Pavilion On Pico Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5916 W. Pico Boulevard, Los Angeles, California 90035
- CMS Provider Number
- 055160
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Pavilion On Pico Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, along with multiple comorbidities including DM2, COPD, heart failure, and HTN, had a missing post-dialysis evaluation in the medical record for one treatment date. During an interview and record review, an LVN confirmed that the post-dialysis evaluation form for that date was not completed, noting this could result in missed changes of condition or undocumented medications given during treatment. Review of the facility’s dialysis management policy showed that licensed nurses are required to complete both pre- and post-dialysis evaluations and maintain all dialysis-related documentation in the resident’s medical record, which was not done in this case.
A resident with multiple health conditions and mild cognitive impairment experienced inadequate discharge planning due to the facility's failure to conduct an IDT meeting and address the resident's personal requests. The Social Services Director's approach was perceived as rude, and the resident felt forced out. Staff acknowledged the resident's rights, but the facility did not follow its discharge policy, leading to ineffective planning.
A facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, who made unrealistic demands. The facility did not develop a care plan to address these behaviors, and the Social Services Director attempted to transfer the resident without proper discharge planning. Staff interviews revealed the facility could accommodate the resident's needs, but the lack of a person-centered care plan led to a deficiency in care.
A facility failed to provide adequate social services to a resident with multiple health conditions, including major depressive disorder. The resident's specific requests, such as early rising and daily laundry, were not accommodated, leading to psychosocial distress. The Social Services Director's approach was perceived as rude, and there was no proper discharge planning or understanding of resident rights, contributing to the deficiency.
Two residents experienced a delay in receiving their meals due to a mix-up with the food trays, leading to a failure in maintaining their dignity. The facility's usual process of serving all residents simultaneously was not followed, as confirmed by an LVN and the DON.
The facility did not follow its menu plan for residents on pureed diets, serving scrambled eggs instead of the prescribed Florentine torta. This substitution was not documented or approved by the Registered Dietitian, potentially compromising the nutritional intake of five residents. The Dietary Supervisor acknowledged the issue, noting the importance of adhering to standardized recipes to ensure adequate nutrition.
The facility failed to provide food in appropriate textures for residents on pureed and soft mechanical diets. Residents on a pureed diet received lumpy oatmeal, contrary to IDDSI standards, posing a choking risk. Additionally, residents on a soft mechanical diet were served bread with hard edges, which was against the facility's guidelines and also posed a choking hazard.
The facility was found to have multiple deficiencies in food storage and hygiene practices, including uncovered trash cans, improper hand hygiene, incorrect food storage, and unsanitary kitchen equipment. These issues could lead to cross-contamination and foodborne illnesses among residents.
The facility failed to maintain a clean garbage area, with debris such as masks and dog poop bags observed around the dumpster. Additionally, a dumpster was overflowing with trash and left uncovered due to a lack of Sunday trash pickup. This failure to adhere to cleanliness and waste management guidelines posed a potential infection risk to residents.
The facility failed to maintain sanitary conditions in the food services department, with six flies observed in the kitchen over two days. The Dietary Supervisor was unaware of the last pest control visit, and the pest control report only noted treatment in the exterior garbage area. This oversight potentially exposed 53 of 54 residents to foodborne illnesses.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to document this change or notify the physician and resident's representative, as required by policy. The resident also refused a follow-up blood draw, and the physician was not informed of this refusal.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to notify the physician as required by policy. Additionally, the resident refused a follow-up TSH test, and there was no documentation of physician notification. Interviews confirmed lapses in communication and documentation, contrary to facility policy.
A resident's LAL mattress was incorrectly set for a weight of 400 lbs instead of the resident's actual weight of 187 lbs, increasing the risk of pressure ulcer development. The resident, with conditions including diabetes and hemiplegia, required maximal assistance. The facility's policies and training materials indicated that mattress settings should be based on weight, but this was not followed, leading to the deficiency.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections due to the absence of a securement device and improper monitoring of catheter drainage. Despite the care plan's requirements, the catheter was not secured, leading to leakage and improper function. Facility staff, including a CNA and LVN, confirmed the catheter's mismanagement, and the resident was transferred to the hospital for further evaluation.
An LVN failed to follow a physician's order to hold Amlodipine for a resident with a pulse rate below the specified threshold. The resident's pulse was 58 BPM, but the LVN prepared the medication for administration until a surveyor intervened, highlighting a significant medication error.
The facility failed to maintain the correct temperature in a medication storage room, with the thermostat reading 90°F, above the acceptable range of 68-77°F. The fan, controlled by the light switch, was off when the light was off, causing the temperature rise. The temperature log was incomplete, missing an entry for one day, contrary to facility policy.
The facility was found non-compliant with room capacity regulations, as two rooms housed five residents each. Despite this, observations indicated sufficient space for resident movement and care provision. Staff and residents reported no concerns, and the administrator requested a waiver, asserting that care was not impeded.
The facility failed to meet federal room size requirements, with 17 out of 20 rooms not providing the mandated square footage per resident. Despite this, staff reported no concerns, and observations showed sufficient space for resident movement and care. A waiver request was submitted, but measurements confirmed non-compliance.
A facility failed to monitor and supervise residents with wandering behaviors, resulting in two elopement incidents. A resident with severe cognitive impairment left the facility unsupervised and was found at a previous address. Another resident, identified as high risk for elopement, left with a family member without triggering the wander-guard alarm. The Maintenance Supervisor could not explain the alarm failure, despite regular checks. Facility policies for wandering and elopement were not effectively implemented.
Incomplete Post-Dialysis Evaluation Documentation for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-dialysis evaluation documentation for a resident who received hemodialysis. The resident was admitted with multiple diagnoses, including DM type 2, muscle weakness, COPD, heart failure, HTN, ESRD, and dependence on renal dialysis. An MDS assessment indicated the resident had intact cognition and required varying levels of assistance with ADLs, and that the resident received hemodialysis treatments. During a concurrent interview and record review with an LVN, the surveyor reviewed the resident’s pre- and post-dialysis evaluation records for March and found that the post-dialysis evaluation for a specific treatment date was missing from the medical record. The LVN confirmed that the post-dialysis evaluation for that date was not present in the record and acknowledged that this omission could result in missing changes of condition or medications given during the treatment. Review of the facility’s “Dialysis Management” policy, last reviewed on 6/20/25, showed that a pre- and post-dialysis evaluation was required to be completed by a licensed nurse and that all documentation concerning dialysis services and care of dialysis residents must be maintained in the resident’s medical record. The missing post-dialysis evaluation demonstrated that the facility did not follow its own policy and procedures for dialysis management and did not maintain a complete medical record for this resident.
Inadequate Discharge Planning and Resident Rights Violation
Penalty
Summary
The facility failed to adequately prepare and orient a resident for a safe and orderly discharge. The deficiency involved the lack of an Interdisciplinary Team (IDT) meeting to discuss the discharge planning for a resident with multiple health conditions, including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident required maximal assistance for activities of daily living and had mild cognitive impairment. Despite these needs, the facility did not conduct an IDT meeting to ensure a comprehensive discharge plan was in place. The discharge planning was initiated not based on the resident's health needs but rather on the resident's personal requests, such as wanting to get up early and requesting daily laundry services. The Social Services Director (SSD) indicated that the facility could not accommodate these demands and sought alternative facilities for the resident, which the resident declined. The SSD's approach to the resident was perceived as rude, and the resident felt as though they were being forced out of the facility. The resident expressed a desire to remain at the facility and was particular about their living arrangements. The facility's staff, including a Certified Nursing Assistant and a Registered Nurse, acknowledged the resident's rights to make choices about their care and daily routine. However, the SSD was unable to articulate the resident's rights regarding freedom of choice and did not follow the facility's policy on discharge and transfer, which requires a discharge summary and post-discharge plan of care. The facility's failure to honor the resident's rights to be treated with kindness, respect, and dignity contributed to the incomplete and ineffective discharge planning process.
Failure to Address Behavioral Health Needs and Implement Person-Centered Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address the resident's behavior of making unrealistic demands, as required by the facility's policy on Behavior/Psychotropic Drug Management. The resident's psychosocial note from a psychiatrist highlighted the need to address the resident's mood and emotional state, which influenced her behavior towards staff. However, the Social Services Director (SSD) failed to accommodate the resident's requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD attempted to transfer the resident to another facility without conducting an interdisciplinary team meeting or understanding the facility's policy on discharge and transfer, which led to the resident feeling unwanted and neglected. Interviews with staff revealed that the facility could accommodate the resident's needs, but the SSD's approach and lack of understanding of residents' rights contributed to the deficiency. The Registered Nurse confirmed that the facility should not transfer the resident due to high demands and emphasized the importance of communicating with the resident to ensure she felt secure and respected. The facility's failure to implement a person-centered care plan and address the resident's behavioral health needs resulted in a deficiency in providing the highest practicable physical, mental, and psychosocial well-being for the resident.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide medically-related social services to Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address Resident 1's behavior of making unrealistic demands and requests, which contributed to the resident's psychosocial distress. The Social Services Director (SSD) failed to accommodate Resident 1's specific requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD's approach to Resident 1 was perceived as rude, and the resident felt pressured to leave the facility. The SSD did not conduct an interdisciplinary team meeting for discharge planning and was unaware of the facility's policy on resident rights regarding freedom of choice. This lack of appropriate social services and communication contributed to Resident 1's distress. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that Resident 1 was generally friendly and understood the limitations of the facility's services. However, the SSD's handling of the situation, including the suggestion of transferring Resident 1 to another facility without proper planning or understanding of resident rights, was inadequate. The facility's failure to address Resident 1's psychosocial needs and demands led to a deficiency in providing the highest practicable well-being for the resident.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents by not serving their meals at the same time as other residents in the dining room. Resident 2, who was admitted with chronic obstructive pulmonary disease, dysphagia, and type 2 diabetes, was observed waiting for her meal while other residents were served. The Minimum Data Set indicated that Resident 2 was severely cognitively impaired and required assistance with eating. During the observation, it was noted that the first food cart arrived, and seven residents received their meals while six others, including Resident 2, continued to wait. Licensed Vocational Nurse 3 acknowledged that the trays were not served simultaneously due to a mix-up and stated that this was not the usual process. The Director of Nursing also confirmed that the expectation was for all residents to receive their meals at the same time to prevent feelings of deprivation or neglect. The delay in serving meals was attributed to a communication issue with the kitchen, resulting in Resident 2 and Resident 42 receiving their meals later than others.
Failure to Follow Menu Plan for Pureed Diets
Penalty
Summary
The facility failed to adhere to its menu plan, which resulted in five out of 54 residents on pureed texture diets receiving scrambled eggs instead of the prescribed Florentine torta. This discrepancy was identified through observation, interviews, and record reviews. The facility's daily menu spreadsheet for residents on pureed diets indicated that they should receive a pureed Florentine torta, but scrambled eggs were served instead. The Dietary Supervisor acknowledged the substitution, stating that the Florentine torta recipe was not smooth when cooked, prompting the use of scrambled eggs for a smoother consistency. However, this change was not documented on the menu spreadsheet, and the Registered Dietitian was not informed of the substitution. The facility's Policies and Procedures for Menu Planning require that any menu changes be documented and approved by the Registered Dietitian or the Food and Nutrition Services Director. The failure to follow the standardized recipe and menu plan potentially compromised the residents' nutritional intake, as the substitution was not aligned with the planned nutritional content. The Dietary Supervisor admitted that not following the standardized recipe could lead to residents receiving inadequate nutrition, which could affect their overall health and well-being.
Failure to Provide Appropriate Food Textures for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs, specifically for residents on pureed and soft mechanical diets. Residents on a pureed International Dysphagia Standardization Initiative (IDDSI) level 4 diet, which requires food to be smooth and pudding-like, were served oatmeal with lumps. This was observed during a trayline inspection, and the Dietary Supervisor confirmed that the lumpy oatmeal posed a potential choking hazard. The facility's policy and procedures, as well as the diet manual, clearly stated that pureed diets should be smooth and free of lumps, aligning with IDDSI standards. Additionally, residents on a soft mechanical diet, intended for those with chewing or swallowing difficulties, received toasted bread with hard edges. The facility's standardized recipe for mechanical soft diets specified that breads should be soft and without hard crusts. The Dietary Supervisor acknowledged that the hard crusts on the bread were inappropriate for residents on this diet, as they could also pose a choking risk. The facility's diet manual reinforced that breads with hard crusts should be avoided for residents on a mechanical soft diet.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The trash can in the handwashing sink room was not covered when not in use, which was against the facility's policy and could lead to the transport of bacteria. Staff members were observed not performing hand hygiene after touching potentially contaminated surfaces, such as the lids of garbage cans, and then handling clean trays and dishes. This lack of hand hygiene was contrary to the facility's policies and the Food Code 2022, which emphasize the importance of handwashing to prevent cross-contamination. In the kitchen, improper food storage practices were noted, with raw chicken stored above ground beef and cooked chicken stored below raw fish, violating the facility's food storage hierarchy. Additionally, several pieces of kitchen equipment and utensils were found to be in poor condition, with dust, rust, and debris present in refrigerators and freezers, and chipped and cracked trays and shelves. These conditions could lead to contamination and were not in compliance with the facility's policies or the Food Code 2022. Other issues included the improper handling of kitchenware, such as using cloths to dry steam table covers instead of air drying, and storing scoops in different orientations, which increased the risk of contamination. Staff food was also found stored in the resident's refrigerator, which could lead to mix-ups and potential allergic reactions for residents. These practices were not aligned with the facility's policies and posed a risk of foodborne illness to the residents.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The garbage area was not maintained free from debris, including masks, dog poop bags, boxes, and dirt on the floor and surroundings of the dumpster. During an observation and interview with the Dietary Supervisor, it was noted that the trash area should be cleaned for infection control purposes. The Maintenance Director also confirmed the presence of debris and stated that it was coming from people walking by, emphasizing the need for cleanliness to prevent contamination. Additionally, one of the dumpsters was observed to be overflowing with trash, and its lid was not closed. This was noted during multiple observations, and the Maintenance Director acknowledged that the trash pickup schedule did not include Sundays, leading to the overflow. The facility's policies and procedures, as well as the Food Code 2022, require that garbage areas be kept clean and receptacles covered to prevent contamination and attract pests. The failure to adhere to these guidelines posed a potential risk of infection to the facility's residents.
Sanitation Deficiency in Food Services Due to Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of six flies observed in the kitchen over a two-day period. Observations were made on different occasions, with flies seen around the preparation area, preparation table, and trayline. During interviews, the Dietary Supervisor acknowledged the presence of flies and expressed uncertainty about the last pest control visit, indicating a lack of awareness regarding pest management in the kitchen. The facility's Policy and Procedures on Pest Control, dated June 28, 2024, emphasized the importance of keeping the facility free from insects and other pests to ensure the health and safety of residents, staff, and visitors. However, a review of the pest control report from October 23, 2024, showed that treatment for large flies was only applied in the exterior garbage area, with no mention of the kitchen. This oversight potentially exposed 53 of 54 residents to foodborne illnesses due to the risk of consuming contaminated food.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to document a significant change in condition for a resident, identified as Resident 2, in accordance with its policy and procedure. Resident 2, who was admitted with diagnoses including hypothyroidism, generalized muscle weakness, and hypertension, had a lab result indicating an elevated thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which was significantly above the normal range. Despite this abnormal result, there was no documentation of a change of condition (COC) being completed, nor was there evidence that the attending physician or the resident's representative was notified of this change. Additionally, Resident 2 refused a follow-up blood draw for TSH, and again, there was no documented notification to the physician regarding this refusal. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed that the facility's process for handling such situations was not followed. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a significant change in condition, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory test results for a resident, as required by their policy and procedure. The resident, who was admitted with diagnoses including hypothyroidism, had a thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which is significantly above the normal range. Despite the facility's policy to notify the attending physician of abnormal lab results, there was no documented evidence that the physician or the resident's representative was informed of the elevated TSH level. Additionally, a change of condition (COC) was not completed, which is part of the facility's process for handling deviations from a resident's baseline condition. Furthermore, the resident refused a follow-up TSH laboratory draw that was ordered six weeks after the initial test. Again, there was no documentation indicating that the physician was notified of the resident's refusal to undergo the blood draw. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed these lapses in communication and documentation. The facility's policy requires that lab results be promptly communicated to the physician to prevent delays in necessary interventions, but this protocol was not followed in this case.
Improper LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that the Low Air Loss (LAL) mattress setting was appropriately set for a resident, identified as Resident 205, which could potentially lead to the redevelopment of pressure ulcers. Resident 205 was admitted with diagnoses including diabetes, hemiplegia, and generalized muscle weakness, and was cognitively intact but required maximal assistance for daily activities. During an observation, it was noted that the LAL mattress pump was set to a weight of 400 lbs, while the resident's actual weight was 187 lbs. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incorrect setting could increase the risk of pressure ulcer development. The resident's care plan focused on skin integrity management and included interventions to prevent skin breakdown. The Director of Nursing (DON) confirmed that LAL mattress settings should be based on the resident's weight, and incorrect settings could lead to a high risk of skin breakdown. The facility's policy and procedures, as well as training materials, indicated that mattress settings should be adjusted according to the resident's weight to provide appropriate pressure reduction. However, the failure to adhere to these guidelines resulted in the deficiency observed during the survey.
Failure to Secure and Monitor Catheter Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for Resident 16, who had an indwelling urinary catheter. The deficiency was identified when it was observed that the resident's suprapubic catheter did not have a securement device or anchor in place, which is necessary to prevent the catheter from being dislodged and causing trauma or infection. The resident's care plan required the catheter to be secured and assessed for proper placement and drainage, but these measures were not followed. As a result, the urine bag was not draining properly, and the resident's diaper was consistently wet, indicating leakage and improper catheter function. The resident, who was admitted with diagnoses including sepsis and acute kidney failure, was unable to understand and make decisions. Despite the care plan's instructions to assess urinary drainage and maintain proper catheter alignment, staff failed to ensure these interventions were implemented. Observations and interviews with facility staff, including a CNA and LVN, confirmed the catheter's improper management and the lack of a securement device. The Director of Nursing acknowledged the oversight, and the resident was eventually transferred to the hospital for catheter reinsertion and evaluation.
LVN Fails to Hold Amlodipine Despite Low Pulse Rate
Penalty
Summary
The Licensed Vocational Nurse (LVN) 4 failed to adhere to a physician's order regarding the administration of Amlodipine, a blood pressure medication, for a resident. The physician's order specified that Amlodipine should be held if the resident's systolic blood pressure was less than 100 or if the pulse rate was below 60 beats per minute (BPM). On the day of the incident, the resident's blood pressure was recorded at 144/73 mmHg, and the pulse rate was 58 BPM, which was below the specified threshold for administering the medication. Despite the resident's pulse rate being outside the parameters for safe administration, LVN 4 proceeded to prepare the Amlodipine for the resident. It was only after the surveyor intervened and prompted LVN 4 to review the blood pressure and pulse rate parameters that LVN 4 acknowledged the error and refrained from administering the medication. This oversight placed the resident at risk for a further decrease in heart rate, as the medication was not held as per the physician's directive.
Medication Storage Room Temperature Deficiency
Penalty
Summary
The facility failed to maintain the correct temperature in one of its medication storage rooms, which could potentially compromise the efficacy of the medications stored there. During an observation and interview, it was noted that the thermostat in the medication storage room indicated a temperature of 90 degrees Fahrenheit, which is above the acceptable range of 68 to 77 degrees Fahrenheit for controlled room temperature. The Registered Nurse Supervisor acknowledged the discrepancy in temperature. Further investigation revealed that the room's fan, which is controlled by the light switch, was not operating when the light was off, contributing to the elevated temperature. Additionally, a review of the room temperature log sheet showed that temperatures were recorded within the acceptable range from November 1 to November 15, but the entry for November 16 was left blank. The Licensed Vocational Nurse confirmed that the log should be completed daily. The facility's policy, revised in January 2018, requires that all medications be stored within specific temperature ranges as per the United States Pharmacopeia and the Centers for Disease Control guidelines. The failure to maintain the correct temperature and to consistently log the temperatures as per policy led to this deficiency.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility was found to be non-compliant with the requirement that resident rooms hold no more than four residents. During an unannounced recertification survey, it was observed that two rooms housed five residents each. Despite the additional occupancy, the rooms were noted to have sufficient space for residents to move freely and for nursing staff to provide care. The residents had enough room to operate wheelchairs, walkers, and canes, and there was adequate space for bedside tables and other resident care equipment. Interviews with staff and residents revealed no concerns regarding the room sizes or the care provided. During a resident council meeting, attendees did not express any issues with their living space. The facility's administrator submitted a request for a waiver to allow more than four residents per room, citing that the room sizes did not impede resident care. The facility's client accommodation analysis confirmed the presence of five beds in the rooms in question.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 17 out of 20 resident rooms did not meet the requirement of at least 80 square feet per resident. The rooms in question were designed to accommodate either two or three residents, but their sizes were insufficient, with two-bedroom units measuring only 140 square feet and three-bedroom units measuring 200 square feet. This deficiency was identified during a recertification survey, where it was noted that the rooms did not meet the federal standards of 160 square feet for two residents and 240 square feet for three residents. Despite the deficiency, staff interviews during the survey indicated no concerns regarding the room sizes, and observations showed that residents had ample space to move freely. The rooms were equipped with necessary furniture and equipment, allowing for freedom of movement and care provision. The facility had submitted a request for a room size waiver, arguing that the room sizes did not impede resident care, and the rooms provided adequate sunlight and ventilation. However, the measurements taken by the maintenance director confirmed the non-compliance with the required room dimensions.
Failure to Monitor and Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of residents with wandering behaviors, leading to two incidents of elopement. Resident 1, who had severe cognitive impairment and was at high risk for elopement, left the facility unsupervised through the front reception area doors. The resident was later found at their previous address, 3.5 miles away. The staff, including a Certified Nurse Assistant (CNA), were unaware of the resident's whereabouts, and the wander-guard alarm system did not activate to alert staff of the resident's departure. Resident 2, who also had cognitive impairments and was identified as a high risk for elopement, left the facility with a family member for a doctor's appointment. Despite wearing a wander-guard bracelet, the alarm system failed to notify staff of the resident's exit. The Maintenance Supervisor, responsible for the wander-guard system, was unable to explain why the alarm did not trigger during these incidents, despite regular checks being conducted to ensure functionality. The facility's policies and procedures for wandering and elopement, as well as the signaling device, were not effectively implemented. The policies required verification of the signaling device's placement and functionality every shift and testing of the alarm functioning of exit doors weekly. However, these measures were insufficient in preventing the elopement of residents, as evidenced by the failure of the wander-guard system to activate during the incidents involving Residents 1 and 2.
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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