Pasadena Park Healthcare And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 2585 E. Washington Blvd., Pasadena, California 91107
- CMS Provider Number
- 055548
- Inspections on file
- 24
- Latest survey
- December 27, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pasadena Park Healthcare And Wellness Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including muscle weakness and Alzheimer's, was unable to reach her call light, which was not placed within her reach as required by her care plan and facility policy. This was confirmed by a nurse and the DON, highlighting a failure to accommodate the resident's needs and potentially delaying necessary care.
A resident at high risk for falls, with a history of osteoarthritis and spondylolisthesis, was not provided with the necessary supervision and assistance during transfers from bed to chair, as required by their care plan. Despite the resident's tendency to transfer independently, the care plan did not address this behavior, leading to an injury. The facility's policies on fall management and resident safety were not effectively implemented, resulting in the resident sustaining an elbow fracture and tendon tears.
The facility failed to provide necessary respiratory care services for two residents, leading to deficiencies in oxygen administration. One resident did not receive continuous oxygen therapy as prescribed, with oxygen saturation levels below the required threshold. The LVN was unaware of the continuous nature of the order. Another resident's oxygen was set below the prescribed level, and the oxygen tubing was not labeled as required. The facility's policy mandates adherence to physician orders and proper labeling of oxygen equipment.
A resident with major depressive disorder experienced verbal abuse from a CNA, who responded with an expletive after the resident used a derogatory term. The incident was witnessed by an RNA and confirmed as verbal abuse by the DON and Administrator, violating the facility's abuse prevention policy.
A resident with major depressive disorder engaged in a verbal altercation with a CNA, who responded inappropriately. The incident, witnessed by an RNA, was not reported to the Administrator within the required two-hour timeframe, violating the facility's policy and state law. The facility's policy mandates immediate reporting of abuse allegations to ensure resident safety and compliance.
Two residents in a facility did not receive their medications as ordered, leading to deficiencies in pharmaceutical services. One resident's medications were left on their overbed table by an LVN, who did not follow the facility's policy requiring medications to be administered within one hour of the scheduled time. Another resident's potassium and Paxlovid were also left on their table, with no care plan for self-administration. The DON confirmed that the facility's policies were not followed, resulting in a delay of necessary care.
The facility failed to provide a safe, clean, and homelike environment for four residents. Issues included unaccounted personal property, an unsanitary shared restroom, stripping wallpaper, and chipped paint in residents' rooms. Staff acknowledged these deficiencies, which were not in line with the facility's policies.
The facility failed to prevent pressure ulcers for two residents by not setting their low air loss (LAL) mattresses according to their weights. One resident's mattress was set at 320 lbs despite weighing 112 lbs, and another's was set at 180 lbs despite weighing 106 lbs. The incorrect settings increased the risk of skin breakdown.
The facility failed to follow safe food storage and hygiene practices, including improper labeling of milk and resident food items, and inadequate hand hygiene by kitchen staff. These deficiencies were confirmed through observations and staff interviews, highlighting non-compliance with the facility's policies and procedures.
The facility failed to ensure that two of three outside garbage cans were covered and closed per policy, as observed during an interview with the Dietary and Maintenance Supervisors. This non-compliance had the potential to attract pests to the facility.
The facility failed to follow its infection control policy for five residents, leading to potential risks of infection. Issues included undated and improperly stored equipment, lack of contact isolation for a resident with MRSA, and oxygen tubing and Foley catheter drainage bags touching the floor. Staff confirmed these practices were against the facility's policies.
The facility failed to maintain a safe and sanitary environment by not emptying a full sharps container in a resident's restroom and improperly storing toilet tissue rolls. The sharps container was filled above the designated fill line, posing a safety risk, while the toilet tissue rolls were found torn, opened, and contaminated, increasing the risk of UTIs for residents.
The facility failed to update a resident's Foley catheter care plan to address the behavior of placing the drainage bag on the floor, despite multiple observations and staff acknowledgments. The resident, who has aphasia and type 2 diabetes, requires substantial assistance and lacks decision-making capacity.
The facility failed to provide a communication board for a resident with severe cognitive impairment and language barriers, and did not ensure another resident received scheduled and requested showers. These deficiencies were confirmed through observations and staff interviews, revealing non-compliance with facility policies on communication aids and bathing schedules.
The facility failed to provide necessary respiratory care services for a resident with chronic respiratory failure and pleural effusion, as an oxygen humidifier was found empty and without sterile water. Staff interviews confirmed that the humidifier should have been changed to ensure the resident's comfort and prevent dryness of the nasal passages.
The facility failed to accurately record and implement a resident's food preferences, leading to incorrect dietary information on the resident's tray card. Despite multiple attempts by the resident's family to correct the error, the dietary profile remained inaccurate, violating the resident's right to preferred meal choices and potentially impacting their nutrition.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments and dependent on assistance for daily activities. One resident's call light was on the floor, and another's was stuck between the bed mattress and rail, making them inaccessible.
The facility failed to ensure that a resident's Coban wrap and Unna boot dressing were applied as per the physician's order. The resident, with chronic kidney disease and congestive heart failure, was observed without the necessary dressings, exposing significant pitting edema. The nursing staff did not monitor the resident to ensure the dressings remained in place, contrary to the facility's policy.
The facility failed to ensure accurate and complete Nurse Staffing Information was posted daily. The information dated 4/26/2024 was not updated on 4/29/2024, and discrepancies were found in the number of CNAs and RNAs listed. Interviews with the DSD and DON confirmed the inaccuracies and the importance of posting accurate staffing information for transparency and resident safety.
The facility failed to ensure that four resident bedrooms met the required 80 square feet per resident in multiple resident bedrooms. Observations and a review of the facility's Client Accommodation Analysis Form confirmed that these rooms only provided 78.2 square feet per resident. Despite this, residents were observed to have enough space to move freely and had necessary furniture.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring that the resident's call light was within reach. The resident, who has diagnoses including muscle weakness, difficulty in walking, Alzheimer's disease, depression, and anxiety, was observed trying to reach for the call light but was unable to do so. The resident expressed that she gives up trying to call for assistance because she cannot reach the call light. This situation was confirmed during an observation and interview with a registered nurse, who acknowledged that the call light was not within the resident's reach and that it was necessary for the resident to have access to it to request assistance. The resident's care plan, which included instructions for the call light to be within reach and answered promptly, was not followed. The facility's policy and procedure on call light communication also indicated that call lights should be placed within the resident's reach. The Director of Nursing confirmed that the call light should be accessible to residents to prevent delays in meeting their needs and providing care. This deficiency in ensuring the call light was within reach has the potential to delay necessary care and services for the resident.
Failure to Provide Supervision During Resident Transfers
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident during transfers from bed to chair and vice versa, which is a deficiency in ensuring a safe environment free from accident hazards. The resident, who was at high risk for falls due to repeated falls, osteoarthritis, and spondylolisthesis, required supervision and touching assistance for transfers as indicated in their Minimum Data Set (MDS) and care plan. Despite this, the resident often transferred independently, leading to an injury. The resident's care plan, which focused on activities of daily living and fall prevention, did not adequately address the resident's behavior of transferring without assistance. The Director of Nursing acknowledged the importance of providing the necessary care, including supervision during transfers, but there was no care plan addressing the resident's tendency to transfer independently. This oversight contributed to the resident's injury, as they reported transferring on their own and subsequently experiencing a sharp pain in their right elbow and forearm. The facility's policies and procedures, including the Fall Management Program and Resident Safety guidelines, emphasized the need for a safe environment and reevaluation of safety risks following incidents. However, these policies were not effectively implemented in the resident's care plan, as it failed to mitigate the safety risks associated with the resident's independent transfers. This lack of adherence to the facility's policies resulted in the resident sustaining an elbow fracture and partial tearing of tendons, as confirmed by medical imaging.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, leading to deficiencies in oxygen administration. For the first resident, the physician's order required continuous oxygen therapy at 2 liters per minute via nasal cannula to maintain oxygen saturation levels at or above 92%. However, observations revealed that the resident was not receiving oxygen as prescribed, with oxygen saturation levels recorded at 90-91%. The Licensed Vocational Nurse (LVN) was unaware of the continuous nature of the order and did not know when or how often to check the resident's oxygen saturation levels. The Director of Nursing (DON) confirmed that the medication administration records did not indicate compliance with the continuous oxygen order. For the second resident, the physician's order specified oxygen administration at 3 to 5 liters per minute via nasal cannula as needed for shortness of breath, with the goal of maintaining oxygen saturation levels at or above 92%. However, the resident's oxygen was set at 2.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not labeled with the date and time of first use, which is required to ensure timely replacement. The LVN acknowledged the discrepancy in oxygen settings and the lack of labeling, and the DON confirmed that the physician's order should have been followed. The facility's policy and procedure for oxygen therapy, revised in November 2017, mandates administering oxygen per physician orders and obtaining oxygen saturation levels as ordered. It also requires notifying the physician if oxygen saturation falls below the specified level and changing the oxygen tubing every seven days with proper labeling. The failure to adhere to these protocols resulted in the identified deficiencies in respiratory care for the two residents.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff, as outlined in their abuse prevention policy. The incident involved a resident who was initially admitted with a diagnosis of major depressive disorder and had intact cognitive skills for daily decision-making. The resident required varying levels of assistance with daily activities. During an altercation, the resident used a derogatory term towards a Certified Nurse Assistant (CNA), who responded with a verbal expletive. This exchange was witnessed by a Restorative Nursing Assistant (RNA), who identified the CNA's response as verbal abuse. The facility's policy defines verbal abuse as any use of oral, written, or gestured communication that includes disparaging and derogatory terms directed at residents. The Director of Nursing and the Administrator confirmed that the CNA's response constituted verbal abuse and should have been reported immediately to prevent escalation and ensure the resident's safety. The facility's policy emphasizes a zero-tolerance approach to any form of resident abuse, including verbal abuse, and mandates immediate reporting of such incidents.
Failure to Report Verbal Abuse Incident Timely
Penalty
Summary
The facility failed to report an incident of verbal abuse involving a resident and a Certified Nurse Assistant (CNA) to the State Survey Agency within the required two-hour timeframe. The incident involved a verbal exchange where the resident used a derogatory term towards the CNA, who then responded with inappropriate language. This exchange was witnessed by a Restorative Nursing Assistant (RNA), who identified the CNA's response as verbal abuse. Despite the facility's policy requiring immediate reporting of such incidents to the Administrator, the staff did not report the incident, resulting in a failure to notify the Department of Public Health (DPH) as mandated by state law. The resident involved in the incident had a history of major depressive disorder and was assessed to have intact cognitive skills for daily decision-making. The resident required varying levels of assistance with daily activities. The facility's policy, revised in December 2023, clearly states that any allegations of abuse must be reported immediately to the Administrator or a designated representative. Interviews with the Director of Nursing, Director of Staff Development, and the Administrator confirmed that the CNA's response was considered verbal abuse and should have been reported promptly to ensure the resident's safety and compliance with reporting requirements.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility nursing staff failed to provide pharmaceutical services for two residents, leading to deficiencies in medication administration. Resident 2, who was admitted with diagnoses including COVID-19, encephalopathy, and end-stage renal disease, did not receive their routine 9 AM medications as ordered. During an observation, it was noted that multiple medications were left on Resident 2's overbed table, and the Licensed Vocational Nurse (LVN) admitted to leaving them there because the resident did not want them at that time. The facility's policy requires medications to be administered within one hour of the scheduled time, and any changes to administration times must be approved by a physician, which was not done in this case. Resident 3, who was admitted with conditions such as COVID-19, spinal stenosis, and hypertension, also did not receive their medications as ordered. The resident's potassium and Paxlovid were left on their overbed table, and the resident stated that they sometimes delay taking the medication due to its taste. The facility's policy mandates that medications must be administered directly by the licensed nurse who prepared them, and there was no care plan in place for self-administration of medication for Resident 3. The LVN acknowledged that they did not ensure Resident 3 took all their medications, which is against the facility's policy. The Director of Nursing (DON) confirmed that the facility's policies were not followed in both cases. The policies require that medications be administered by the licensed nurse and that any self-administration of medication must be approved by the Interdisciplinary Team and the resident's attending physician. The failure to adhere to these policies resulted in a delay of necessary care and treatment for both residents, as the staff did not ensure the medications were taken as prescribed.
Failure to Provide a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for four of seven sampled residents. Resident 3's personal property was not protected from loss, resulting in multiple personal items being unaccounted for during an inventory. The facility's policy required that personal belongings be inventoried and logged upon admission and readmission, but this was not adequately followed, leading to the loss of Resident 3's items, including clothing and a cane. Interviews with the Social Service Director and the Director of Nursing confirmed the failure to ensure the safety of Resident 3's belongings as per the facility's policy. Resident 51's shared restroom was found to be unsanitary, with a dried brown smear on the wall near the toilet flush handle. This condition was observed during a survey and confirmed by Resident 51, who expressed discomfort using the restroom due to its unclean state. Housekeeping staff, the Infection Prevention Nurse, and the Director of Nursing all acknowledged that the restroom should be kept clean to prevent the spread of infection and ensure a comfortable environment for the residents. Resident 62's room had wallpaper stripping off around the call light panel, and Resident 15's room had long scratched up and chipped paint on the wall behind the head of the bed. These conditions were observed during the survey and confirmed by the Maintenance Supervisor and the Director of Nursing, who both stated that the residents' rooms should be well-maintained to provide a homelike environment. The facility's policies on resident rooms and maintenance services were not adequately followed, resulting in an environment that was not comfortable or well-maintained for the residents.
Failure to Properly Set LAL Mattresses for Residents
Penalty
Summary
The facility failed to implement appropriate interventions to prevent pressure ulcers for two residents by not setting their low air loss (LAL) mattresses according to their weights. Resident 17, who was admitted with diagnoses including Parkinson's disease, peripheral vascular disease, and dementia, was observed lying on an LAL mattress set at 320 lbs, despite weighing only 112 lbs. The Director of Nursing (DON) confirmed that the mattress setting was incorrect and could place the resident at high risk for skin breakdown. Resident 17's care plan included the use of an LAL mattress for skin management, but the incorrect setting was not adjusted to match the resident's weight. Similarly, Resident 54, who was admitted with Alzheimer's disease and contractures, was observed lying on an LAL mattress set at 180 lbs, despite weighing only 106 lbs. The DON confirmed that this setting was also incorrect and could increase the risk of skin breakdown. Resident 54's physician's order allowed for the adjustment of the LAL mattress setting based on the resident's weight and comfort, but this was not done. Both residents were at risk of developing pressure ulcers due to the improper settings of their LAL mattresses.
Failure to Follow Safe Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to follow their policies and procedures on safe food storage, which was observed during a survey. Specifically, four gallons of milk in the kitchen refrigerator were not labeled with an open and/or use-by date. Additionally, food items in the resident's fridge were not labeled with a date and/or resident's name. These labeling deficiencies were confirmed through observations and interviews with the Registered Dietician (RD) and Dietary Staff (DS), who acknowledged the importance of proper labeling for resident safety and compliance with facility policies. Furthermore, the facility did not ensure that Kitchen Staff 1 (KS 1) performed proper hand hygiene and changed gloves after washing dishes and moving from the dirty area to the clean area. This was observed during a survey, where KS 1 was seen washing dishes and then handling clean utensils without changing gloves or washing hands. The RD and DS confirmed that this practice was against the facility's infection control policies and posed a risk of cross-contamination. The facility's policies and procedures, including those on infection control, food brought in by visitors, food storage, and labeling and dating of foods, were reviewed and found to be in place. However, the observed practices did not align with these policies, leading to potential risks for food-borne illnesses among residents. The staff interviews highlighted the importance of adhering to these policies to ensure resident safety and prevent contamination.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two of three outside garbage cans were covered and closed per facility policy and procedure. During an observation and interview with the Dietary Supervisor (DS) and Maintenance Supervisor (MS), it was noted that one blue trash can filled with trash was uncovered with no lid, and one grey trash can overflowing with trash was not covered with a lid. Both supervisors acknowledged that the trash bins should always be covered to prevent cross-contamination, rodents, and pests from getting into the trash. A review of the facility's policy and procedure titled 'Waste Management' indicated that waste containers must be closable, puncture-resistant, and leak-proof. The policy also stated that food waste should be placed in covered garbage and trash cans. The failure to adhere to these procedures had the potential to attract pests to the facility and its residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow its infection control policy for five residents, leading to potential risks of infection and transmission. For Resident 25, the humidifier bottle was undated and disconnected from the oxygen tubing, and the BiPAP mask was not stored in a plastic bag, exposing the equipment to bacteria. The Licensed Vocational Nurse confirmed these observations and acknowledged that the equipment should have been properly labeled and stored to prevent contamination. The Infection Preventionist Nurse also stated that the improper handling of the humidifier and BiPAP mask could lead to bacterial infections, including Legionnaires' disease. Resident 81, who had a positive MRSA result, was not placed on contact isolation as required by the facility's protocol. The Infection Preventionist Nurse confirmed that the resident should have been isolated to prevent the spread of the infection. The facility's policy indicated that residents with MDRO infections should be evaluated for room placement and contact precautions, but this was not followed for Resident 81. For Resident 294, the oxygen tubing was observed touching the floor, which the Director of Nursing and Infection Preventionist Nurse acknowledged as a risk for infection. Similarly, Resident 11's oxygen nasal cannula tubing was not labeled with a date and was also touching the floor. The Central Supply staff and Licensed Vocational Nurse confirmed that the tubing should be dated and kept off the floor. Lastly, Resident 84's Foley catheter drainage bag was observed on the floor multiple times, which staff confirmed should not happen to prevent contamination. The facility's infection control policies were not adhered to, leading to these deficiencies.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by not emptying a full sharps container located in a resident's restroom. During an observation and interview with Central Supply, it was noted that the sharps container was filled above the designated fill line, posing a safety risk for residents and staff. The facility's policy indicated that sharps containers should be replaced when they are three-quarters full, but this was not adhered to, creating unsafe conditions for potential needlestick injuries and infections. Additionally, the facility did not ensure that unused toilet tissue rolls were clean, unopened, and stored in a sanitary manner. During an observation and interview with the Infection Preventionist, four toilet tissue rolls were found stacked on a towel rack, with three rolls having torn and opened wrapping, and one roll showing a brown water mark residue. The Infection Preventionist confirmed that the toilet tissues were improperly stored and contaminated, which could lead to urinary tract infections if used by residents. The facility's policy emphasized maintaining a safe, sanitary, and comfortable environment, which was not followed in this instance.
Failure to Update Foley Catheter Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident with a Foley catheter, specifically neglecting to address the resident's behavior of placing the catheter drainage bag on the floor. This oversight was identified through observations and interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse Supervisor (RNS), and the Director of Nursing (DON). The resident, who has diagnoses of aphasia and type 2 diabetes, was observed multiple times with the catheter drainage bag on the floor, which poses a risk for infection. Despite these observations, the care plan did not include interventions to prevent this behavior. The resident's medical records indicated that he does not have the capacity to understand and make decisions, and he requires substantial assistance with daily activities. The facility's policies and procedures require updating care plans based on assessed needs, but this was not done in this case. The Minimum Data Set (MDS) Coordinator confirmed that the care plan should have been updated to address the specific behavior, and the DON acknowledged that the care plan should have included proper goals and interventions to manage the issue.
Failure to Provide Communication Board and Scheduled Showers
Penalty
Summary
The facility failed to ensure that Resident 44 was provided with a communication board that was readily accessible and in a language the resident could understand. Resident 44, who was admitted with diagnoses including hemiplegia, hemiparesis, and dementia, was observed multiple times without a communication board in her room. Interviews with various staff members, including CNAs, the Social Services Director, and the Director of Nursing, confirmed that the resident did not have a communication board, which was necessary for her to communicate her needs effectively. The facility's policy required the provision of adaptive devices like communication boards for residents with communication challenges, but this was not adhered to in Resident 44's case. The facility also failed to provide Resident 290 with a scheduled and requested shower. Resident 290, who was admitted with diagnoses including type 2 diabetes mellitus, spinal stenosis, and polyosteoarthritis, did not receive a shower from the date of admission through several days thereafter. Despite informing the staff of her need for a shower, Resident 290's requests were not fulfilled. Interviews with staff, including an LVN and a Registered Nurse Supervisor, revealed that showers were important for residents' well-being and satisfaction, but the facility's shower schedule and staff practices did not ensure that Resident 290 received the necessary care. The facility's policies on translation or interpretation services and accommodation of residents' communication needs, as well as the policy on shower and bathing, were not followed in these instances. The lack of a communication board for Resident 44 and the failure to provide a shower for Resident 290 resulted in deficiencies in the care and services provided to these residents, potentially impacting their ability to perform activities of daily living and their overall well-being.
Failure to Provide Necessary Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident, as observed when an oxygen humidifier being used was empty and did not contain sterile water. This was in violation of the facility's policy and procedure, which mandates the use of sterile water in oxygen humidifiers to prevent dryness of the nasal passages. The resident, who had chronic respiratory failure with hypoxia and pleural effusion, was found lying in bed with an empty oxygen humidifier labeled 4/24/2024, despite a physician's order dated 4/3/2024 to change the humidifier as needed for oxygen use. Interviews with staff, including the Minimum Data Set (MDS) coordinator and the Director of Nursing (DON), confirmed that the oxygen humidifier should have been changed when it was empty to ensure the resident's comfort and prevent dryness of the nasal passages. The facility's policy on oxygen therapy, revised in November 2017, also indicated the need to administer oxygen under safe and sanitary conditions per physician's orders. The resident's Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognitive skills and required total dependence for various activities of daily living, further emphasizing the need for diligent care by the facility staff.
Failure to Accurately Record and Implement Resident's Food Preferences
Penalty
Summary
The facility failed to accurately record and implement the food preferences for Resident 25, who had severe cognitive impairments and multiple medical conditions, including hemiplegia, hemiparesis, acute respiratory failure with hypoxia, dysphagia, and gastroesophageal reflux disease. Despite Resident 25's dietary profile indicating a preference for no raw onions and allergies to pepper and chili, the dietary tray card incorrectly listed dislikes of bacon, pork, and ham, which Resident 25 actually enjoyed. This discrepancy was confirmed during an interview with Resident 25 and further corroborated by Family Member 1, who stated that the incorrect information was never communicated to the facility and that multiple attempts to correct it had failed. The Dietary Supervisor (DS) acknowledged the error but could not recall or provide documentation of who provided the incorrect information. The facility's policy and procedure for dietary profiles and resident preference interviews require that dietary profiles reflect current nutritional needs and food preferences, and that any updates be documented in the medical record and tray card in a timely manner. The failure to honor Resident 25's food preferences resulted in a violation of the resident's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, leading to potential safety risks. Resident 18, who has severe cognitive impairment and is dependent on assistance for daily activities, was observed with the call light on the floor, out of reach. Despite the resident's inability to make decisions, the call light was not accessible, which was confirmed by the Licensed Vocational Nurse who acknowledged the importance of having the call light within reach for safety and quick assistance. Similarly, Resident 34, who has moderately impaired cognitive skills and is totally dependent on assistance for daily activities, was found with the call light stuck between the bed mattress and bed rail, making it unreachable. The resident attempted to reach the call light but was unable to do so. The Director of Nursing confirmed that the call light is essential for residents to communicate their needs and that its inaccessibility poses a risk to the residents' needs being unmet. The facility's policy mandates that call cords be within residents' reach, which was not adhered to in these cases.
Failure to Apply Coban Wrap and Unna Boot Dressing as Ordered
Penalty
Summary
The facility failed to ensure that a resident's Coban wrap and Unna boot dressing were applied to the resident's bilateral lower extremities as indicated on the physician's order. The resident, who had chronic kidney disease and congestive heart failure, was observed without the necessary dressings on multiple occasions. The physician's order specified that the dressings should be applied every Friday and removed every Wednesday, but during observations on 4/29/2024 and 4/30/2024, the resident did not have the dressings on, exposing significant pitting edema. The Treatment Nurse confirmed that the dressings should have been in place and were not removed according to the schedule. The resident was unaware of who removed the dressings, and the Director of Nursing acknowledged that the nursing staff should have monitored the resident to ensure the dressings remained in place. The facility's policy indicated that each resident should receive the necessary care and services to maintain their highest practicable physical, mental, and psychological well-being, which was not adhered to in this case. This failure had the potential to worsen the resident's edema and affect their physical comfort and well-being.
Inaccurate and Outdated Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure the Nurse Staffing Information posted was accurate and complete in accordance with the facility's policy and procedure. Specifically, the facility did not remove the Nurse Staffing Information dated 4/26/2024 and post the updated information for 4/29/2024. Additionally, the posted information did not reflect the correct total number and actual hours of unlicensed nursing staff directly responsible for resident care. This was observed during a survey on 4/29/2024 at 11:20 AM, where the posted information was outdated. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the inaccuracies and the importance of posting accurate staffing information for transparency and resident safety. Further review of the Daily Posted Nurse Staffing for 4/29/2024 and 5/1/2024 revealed discrepancies in the number of Certified Nursing Assistants (CNAs) and Restorative Nursing Assistants (RNAs) listed. The DSD acknowledged that the posted numbers were incorrect and should have been updated to reflect the actual staffing. The facility's policy, revised on January 1, 2012, mandates the daily posting of accurate nurse staffing information, including the total number of unlicensed nursing staff per shift. The failure to adhere to this policy had the potential to misinform residents, visitors, and family members about the facility's staffing ratios and available resources for resident care.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that four of 44 resident bedrooms (Rooms 12, 14, 35, and 37) met the required 80 square feet per resident in multiple resident bedrooms. During an observation from 4/29/2024 to 5/2/2024, it was found that these rooms measured 312.8 square feet each, equating to only 78.2 square feet per resident. This deficiency was confirmed through a review of the facility's Client Accommodation Analysis Form dated 5/1/2024. Despite the space constraints, residents in these rooms were observed to have enough space to move freely and had beds and side tables with drawers. The Department recommended approval of a room waiver request for these rooms.
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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