with significant cognitive impairment without performing appropriate hand hygiene. After handling soiled linens with gloved hands, the aide failed to change gloves and perform hand hygiene before touching the resident. The DON confirmed that both facility and hospice staff are required to perform hand hygiene before and after resident care, and acknowledged the failure to follow this protocol.
Inaccurate Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurate and complete for several residents who used side rails. Specifically, for four residents reviewed, there were discrepancies and inaccuracies in the measurements and zone assessments for bed entrapment risks. The facility's own policies required regular inspection and assessment of bed frames, mattresses, and side rails, including the evaluation of specific entrapment zones as outlined by FDA guidance. However, the assessments documented in the residents' records did not match the actual measurements and findings when re-assessed by staff using the appropriate measurement device. For one resident, the initial entrapment assessment indicated that several zones failed, but a subsequent assessment revealed different measurements and additional failed zones, indicating the original documentation was inaccurate. Another resident's assessment form was incomplete, with critical sections left unmarked, and the zone assessments did not match the findings from a later, more accurate measurement. In both cases, the staff acknowledged that the original assessments were not accurate compared to the re-assessments conducted during the survey. Similar discrepancies were found for two other residents, where the bed inspection measurements and entrapment assessments on file did not align with the actual measurements taken during the survey. In some cases, the beds were measured using a similar bed rather than the actual bed in use, and the results showed differences in mattress length and zone pass/fail status. These failures to accurately assess and document bed system safety had the potential to negatively impact residents by increasing the risk of entrapment.
Failure to Update Care Plan for Suprapubic Catheter Change
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the current size of the resident's suprapubic indwelling urinary catheter. The resident had a new catheter of size 18 French inserted on 2/7/25, as documented in the urology procedure report. However, the care plan continued to reference previous catheter sizes and did not include the updated information regarding the new catheter size. During interviews and medical record reviews, facility staff, including an RN, the Administrator, and the DON, acknowledged that the care plan had not been updated to reflect the resident's current catheter size. The facility's policy requires ongoing assessment and revision of care plans as resident information and conditions change, but this was not followed in this instance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location accessible to residents, staff, and visitors. During an inspection of the nursing station and facility bulletin board, the Director of Nursing (DON) confirmed that the daily nurse staffing record was kept in a binder at the nursing station and was not posted for public viewing. The DON was unsure of the correct location for posting this information.
Improper Storage of Garbage in Dumpster
Penalty
Summary
The facility failed to ensure proper storage of garbage in its outside dumpster, as observed during a survey. The dumpster lid was found partially propped open by garbage bags, preventing it from fully closing. This observation was confirmed by the Maintenance Supervisor, who acknowledged that the lid should remain closed at all times. Facility policy requires daily inspection of garbage cans to ensure no debris is present around the area and that lids are closed, in accordance with the FDA Food Code, which mandates tight-fitting lids to prevent pest and rodent entry.
Incomplete Medical Record Documentation for Resident Treatment
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as evidenced by missing documentation in the Treatment Administration Record (TAR) for April 2025. Specifically, the TAR lacked entries from licensed nurses for the application of ciclopirox external cream and wound care on two dates, as well as for the application of econazole nitrate external cream on one date. These omissions were identified during a review of the resident's physician's orders, which included specific instructions for topical antifungal treatments to the fingernails due to a fungal infection. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed the missing documentation and stated that if a licensed nurse did not document a treatment, it was considered not completed. The DON also acknowledged that she was responsible for weekly audits of the Medication Administration Record (MAR) and TAR, as the facility did not have a Medical Record Director or dedicated medical records staff. The facility's policy required objective, complete, and accurate documentation of all treatments and services performed, which was not met in this instance.
Room Exceeds Maximum Resident Occupancy
Penalty
Summary
During an initial tour of Room A, surveyors observed that the room contained five beds, each occupied by a resident, resulting in five residents sharing a single room. The facility administrator confirmed the presence of five residents in Room A and acknowledged that the room did not meet the required square footage for that number of occupants. The administrator also indicated the facility's intention to continue with a room variance waiver for this room. This situation was identified as a failure to comply with regulations limiting the number of residents per room, as Room A exceeded the maximum occupancy allowed.
Insufficient Square Footage Provided in Multi-Resident Room
Penalty
Summary
Room A was observed to be a five-bed room occupied by five residents, with a total area of 392 square feet. This configuration resulted in each resident having 78.4 square feet of space, which is below the required minimum of 80 square feet per resident for multiple occupancy rooms. During an interview, the Administrator confirmed the room's measurements and acknowledged that the space per resident did not meet regulatory requirements. The deficiency was identified during an initial tour and confirmed through direct observation and staff interview.
Failure to Implement Updated Infection Control Guidelines
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was knowledgeable about the updated CDC guidelines for pneumococcal immunization and the implementation of enhanced barrier precautions. The IP was unaware of the current CDC recommendations for the use of PCV 15 or 20 vaccines and continued to administer only PPSV 23 to residents. This lack of awareness and adherence to updated guidelines was confirmed during an interview and document review with the IP, who admitted to not tracking the type of vaccine needed based on the new guidelines. Additionally, the IP did not implement enhanced barrier precautions for residents with conditions that required such measures, such as chronic wounds or indwelling medical devices, as per the new CMS guidelines effective April 1, 2024. Resident 22, who was readmitted to the facility with a Stage 4 pressure ulcer and an infected left hip surgical wound, was not placed on enhanced barrier precautions. During a wound treatment observation, it was noted that there was no signage or isolation cart with gloves and gowns outside the resident's room, and staff were not performing the necessary hand hygiene or donning gloves and gowns. The IP confirmed that Resident 22 should have been placed on enhanced barrier precautions due to the severity of the wounds but admitted that no residents in the facility were on such precautions. Further interviews with the Director of Nursing (DON) and the Administrator revealed that the facility had residents with indwelling urinary catheters and gastrostomy tubes who were also not placed on enhanced barrier precautions. The DON relied on the IP for current infection control guidelines and was not informed about the new CMS guidelines for enhanced barrier precautions. The Administrator expected the IP to report any new infection prevention and control updates during the quarterly assurance meetings but was unaware that the enhanced barrier precautions were not being implemented for appropriate residents in the facility.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer PCV 15/PCV 20 immunizations to 20 nonsampled residents in accordance with the CDC's updated recommendations. The facility's policies and procedures were outdated, only offering PPSV 23, and did not include the newer PCV 15 or PCV 20 vaccines. This failure was identified through interviews, medical record reviews, and facility document reviews, which showed that residents were not offered the updated vaccines, increasing their risk of being inadequately vaccinated for pneumococcal disease and its associated complications. The medical records of several residents, including Residents 1, 3, 4, 5, 6, 8, 13, 16, 18, 19, 21, 23, 24, 25, 29, 30, 31, and 33, were reviewed and found to lack documentation of being offered PCV 15 or PCV 20 after receiving PPSV 23. The facility's Infection Preventionist (IP) admitted to only offering PPSV 23 due to a lack of awareness of the updated CDC guidelines and the absence of a tracking system for pneumococcal vaccine history. The facility's consent forms and immunization records did not specify the type of pneumococcal vaccine administered, further complicating the tracking and compliance with updated guidelines. Interviews with the IP and the Director of Nursing (DON) confirmed that the facility did not have a system in place to track the specific types of pneumococcal vaccines administered to residents. The IP acknowledged the oversight and the need to update the facility's policies and procedures to align with the CDC's current recommendations. The lack of proper documentation and tracking led to residents not being offered the appropriate vaccines, as per the updated guidelines, thereby failing to ensure their pneumococcal immunization was current and complete.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify five residents (Residents 10, 22, 32, 35, and 38) or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in March 2017, mandates that residents or their representatives be informed in writing about the bed hold policy prior to any transfer or therapeutic leave. However, the facility did not adhere to this policy for the residents reviewed, potentially leaving them unaware of their rights to request a bed hold upon transfer. For Resident 10, there was no documented evidence in the General Nurses' Notes for January 2024 that the resident or their representative was provided with information about the bed hold policy upon transfer to Hospital A. Similarly, Resident 22's records for January and March 2024 lacked documentation of bed hold policy notification. The MDS Nurse confirmed these findings during an interview. Resident 35's records for December 2023 and February 2024 also did not show evidence of bed hold policy notification, which was verified by the MDS Nurse and the DON. Resident 32's records indicated a transfer to an acute care hospital on January 17, 2024, but there was no documentation that the resident or their representative was informed about the bed hold policy. This was confirmed by RN 1 and the SSD. Lastly, Resident 38, who was transferred to an acute care hospital on March 26, 2024, also did not receive written notification about the bed hold policy, as verified by the Business Office Manager and the DON. The facility lacked a specific bed hold notification form, relying only on a notice of transfer or discharge form, which did not fulfill the requirement for informing residents or their representatives about the bed hold policy.
Inaccurate MDS Assessments for Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for 11 of 17 reviewed residents were accurate, specifically regarding the residents' pneumococcal vaccination status. This deficiency was identified through interviews and medical record reviews, revealing that the MDSs inaccurately indicated that residents were up to date with their pneumococcal vaccinations. For instance, Resident 21's MDS was marked as up to date despite not being offered the Pneumococcal Conjugate Vaccine 20 (PCV 20) as required by current guidelines. Similarly, Resident 25's vaccination history was incorrectly documented, and the resident was not offered the appropriate vaccine to be considered up to date. Further investigation showed that several residents, including Residents 3, 16, 19, 23, and 27, had discrepancies in their immunization records. These residents either did not receive the updated pneumococcal vaccines or their records did not accurately reflect the type of vaccine administered. For example, Resident 3's records showed a pneumococcal vaccine was administered in 2020, but it was not clear if the resident was offered the updated PCV 20 or PCV 15 followed by PPSV 23 until much later. Resident 27's records lacked follow-up on vaccination status, and the resident was not offered the pneumococcal vaccine in the facility. Additionally, Residents 15, 18, 31, and 33 had inaccuracies in their MDS documentation regarding their pneumococcal vaccination status. Resident 15's MDS indicated the vaccine was offered and declined, but there was no documented evidence of education or consent. Residents 18, 31, and 33 had their MDSs marked as up to date despite incomplete or unclear vaccination records. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and MDS Coordinator confirmed these findings, indicating a lack of adherence to updated CDC guidelines and proper documentation practices.
Failure to Follow Physician's Orders and Collaborate with Hospice Care
Penalty
Summary
The facility failed to ensure Resident 22's abduction pillow and bilateral heel protectors were in place while in bed per the physician's orders. Additionally, the facility did not ensure Resident 22 did not wear the left knee immobilizer while in bed, as per the physician's order. The facility also failed to provide other bowel management medication interventions as needed for Resident 22, who was at risk for constipation due to Norco medication. These deficiencies were verified through observations, interviews, and medical record reviews with the LVN and DON, who acknowledged the findings. The facility failed to ensure proper collaboration between the hospice care team and the facility for Residents 20 and 36. For Resident 20, there was no documented evidence that the hospice care team reviewed or acknowledged the resident's care plans. This was confirmed through an interview and medical record review with the IP, who stated that the hospice care team should be updated and informed of the resident's care plans to ensure agreement with the plan of care. For Resident 36, the facility did not ensure a hospice care member participated in the Quarterly IDT meeting. The medical record review showed no documented evidence that the hospice care team was aware of or had signed the updated care plans. The IP verified these findings and stated that the hospice care team should be part of the IDT meeting and review care plans to ensure agreement with the resident's plan of care. The DON also acknowledged that the hospice staff did not sign the care plans or have documented evidence of reviewing them for Residents 20 and 36.
Food Safety and Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements were met in the kitchen, leading to multiple deficiencies. Observations revealed that cutting boards and kitchen equipment were in unsanitary conditions, with cutting boards heavily marred and kitchen utensils such as a frying pan, slotted spoon, ice cream scooper, and lime squeezer found with encrusted grease, melted handles, and dried food particles. Additionally, food items were not discarded by their best-by dates, and temperatures of food items were not checked prior to preparation or distribution, with shredded cheddar cheese and fresh green salad found within the danger zone for bacterial growth. Personal belongings were also improperly stored in the kitchen's clean utility room, posing a risk of cross-contamination and infection control issues. Furthermore, kitchen staff failed to maintain proper hand hygiene, as observed when the DSS did not wash hands between sanitizing a preparation table and handling food. Food was also transported uncovered through an outdoor dry storage room, increasing the risk of contamination. Lastly, a resident did not receive the correct diet texture as ordered, with a meal ticket indicating a regular NAS diet but the plate containing mechanical soft turkey. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control Practices
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were practiced for residents with indwelling urinary catheters and gastrostomy tubes (GT). Multiple residents were observed with these medical devices, but there was no evidence of EBP signage or personal protective equipment (PPE) availability in their rooms. Interviews with staff confirmed that EBP was not being observed, and the Infection Preventionist (IP) acknowledged the need for EBP to protect against transmission-based infections. The Director of Nursing (DON) also confirmed the lack of EBP practices in the facility, despite being aware of the requirements for residents with indwelling medical devices and wounds. The facility also failed to ensure proper hand hygiene practices were followed by staff. During a wound treatment observation, a Licensed Vocational Nurse (LVN) was seen changing gloves multiple times without performing hand hygiene in between. This was confirmed by the LVN and the IP, who stated that staff were expected to perform hand hygiene when changing gloves. Additionally, the resident with the wound was not placed on enhanced barrier precautions, which was verified by the IP and acknowledged as necessary due to the resident's condition. Furthermore, the facility did not ensure proper storage and labeling of medical equipment. An opened Yankauer suction tool was observed stored with miscellaneous items and without a label, which was confirmed by the IP as a potential source of infection. The DON acknowledged that the Yankauer suction should be stored separately and labeled with the date opened. Additionally, an LVN was observed administering medication through a GT without wearing a gown, which was against the enhanced barrier precautions required for residents with GTs. This was confirmed by the LVN and the DON, who admitted to misunderstanding the requirements for EBP.
Failure to Promote Dignity and Respect for Residents
Penalty
Summary
The facility failed to ensure the staff provided care and promoted dignity and respect for three residents. CNA 3 and CNA 2 were observed standing over Residents 8 and 35, respectively, while assisting them with meals, contrary to the facility's policy that requires staff to sit at eye level with residents during feeding. Both CNAs acknowledged that they were supposed to sit while feeding the residents. The Director of Staff Development (DSD) and the Director of Nursing (DON) were informed and acknowledged these findings. Additionally, the facility failed to ensure Resident 5's body was fully covered while being transported from the shower room to her room. CNA 4 was observed wheeling Resident 5 in a shower chair with a blanket that did not fully cover her left side, exposing her lower back, hip, and upper thigh. The Administrator confirmed the observation and acknowledged that the resident's dignity was compromised. Resident 5, who was cognitively intact, expressed feeling embarrassed upon learning about the exposure.
Failure to Inform Residents of Bed Side Rail Risks
Penalty
Summary
The facility failed to fully inform two residents or their responsible parties about the risks associated with the use of bed side rails, specifically regarding the entrapment assessment for Zone 6. Resident 9 had a bed that failed the Zone 6 measurement, indicating a potential risk for entrapment. Despite this, neither the resident nor their family was notified of the failed measurement. The resident was observed with a padded left side rail and was able to move their upper extremities. The facility's Administrator confirmed that there was no documented evidence that the resident or their family had been informed of the failed Zone 6 measurement. Similarly, Resident 32 was observed with bilateral half side rails elevated and stated that they did not use the side rails since admission. The resident's bed also failed the Zone 6 measurement, but there was no documentation showing that the resident was informed of this specific risk. The facility's Infection Preventionist (IP) and Administrator both confirmed that the bed inspection process was only conducted annually and that the resident was not specifically informed about the failed Zone 6 measurement. The facility's policies and procedures (P&P) require that residents be informed of their care and treatment options, including the risks and benefits of side rail use. However, in these cases, the facility did not adhere to its own P&P, resulting in a lack of informed consent for the use of side rails. Both the Director of Nursing (DON) and the Administrator acknowledged the findings, confirming that the residents were not fully informed about the specific risks associated with their bed side rails failing the Zone 6 entrapment assessment.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident 37's call light was within reach, which is a violation of their policy and procedure. During an initial tour, the call light was observed on the floor on the right side of the resident's bed. This was confirmed by a CNA who admitted to not noticing the call light on the floor when raising the bed. The Director of Nursing (DON) stated that the expectation is for call lights to be answered within two minutes and always be within the resident's reach. Resident 37 was admitted to the facility with no capacity to understand and make decisions, as indicated in their health and physical examination. The resident's Minimum Data Set (MDS) showed that they required dependent assistance for rolling in bed and transferring from bed to chair, meaning the helper would do all the effort. This failure to provide reasonable accommodation had the potential to negatively impact the resident's psychosocial well-being or result in a delay in providing care and services.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor Resident 26's food preferences, which were clearly documented in both the resident's meal tray ticket and nutritional assessment. During a dining observation, Resident 26 was served white rice, despite his stated and documented preference against it. The resident confirmed that he had not eaten rice for two years and did not like it. This discrepancy was verified by the Social Services Director (SSD) during an observation and interview, where the untouched rice on Resident 26's plate was noted. The medical record review showed that Resident 26 had the capacity to understand and make decisions, and his food dislikes were well-documented, including rice. Despite this, the facility's staff failed to adhere to the resident's documented food preferences, as outlined in the facility's policies and procedures. The Director of Nursing (DON) was informed and acknowledged the findings, confirming the failure to comply with the resident's dietary choices.
Failure to Provide and Document Advance Directives
Penalty
Summary
The facility failed to inform and provide written information regarding the rights to formulate advance directives to Resident 35. Despite Resident 35 having the capacity to understand and make decisions, there was no documented evidence that the resident was offered or received information about formulating an advance directive. The Social Services Director (SSD) confirmed that there was no documentation to show that the information was provided to Resident 35 upon admission or at any later time. For Resident 10, the facility did not ensure that a copy of the advance directive was readily available in the resident's medical record. Although Resident 10 had an advance directive, the SSD kept the document in a separate binder in her office drawer, and it was not placed back in the resident's medical record after a hospital visit. The SSD acknowledged that the advance directive should have been accessible in the medical record. Similarly, Resident 12's medical record did not contain a copy of the advance directive, despite the resident's family member informing the SSD that one existed. The SSD failed to follow up with the family to obtain the document. The SSD confirmed that she did not verify if she had followed up to obtain the advance directive, and the Director of Nursing (DON) acknowledged these findings.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify Resident 32 and/or their representative of the transfer to an acute care hospital in writing, as required by the facility's policy and procedure (P&P) on transfer or discharge notice. The P&P mandates a 30-day written notice for transfers or discharges, or as soon as practicable in urgent medical situations, including details such as the reason for transfer, effective date, location, and appeal rights. However, when Resident 32 was transferred from a medical appointment to an acute care hospital, the facility did not provide the required written notification to the resident or their representative. Resident 32, who had the capacity to understand and make decisions, was admitted to the facility and later transferred to the hospital. The facility contacted Resident 32 via cell phone to inquire about the status of the medical appointment, and the resident informed them of the hospital admission. Despite this, the facility did not follow through with the written notification process. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the oversight, with the SSD acknowledging the failure to provide the necessary written notice.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan for a newly admitted resident, identified as Resident 441. During an initial tour, Resident 441 mentioned that while the Social Services Director (SSD) discussed physical therapy for walking and returning home, there was no discussion or provision of a summary of her baseline care plan. A review of Resident 441's medical records confirmed that there was no documented evidence showing that she was informed or provided with a summary of her baseline care plan. The facility's policy requires that residents and their representatives be given a summary of the baseline care plan, which includes initial goals, medications, dietary instructions, services, treatments, and any updates to the comprehensive care plan. However, this was not adhered to in the case of Resident 441. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the care plan should be completed within 24 hours of admission, and a care plan meeting should be conducted within 72 hours. The DON confirmed that the facility did not routinely provide copies of the summary baseline care plan to residents unless requested, although residents were informed of their care. The DON verified that there was no documentation to show that Resident 441 was provided with a copy of the summary baseline care plan, highlighting a lapse in the facility's adherence to its own policies and procedures.
Failure to Address Resident's Noncompliance with Physician's Order
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the individual care needs of Resident 22. Despite a physician's order dated 3/19/24, requiring the application of a hip abduction pillow at all times while in bed, the care plan did not include a problem to address Resident 22's noncompliance with this order. Medical record reviews and observations revealed that Resident 22 had episodes of removing the abduction pillow, and this noncompliance was not documented in the care plan. The resident, who had the capacity to understand and make decisions, expressed her right to remove the pillow, leading to frequent visual checks by the staff to ensure her safety and comfort. During an observation on 4/3/24, the abduction pillow was found removed and placed at the side of Resident 22's bed. Both LVN 1 and the DON confirmed that the pillow should have been in place as per the physician's order. The DON acknowledged that Resident 22 had episodes of noncompliance and verified that there was no care plan problem addressing this issue. This oversight posed a risk of not providing appropriate, consistent, and individualized care to Resident 22.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of Resident 11. Despite the facility's policy stating that activities should be based on a comprehensive resident-centered assessment and preferences, Resident 11 was observed multiple times lying awake in bed without any engagement or stimulation. Interviews with the resident's representative and a CNA confirmed that the facility did not provide activities for Resident 11, relying instead on the resident's family to provide music and turn on the television during visits. The medical record review showed that Resident 11 had severe cognitive impairment and required prompts and cues to participate in activities, yet the facility did not adhere to the care plan interventions, which included providing room visits and sensory stimulation three times a week. The Activity Attendance Record for March and April 2024 showed significant gaps in activity provision, with no activities recorded from April 1 to April 4, 2024, and inconsistent activity engagement throughout March 2024. The Activity Director and the DON both acknowledged the findings, verifying that Resident 11 was not provided with the necessary daily activities as identified in the activity assessment and care plan. This failure had the potential to cause Resident 11 to experience feelings of social isolation and frustration.
Deficiencies in Catheter Care and Adherence to Guidelines
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters received the necessary care to prevent urinary tract infections (UTIs). For Resident 35, the facility did not document catheter care every shift as required. Observations showed that the resident's catheter tubing contained cloudy urine with white particles, and there was no standing order for catheter care every shift. Interviews with staff confirmed the lack of documentation and standing orders for catheter care, which was acknowledged by the Director of Nursing (DON). The resident's medical records also lacked evidence of consistent catheter care documentation, despite the care plan indicating it should be done every shift and as needed. For Resident 20, the facility did not follow the CDC's guidelines for catheter maintenance. The resident had a physician's order to change the Foley catheter bag weekly, which contradicts the CDC's recommendation to change catheters and drainage bags based on clinical indications rather than at fixed intervals. The Infection Preventionist (IP) and the DON confirmed that the weekly changes increased the risk of infection and acknowledged that the facility's policy should align with the CDC's guidelines. The resident's medical records showed that the catheter bag was changed weekly, as per the physician's order, but this practice was not in line with best practices for infection control. These deficiencies in catheter care and adherence to guidelines had the potential to put both residents at risk for UTIs. The facility's failure to document catheter care consistently and to follow evidence-based guidelines for catheter maintenance were significant lapses in ensuring the residents' health and safety. The DON and other staff members acknowledged these issues during interviews, highlighting the need for improved practices and adherence to established protocols.
Failure to Ensure Nutritional Needs Met
Penalty
Summary
The facility failed to ensure the nutritional needs of Resident 32 were met. During an observation, it was noted that Resident 32 consumed less than 50% of his meal tray, which included white bread with herbs, zesty lasagna, green beans, a banana, boost, chicken noodle soup, a cookie, grape juice, and water. The staff member (IP) responsible for removing the meal tray did not offer an alternative meal to Resident 32, despite verifying that the resident had eaten less than 50% of the meal. This oversight was confirmed during a follow-up interview with the IP, who acknowledged the failure to offer an alternative meal as required by the facility's protocol. Resident 32 had a history of weight fluctuations, as evidenced by the medical record review showing weights ranging from 168 lbs to 180 lbs over a few months. The resident was cognitively intact and had a physician's order for a regular diet with a large protein portion. Despite these directives, the failure to offer an alternative meal when the resident consumed less than 50% of the provided meal tray was a significant lapse in ensuring the resident's nutritional status. Both the DON and the RD confirmed that the staff should have offered an alternative meal to maintain the resident's nutritional health.
Failure to Ensure Proper Care for Residents with Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that three residents with gastrostomy tubes (GT) received appropriate care. Specifically, a Certified Nursing Assistant (CNA) was observed turning off a resident's GT feeding machine, which is outside the scope of practice for a CNA. The CNA admitted to turning the machine on and off to assist the charge nurse, despite knowing it was not within their scope of practice. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that only licensed nurses are authorized to operate the GT feeding machines. Additionally, the facility failed to label the GT tubing for three residents, which is necessary to ensure the tubing is changed daily. During an initial tour, it was observed that the GT tubing for these residents was not labeled. A Licensed Vocational Nurse (LVN) verified the absence of labels and acknowledged that the tubing should be labeled to ensure it is changed every 24 hours. The DON confirmed that the charge nurses are expected to change and label the GT feeding, syringe, and tubing every 24 hours, but this was not done for the three residents in question.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents. For Resident 17, the facility did not administer oxygen therapy as per the physician's order. The resident was observed receiving oxygen at 3 LPM via nasal cannula, whereas the physician's order specified 2 LPM. This discrepancy was verified by an LVN and acknowledged by the DON during an interview. For Resident 2, the facility failed to ensure proper maintenance and availability of respiratory equipment. The resident's suction machine canister was not discarded after use, and the suction machine bag was not dated. Additionally, there was no oxygen bag available for the resident's nasal cannula when using a portable oxygen tank. These issues were confirmed by an LVN and acknowledged by the DON, who stated that the suction machine canister should be replaced after each use and oxygen bags should be dated and changed weekly.
Incomplete Dialysis Assessments
Penalty
Summary
The facility failed to ensure ongoing assessment before, during, and after dialysis treatments for a resident requiring such services. Specifically, the dialysis communication forms for the resident on two separate dates were incomplete. The forms lacked necessary documentation, including the assessment of the dialysis access site and post-dialysis assessments of bruit and thrill, which are critical to ensure the dialysis site is functioning properly. The resident had an AV shunt in the left upper arm, and the facility's policy required checking the shunt for bruit and thrill every shift. However, these assessments were not documented as completed on the specified dates. During interviews, the Infection Preventionist (IP) confirmed that the dialysis communication forms were incomplete and acknowledged the importance of assessing the bruit and thrill to ensure the dialysis site was working and accessible. The Director of Nursing (DON) also acknowledged the findings. The lack of proper documentation and assessment could potentially lead to negative outcomes for the resident undergoing dialysis treatment.
Failure to Timely Replace Emergency Medication Kit
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services to meet the needs of residents by not replacing the emergency kit for oral medications in a timely manner. The facility's policy and procedure (P&P) required staff to notify the pharmacy immediately after an emergency kit was opened, and the pharmacy was to replace the kit the next working day. However, during an inspection, it was observed that the emergency kit, which had been opened on 3/30/24 to remove levofloxacin 250 mg, was still locked with a white zip tie on 4/3/24, indicating it had not been replaced. The Infection Preventionist (IP) confirmed that the staff failed to notify the pharmacy immediately, resulting in a delay in replacing the emergency kit. Further investigation revealed that the pharmacy technician did not receive notification from the facility about the opened emergency kit until 4/3/24, four days after it was opened. The Director of Nursing (DON) acknowledged the findings during an interview. This delay in communication and replacement of the emergency kit could potentially lead to a decreased availability of necessary medications in an emergency situation.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two residents reviewed for unnecessary medications. For Resident 22, the Pharmacy Consultant recommended providing a duration of therapy for enoxaparin (Lovenox) in February 2024, but there was no documented evidence that the physician was notified or that the recommendation was acted upon. The Director of Nursing (DON) confirmed that there was no documentation showing the physician's agreement or disagreement with the recommendation. For Resident 32, the Pharmacy Consultant also recommended providing a duration of therapy for Lovenox in March 2024. Although the DON stated that the prescribing physician was informed and responded to continue the same order, there was no documented rationale provided by the physician for not acting upon the Pharmacy Consultant's recommendation. The DON verified that the physician did not provide a rationale for continuing the medication order as it was.
Failure to Conduct AIMS Assessments for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically for two residents who were prescribed antipsychotic medications. Resident 35 had an order for olanzapine but was not assessed using the Abnormal Involuntary Movement Scale (AIMS) to monitor for side effects such as tardive dyskinesia. Despite the facility's policy requiring such assessments, there was no documented evidence that the AIMS assessment was completed for Resident 35. Both the RN and the DON confirmed the lack of AIMS assessment and acknowledged that the facility did not have a form for this assessment. Similarly, Resident 20 was prescribed bupropion and quetiapine but was also not assessed using the AIMS test. The medical record review showed no documented evidence of the AIMS assessment for these medications. Both the LVN and the DON verified that the facility did not perform the AIMS assessment for Resident 20 or any other residents on antipsychotic medications. The DON stated that the facility would implement the AIMS assessment moving forward.
Unattended Medications on Medication Cart
Penalty
Summary
The facility failed to ensure medications were not left unattended on the medication cart for one of two residents reviewed for medication administration. During a medication pass observation, an LVN was seen preparing medications for a resident, including Amantadine, Decousate sodium, Rivastigiminie, Oxybutynin, Carbidopa levodepa, Vitamin D3, Vitamin C, Multivitamin with minerals, and Potassium Chloride. The LVN crushed the tablets, mixed them with water, and placed them in a tray on the medication cart. The LVN then left the tray unattended on the cart in a hallway where staff, visitors, and residents passed through, while she went to look for an overbed table. The LVN later acknowledged that she should not have left the medications unattended. The facility's policy and procedure (P&P) titled Storage of Medication, revised in April 2019, states that drugs and biologicals must be stored in locked compartments and not left unattended on the medication cart. The Director of Nursing (DON) was informed of the findings and acknowledged the deficiency. This failure had the potential for medication diversion, as the medications were left in an unsecured area accessible to unauthorized individuals.
Failure to Follow Dietary Guidelines and Menus
Penalty
Summary
The facility failed to ensure that puree recipes and renal and CCHO menus were followed for several residents. Specifically, the facility did not adhere to the standardized recipes for pureed meats and vegetables, resulting in improper preparation of meals for residents on pureed diets. For instance, the Dietary Services Supervisor (DSS) added turkey broth and turkey slices together before blending, contrary to the recipe instructions, and used the wrong recipe for pureed roasted red potatoes. These actions were verified by the DSS and the Registered Dietitian (RD), who confirmed that the recipes were not followed as required. Additionally, the facility did not comply with the renal diet requirements for two residents on pureed renal diets. Instead of providing brown rice with margarine and wheat bread as specified in the menu, the DSS served pureed roasted red potatoes, which are not suitable for renal diets due to their high potassium content. The DSS acknowledged the substitution and the lack of brown rice, and the RD confirmed that the correct menu items should have been provided. Furthermore, the facility failed to follow the CCHO diet menu for ten residents. During a trayline observation, the Dietary Aide served sherbet instead of the plain ice cream listed on the menu. The Dietary Aide admitted to not following the menu, and the RD confirmed that the correct menu items should have been served. The Director of Nursing (DON) acknowledged all the findings, indicating a systemic issue with adherence to dietary guidelines and menu planning in the facility.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing and safe temperature. During a test tray evaluation, the temperatures of roast turkey with Bernaise sauce, cauliflower and peas, and herb roasted red potatoes were found to be significantly below the recommended holding temperature of 135 degrees Fahrenheit, with readings of 102 and 103 degrees Fahrenheit. This was verified by the Dietary Services Supervisor (DSS) and a Certified Nursing Assistant (CNA). Additionally, three residents complained about receiving cold food, with one resident specifically mentioning receiving frozen french fries. The Registered Dietitian (RD) confirmed that the temperatures were below the recommended levels and acknowledged the residents' complaints about cold food, which could affect their willingness to eat and potentially lead to weight loss. The facility's policy and procedure (P&P) for food preparation and service, dated April 2019, stipulates that hot foods should be maintained at temperatures above 135 degrees Fahrenheit to prevent the growth of harmful pathogens. The RD reiterated that hot foods should be kept hot and cold foods kept cold to ensure palatability and safety. The failure to maintain appropriate food temperatures was observed during a test tray evaluation and through resident interviews, indicating a systemic issue in food service that could impact resident satisfaction and health.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the medical record for three residents was complete and accurate. For Resident 26, the facility did not discontinue an active physician's order for no weight bearing status and the use of a left arm sling, despite the resident stating that his orthopedic physician had advised discontinuation of the sling support. The Director of Nursing (DON) acknowledged that the orders should have been discontinued but were not removed by the licensed nurses. For Resident 35, the facility failed to ensure the accuracy of a physician's order for Dulcolax medication. The order was to administer Dulcolax if Milk of Magnesia (MOM) was ineffective, but there was no order for MOM in the resident's records. An RN verified the inaccuracy and stated that the order should have been for MOM daily as needed, not for docusate sodium. The DON was informed and acknowledged these findings. For Resident 32, the facility inaccurately documented the resident's meal consumption. During an observation, Resident 32 was seen eating less than 50% of his meal, but the meal consumption was documented as 100%. The Infection Preventionist (IP) verified that the CNA should not have documented 100% consumption without observing the actual amount eaten. The DON was informed and acknowledged these findings.
Failure to Collaborate with Hospice Staff on Care Plans
Penalty
Summary
The facility failed to ensure that hospice and facility staff worked collaboratively in the plan of care for two hospice residents, as per the hospice contract agreement. For Resident 20, who was admitted under Hospice A, there was no documented evidence that the hospice care team reviewed or acknowledged the resident's care plans. The IP confirmed that the hospice care team was not updated or informed of the resident's care plans, despite providing care to the resident. The DON acknowledged these findings during an interview. Similarly, for Resident 36, who was admitted under Hospice B, there was no documented evidence that the hospice care team was aware of new and updated care plans. The care plans were not signed off by the hospice care team, and there was no evidence of hospice staff participation in the Quarterly IDT meeting. The DON confirmed that the hospice care team did not sign the care plans after review and agreed that they should participate in IDT meetings. The DON acknowledged these findings during an interview.
Failure to Follow Up on Bed Entrapment Assessments
Penalty
Summary
The facility failed to follow up on bed entrapment assessments for two residents, leading to potential safety risks. Resident 32 was observed with elevated bilateral half siderails, and the bed inspection showed that Bed #15 failed Zone 6, indicating a risk of entrapment. Despite this, the facility did not reassess or adjust the bed to mitigate the risk. The Administrator confirmed that no follow-up actions were taken after the failed assessment, and the bed was not re-adjusted or replaced to ensure safety. Similarly, Resident 9's bed also failed the Zone 6 measurement, indicating a potential entrapment risk. The resident was observed with a padded left side rail, and the bed inspection document confirmed the failure. The Administrator acknowledged that no interventions were conducted to address the failed Zone 6 measurement, and the maintenance staff was not notified to reassess or adjust the bed. Both residents were at risk due to the facility's failure to follow up on the bed entrapment assessments. The facility's policies and procedures required regular inspections and reassessments to prevent such risks, but these were not adhered to, leading to potential safety hazards for the residents.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to ensure the quarterly MDS assessment for Resident 21 was completed within 14 calendar days of the Assessment Reference Date (ARD). The medical record review showed that Resident 21's MDS Quarterly assessment, which had an ARD of 2/19/24, was initiated but remained open and not submitted by the required completion date of 3/4/24. During an interview and concurrent medical record review on 4/3/24, the MDS Nurse confirmed that the assessment was not completed. The Director of Nursing (DON) was informed and acknowledged these findings on 4/5/24.
Late Submission of MDS Quarterly Assessment
Penalty
Summary
The facility failed to transmit the MDS (Minimum Data Set) assessment data timely for one resident, identified as Resident 14. According to the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual, a Quarterly Review Assessment must be submitted no later than 14 days after the assessment's completion date. Resident 14's MDS Quarterly assessment was completed on 2/28/24 but was not submitted until 3/28/24, which was beyond the required timeframe. The MDS Nurse confirmed that the assessment should have been submitted by 3/13/24 and acknowledged that the submission was late. The Director of Nursing (DON) was informed and acknowledged the finding.
Room Over-Occupancy in Room A
Penalty
Summary
The facility failed to ensure Room A did not accommodate more than four residents. During an initial tour, it was observed that Room A had five occupied beds, which was confirmed by the Administrator. The Administrator acknowledged that Room A had less square footage than required and mentioned the facility's intention to continue with the room variance waiver for Room A.
Room Size Deficiency in Five-Bed Room
Penalty
Summary
The facility failed to ensure Room A met the required minimum of 80 square feet per resident. Room A, a five-bed room, measured 392 square feet in total, providing only 78.4 square feet per resident when fully occupied. This deficiency was observed during an initial tour of the room, which was occupied by five residents at the time. The Administrator confirmed the room's measurements and acknowledged that the space per resident did not meet the regulatory requirement. The Administrator also mentioned the facility's intention to continue with the room variance waiver for Room A.
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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