Pico Rivera Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pico Rivera, California.
- Location
- 9140 Verner Street, Pico Rivera, California 90660
- CMS Provider Number
- 055170
- Inspections on file
- 29
- Latest survey
- March 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pico Rivera Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment missed several doses of prescribed antibiotics for a UTI and refused a scheduled suprapubic catheter change. Nursing staff did not notify the PCP about the missed doses or the refusal, and documentation was lacking, despite facility policy requiring such notifications and documentation.
Three residents with respiratory conditions did not receive oxygen therapy as ordered, and their oxygen saturations were not accurately monitored while on supplemental oxygen. Nursing staff assessed oxygen levels on room air instead of during oxygen administration, and oxygen flow rates were not set according to physician orders. The DON confirmed that these actions did not follow physician orders or facility policy.
A facility failed to maintain resident confidentiality by not removing identifiable information from a GT feeding bottle before disposal. A resident's name was found on the bottle in the trash, contrary to the facility's policy. Staff acknowledged the oversight, emphasizing the need to de-identify information to protect privacy.
A facility failed to develop a care plan for a resident exhibiting teeth grinding behavior, despite the resident's severe cognitive impairment and dependence on staff. Staff interviews confirmed awareness of the behavior, which should have been addressed per the facility's care plan policy.
A facility failed to display 'No Smoking/ Oxygen in Use' signs for a resident using an oxygen concentrator, as required by policy. The resident, with severe cognitive impairment and multiple health issues, was observed without the necessary warning signs on multiple occasions. Staff acknowledged the oversight and the associated safety risks.
A facility failed to maintain a medication error rate below five percent, resulting in a 21.43% error rate. An LVN administered six oral medications simultaneously to a resident with dysphagia, leading to the resident's inability to swallow the medications properly. The resident's care plan required specific interventions for safe swallowing, which were not followed, resulting in a significant medication error.
A resident with dysphagia was not assessed for swallowing ability before medication administration, leading to a significant medication error. The LVN attempted to give multiple oral medications at once, contrary to the resident's care plan, resulting in the resident's inability to swallow the pills. The facility's policies for safe medication administration were not followed, posing a risk of aspiration or choking.
A resident with specific dietary needs was not offered alternative meals despite expressing dissatisfaction with the food provided. The resident, who was on a controlled carbohydrates, no added salt diet with a dysphagia mechanical soft texture, consistently ate less than 25% of her meals. Facility staff failed to follow policy by not offering an alternative menu, potentially impacting the resident's nutritional status and quality of life.
The facility failed to implement proper infection control practices for two residents. A resident with respiratory symptoms was not placed on isolation precautions, contrary to facility policy, risking infection spread. Another resident's nasal cannula was observed touching the floor, posing a risk of bacterial contamination and respiratory infection. Staff acknowledged these lapses, highlighting deficiencies in maintaining a safe environment.
Failure to Notify PCP of Missed Antibiotic Doses and Catheter Change Refusal
Penalty
Summary
The facility failed to ensure that the primary care provider (PCP) was notified regarding missed doses of an antibiotic and a refusal of a suprapubic catheter change for one resident. The resident, who had moderate cognitive impairment and was dependent for activities of daily living, missed several doses of Macrobid prescribed for a urinary tract infection (UTI) on three separate occasions. Nursing staff did not inform the PCP about these missed doses, with one nurse stating the resident was at dialysis during medication times and another nurse indicating they did not think notification was necessary. Documentation in the resident's clinical record did not reflect PCP notification for the missed doses, and facility policy required that missed medications be documented and the PCP notified. Additionally, the same resident refused a scheduled suprapubic catheter change as ordered by the PCP. Nursing and wound care progress notes confirmed the refusal, but there was no documentation that the PCP was notified of this refusal. Interviews with nursing staff and review of facility policy revealed that the PCP should have been informed of the refusal to obtain further orders for monitoring and care. The facility's policies required notification of the PCP for refusals of treatment or medication, but this was not followed in the resident's case.
Failure to Administer and Monitor Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not administering oxygen as per physician's orders and not accurately checking oxygen saturations. For one resident with a history of pneumonitis and acute pulmonary edema, the physician's order required oxygen at 3 liters per minute via nasal cannula, with titration up to 5 liters if oxygen saturation dropped below 89%. However, documentation showed that oxygen saturations were assessed while the resident was on room air, not while receiving supplemental oxygen as ordered. Another resident with chronic respiratory failure and hypercapnia had orders for continuous oxygen at 2 liters per minute via nasal cannula, with titration up to 5 liters for oxygen saturation below 92%. The resident's oxygen saturations were also assessed on room air, and observation revealed the oxygen tank was set at 1 liter instead of the ordered 2 liters. The nurse confirmed that oxygen should have been set at the correct rate and that oxygen saturations should be checked while the resident was receiving oxygen. A third resident, also with chronic respiratory failure and hypercapnia, had orders for oxygen at 2 liters per minute via nasal cannula, with titration up to 5 liters for oxygen saturation below 92%. This resident's oxygen saturations were similarly assessed on room air, and the oxygen tank was set at 2.5 liters. The nurse admitted to not having checked the resident's oxygen saturation that morning. The Director of Nursing confirmed that staff did not follow physician orders or facility policy, as oxygen was not administered or monitored as required.
Failure to De-identify Resident Information on Disposed GT Feeding Bottles
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from a gastrostomy tube (GT) feeding bottle before disposal. During observations on two separate occasions, the GT feeding bottle with the resident's name was found in the trash can in the resident's room. This practice was contrary to the facility's policy, which required the removal or obscuring of personal information from such items before disposal to protect resident privacy. The resident involved had a history of severe cognitive impairment and was dependent on staff for daily activities. The facility's staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), acknowledged the oversight and confirmed that the resident's information should have been de-identified before disposal. The facility's policy on enteral feeding disposal, revised in March 2023, clearly stated the requirement for de-identifying resident information to maintain privacy and confidentiality.
Failure to Care Plan for Teeth Grinding Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who exhibited teeth grinding behavior. This deficiency was identified during a review of the resident's records, which showed no care plans addressing this behavior despite the resident's severe cognitive impairment and complete dependence on staff for activities of daily living. The resident, who had been admitted and readmitted to the facility, had diagnoses including gastrostomy, cognitive communication deficit, dementia, and adult failure to thrive. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the resident's teeth grinding behavior was known and should have been care planned. The facility's policy on comprehensive person-centered care plans indicated that assessments and revisions should occur as residents' conditions change. However, the lack of a care plan for the teeth grinding behavior demonstrated a failure to adhere to this policy, potentially delaying appropriate care or treatment for the resident.
Failure to Display Oxygen Warning Signs
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its policy for a resident using an oxygen concentrator. Observations on multiple occasions revealed that there were no 'No Smoking/ Oxygen in Use' signs displayed on the entrance door or inside the room of the resident who was using an oxygen concentrator. This oversight was noted during observations on January 6th and 7th, 2025, where the resident was seen lying on the bed with the oxygen concentrator at the bedside, yet no warning signs were present. The resident in question was admitted to the facility on December 18th, 2024, with diagnoses including cirrhosis of the liver, generalized muscle weakness, dysphagia, and depression. The resident's cognitive skills were severely impaired, requiring various levels of assistance for daily activities. The facility's policy, revised in October 2010, mandates the placement of 'No Smoking/ Oxygen in Use' signs for rooms where oxygen is administered. Interviews with staff, including an LVN and the Director of Staff Development, confirmed the absence of these signs and acknowledged the potential safety risks involved, emphasizing the importance of these signs in preventing fire hazards and ensuring safety during emergencies.
Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 21.43% error rate identified during a survey. This was due to six medication errors out of 28 opportunities for error, specifically involving Resident 43. The Licensed Vocational Nurse (LVN) 1 administered six oral medications simultaneously to Resident 43, who had a diagnosis of dysphagia, leading to the resident's inability to swallow the medications properly. Resident 43 had a medical history that included dysphagia, dementia, and encephalopathy, which impaired her cognitive abilities and required supervision for eating and maximal assistance for personal care. Her care plan indicated the need for a puree diet and thin liquids, with specific interventions to aid safe swallowing, such as giving smaller bites and sips, double swallows, and chin tucks. Despite these precautions, LVN 1 attempted to administer multiple medications at once, contrary to the care plan and physician orders that allowed for medications to be crushed and mixed with food if necessary. During the medication pass, LVN 1 observed that Resident 43 was unable to swallow the pills, which remained on her tongue despite multiple attempts to encourage swallowing with water. The Speech Language Pathologist and Director of Nursing later confirmed that administering several medications at once was inappropriate for Resident 43, given her condition. The facility's policy and job description for LVNs emphasized safe medication administration, which was not adhered to in this instance, resulting in a significant medication error rate.
Failure to Assess Swallowing Ability Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 43, was assessed for swallowing ability prior to administering oral medications. Resident 43, who had a history of dysphagia, dementia, and encephalopathy, was observed during a medication pass where the Licensed Vocational Nurse (LVN 1) attempted to administer multiple oral medications at once. Despite Resident 43's inability to swallow the medications, LVN 1 continued to encourage the resident to swallow, resulting in the medications remaining on the resident's tongue. Resident 43's medical records indicated a diagnosis of dysphagia and a care plan that required specific interventions for safe swallowing, including the use of speech therapy and the administration of medications in a crushed form mixed with food. However, during the medication pass, LVN 1 did not adhere to these interventions and attempted to administer whole pills, which Resident 43 was unable to swallow. The Speech Language Pathologist (ST) confirmed that Resident 43 was at risk of choking and recommended administering one pill at a time or crushing the medications. The Director of Nursing (DON) acknowledged that the best practice would have been to assess Resident 43's ability to swallow before administering medications and to give one medication at a time. The facility's policy and procedure for administering medications emphasized the importance of safe and timely administration, which was not followed in this instance. The failure to adhere to the care plan and facility policies resulted in a significant medication error, posing a risk of aspiration or choking for Resident 43.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences and offer an alternative menu for a resident, identified as Resident 75, which had the potential to impact the resident's nutritional status and quality of life. Resident 75, who was cognitively intact and had the capacity to understand and make decisions, was on a controlled carbohydrates, no added salt diet with a dysphagia mechanical soft texture. Despite these dietary requirements, the resident expressed dissatisfaction with the meals provided, stating that she only ate the fruit and drank the milk, and felt she was not eating enough. Observations and interviews revealed that Resident 75 consistently ate less than 25% of her meals and was not offered alternatives when she expressed dislike for the food. A Certified Nursing Assistant (CNA) confirmed that the resident had not been offered an alternative menu, despite the facility's policy requiring CNAs to inform the charge nurse if a resident ate less than 50% of their meal. The Licensed Vocational Nurse (LVN) and the Registered Dietician (RD) were not informed of the resident's dissatisfaction, and the Dietary Supervisor (DSS) stated that a diet communication slip should have been sent to the kitchen to request a substitute. The facility's policy and procedure indicated that residents who do not like the menu item should be given an alternate food of similar nutritive value, and menu alternates should be planned and available for all meals. However, this policy was not followed for Resident 75, leading to the deficiency. The RD and DSS acknowledged the importance of honoring the resident's food preferences to prevent potential weight loss and ensure the resident's satisfaction with her meals.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, leading to potential risks of infection spread. Resident 189, who exhibited symptoms of a respiratory infection, including a productive cough and fever, was not placed on isolation precautions as required by the facility's policy. Despite the presence of symptoms and pending test results for COVID-19, influenza, and RSV, Resident 189 was observed not on contact or droplet isolation. The Infection Prevention Nurse confirmed that Resident 189 should have been isolated to prevent the spread of infection. Additionally, the facility did not ensure that Resident 23's nasal cannula, used for oxygen administration, was kept off the floor. Observations on two separate occasions revealed the nasal cannula touching the floor, which posed a risk of bacterial contamination and potential respiratory infection for Resident 23. The Licensed Vocational Nurse and the Infection Prevention Nurse both acknowledged that the nasal cannula should not have been in contact with the floor, as it could lead to infections such as pneumonia. The facility's failure to adhere to its own infection control policies for both residents highlights deficiencies in maintaining a safe environment. The lack of isolation precautions for Resident 189 and improper handling of medical equipment for Resident 23 could have contributed to the spread of infections within the facility, affecting both residents and staff.
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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