Playa Del Rey Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Playa Del Rey, California.
- Location
- 7716 Manchester Avenue, Playa Del Rey, California 90293
- CMS Provider Number
- 555004
- Inspections on file
- 59
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Playa Del Rey Center during CMS and state inspections, most recent first.
A CNA exited a resident room wearing a used gown and discarded it in a trash bin across the hallway instead of in a designated trash bin inside the room. In interviews, the CNA acknowledged that PPE should be discarded inside the room and that failure to do so could increase the risk of cross-contamination and make residents sick. The IPN confirmed that PPE is required to be discarded in designated in-room trash bins to prevent spread of infection, and facility policy states that staff receive training on proper donning, use, and disposal of PPE.
A resident with intact cognition and decision-making capacity was admitted with personal belongings, but staff did not complete the required Inventory of Personal Effects at admission, did not label the resident's clothing, and did not document the items brought in. Weeks later, an inventory form listed various belongings but did not reflect an admission inventory. The resident reported that bags of clothing, including favorite garments, went missing during the stay and stated that no personal inventory form was provided. A CNA confirmed that CNAs and licensed nurses are responsible for documenting residents' personal items on the inventory form upon arrival and updating it with any changes.
A resident with anxiety and depression had a PRN order for alprazolam 0.5 mg daily for episodes of inability to relax, but the facility failed to ensure the medication was available for use. The MAR showed no alprazolam administration over an extended period, and the resident reported requesting the medication multiple times and being told by an LVN it was not available, with non-pharmacological interventions offered instead. The pharmacist stated she received the alprazolam order but could not dispense it without a required handwritten physician signature and that staff did not follow up with the pharmacy for several days. Alprazolam was not stocked in the e-kit, and nursing leadership acknowledged that PRN medications were supposed to be available within two days of admission and that the facility’s medication administration policy for safe and timely administration could not be followed in this case.
A newly admitted resident who had recently undergone hip surgery did not have a baseline care plan developed within 48 hours as required by facility policy. The resident required significant assistance with ADLs, including toileting, bathing, and transfers, and was being monitored for pain and anticoagulant therapy. Staff confirmed the delay in care planning, which meant the care team may not have been fully informed of the resident's immediate needs.
A resident admitted with a hip surgical wound did not receive required monitoring and assessment for infection and wound complications. Nursing staff failed to document daily and weekly wound checks, did not assess the wound during episodes of reported pain, and only observed the dressing rather than the incision itself. The resident's follow-up with the surgeon was delayed, and the wound was not evaluated by a specialist until after dehiscence occurred, resulting in the resident seeking emergency care for infection.
A resident recovering from hip surgery did not receive required non-pharmacological pain interventions as ordered by the physician, and was administered Tramadol outside of prescribed parameters, with staff failing to document pain assessments and interventions according to facility policy.
Two residents with no dietary restrictions or dislikes did not receive the pork sausage patty listed on their meal tickets and the approved menu during breakfast. Both residents had medical conditions requiring adequate protein and calorie intake, and their trays were missing the specified item. Dietary and nursing staff confirmed the omission and acknowledged that the trays should have matched the meal tickets.
A resident with documented dislikes for orange juice and hot cereal was served both items on her breakfast tray, despite clear indications on her Dietary Profile and Meal Ticket. The resident, who was cognitively intact and able to communicate her preferences, reported the issue to staff, but only the orange juice was removed. The facility's policy requiring alternative selections for refused foods was not followed, resulting in the resident feeling angry and distressed.
A resident's medical records contained multiple documentation errors, including conflicting information about the surgical site location, misinterpretation of clinical terms, and incorrect timing of wound dehiscence. These inaccuracies were confirmed by both the DON and the treatment nurse, and did not meet the facility's standards for accurate nursing documentation.
A resident who was dependent on staff for toileting and personal hygiene was found lying in bed with a soaked diaper and wet bed linens, having not received morning care or a diaper change. The CNA acknowledged not checking the resident's diaper at the start of the shift, despite the care plan and facility policy requiring regular perineal care to maintain cleanliness and prevent complications.
The facility did not post current Direct Care Service Hours Per Patient Day (DHPPD) information as required, with the posted data found to be three days old. The Director of Staff Development confirmed the information was outdated and should be updated daily, in accordance with facility policy requiring daily posting of nurse staffing data for each shift.
Two residents' medications and supplements were not properly labeled: one resident's supplements were stored with only a room number as an identifier, and another resident's morphine was found with a medication label belonging to a different, discharged resident. Staff confirmed that all medications and supplements should be labeled with the resident's name and date of birth, in accordance with facility policy.
The facility did not update physician orders after receiving a telephone order to change the medication administration route for a resident with a g-tube, and also failed to complete an initial skin assessment for another newly admitted resident with multiple health conditions. These actions resulted in incomplete medical records and potential confusion for staff regarding care procedures.
A LVN was observed removing and discarding a used PPE gown in a hallway linen hamper instead of inside a resident's room, contrary to facility policy and infection control protocols. Staff interviews and policy review confirmed that used PPE should be disposed of in the resident's room to prevent cross contamination.
The facility did not meet the required minimum of 80 square feet per resident in 23 multiple occupancy rooms. Although residents were observed to have space for movement and personal property, facility records and a waiver request confirmed that these rooms were below the required size standard.
Two residents with physical limitations were not provided access to the weekly menu or alternative meal choices, as menus were only posted outside the kitchen and not made available to those unable to access them. Both residents, who had decision-making capacity, were unaware of their food options and reported not being offered choices, resulting in them eating only what was served.
A resident with severe cognitive impairment and multiple diagnoses was found to have their call light out of reach while in bed. Staff confirmed the call light was not accessible and acknowledged the importance of ensuring it is within reach, in accordance with facility policy.
A resident with dysphagia and a g-tube had a change in physician orders allowing medications to be taken orally, but the care plan was not updated to reflect this change. The care plan continued to address swallowing food and drinks but did not include interventions for oral medication administration, despite the resident's ongoing risk for swallowing difficulties. Staff and physician interviews confirmed the care plan was not revised, which could cause confusion.
A resident with a history of syncope and hypertension received losartan despite physician orders to hold the medication if systolic blood pressure was below 110 mmHg. Documentation showed the medication was administered on two occasions when the resident's blood pressure was below the specified threshold, contrary to facility policy and physician instructions.
A resident with significant physical and cognitive impairments was not assisted out of bed during mealtimes, despite a physician order and facility policy requiring such support. Staff were unaware of the order, and the care plan did not include this intervention, resulting in the resident consistently eating meals in bed.
A resident with atrial fibrillation and heart failure was prescribed amiodarone and carvedilol, and the pharmacist recommended monitoring for bradycardia due to the combined effects of these medications. However, there was no documentation that a physician reviewed or responded to this recommendation, as required by facility policy. The MRR was not reviewed by the responsible RN, and the DON had resigned, resulting in the recommendation not being communicated to the physician.
A resident with hypertension, cardiac arrhythmia, and hyperkalemia did not receive clonidine as ordered for elevated systolic blood pressure on 33 occasions. Although BP was checked as required, the MAR showed the medication was not administered or documented when indicated, and an LVN confirmed the omission. Facility policy required administration and documentation per physician orders, which was not followed.
A resident with mental health diagnoses experienced repeated verbal outbursts and threatening behavior from a roommate with a history of psychiatric disorders. Despite a care plan requiring one-to-one supervision for the roommate, staff left the resident unsupervised, allowing an incident where the roommate yelled, touched the resident's shoulder, and threatened with a butter knife. This failure to follow the facility's abuse policy resulted in the resident feeling unsafe and experiencing mental abuse.
A resident with multiple chronic conditions developed a right femur fracture of unknown origin, which was identified after complaints of increased pain. The resident, who was cognitively intact, denied any fall, abuse, or injury, and staff interviews confirmed no known cause. Despite facility policy requiring reporting of unusual occurrences, the incident was not reported to the state agency, as the Administrator determined the fracture was pathological and not of unknown origin.
A resident with impaired cognition and mobility, using a low air loss mattress (LALM), was being changed by a CNA who did not set the mattress to static mode or use the required two-person assist, resulting in the resident rolling off the bed and falling. Facility policy and staff interviews confirmed these safety steps were necessary to prevent such incidents.
A nurse failed to document the administration of seven scheduled medications for a resident with stroke, hemiplegia, and diabetes, despite facility policy requiring immediate documentation in the MAR. The nurse admitted the medications were given but not recorded due to being busy, resulting in no indication in the record that the resident received the medications.
A resident with diabetes and impaired cognition did not receive a scheduled dose of Lispro insulin on time because an LVN was busy, as confirmed by review of the MAR and staff interview. Facility policy required medications to be given within one hour of the scheduled time, but this was not followed, resulting in a medication error.
A resident with an indwelling catheter and obstructive uropathy experienced ongoing pain due to improper catheter management, which was reported to CNAs and LVNs but not addressed for several days. The pain interfered with participation in PT and daily activities, and pain medication was not administered as ordered. Staff interviews and record reviews confirmed the resident's pain was not managed according to facility policy.
A resident with quadriplegia and a suprapubic catheter did not receive a scheduled catheter lavage as ordered, despite repeated requests throughout the day. Due to staff shortages and competing priorities, the procedure was delayed for several hours, leading the resident to experience abdominal spasms and discomfort.
A resident with an indwelling Foley catheter and a history of obstructive uropathy repeatedly reported penile pain, which was not thoroughly assessed or managed by staff. Despite orders for as-needed acetaminophen, pain medication was not consistently administered, and the catheter was observed to be improperly secured, causing discomfort. The resident's pain led to refusal of therapy, and staff interviews confirmed a lack of timely pain assessment and intervention.
Nursing staff did not demonstrate competency in securing a Foley catheter for a resident with urinary tract conditions, resulting in several days of pain and discomfort. The resident repeatedly reported pain, and family members observed the catheter pulling. Staff were unable to properly secure the catheter due to lack of knowledge about the securing device, leading to ongoing irritation at the insertion site.
A resident with a history of depression and anxiety disorder experienced increased confusion, which was observed by a CNA and should have triggered a Stop & Watch notification. However, the CNA did not inform the charge nurse, and no documentation or notifications were made to the physician or responsible parties, despite facility policy and the resident's care plan requiring such actions.
Nursing staff failed to follow physician orders for medication administration and monitoring for two residents. In one case, an LVN did not check a resident's blood pressure in the required supine position before giving Droxidopa. In another, blood sugar checks were not performed or documented before insulin administration as ordered. The DON confirmed these lapses, and facility policy requires staff to demonstrate competency in such procedures.
A nurse failed to perform hand hygiene after removing gloves and before donning new gloves while caring for a resident who was totally dependent for ADLs and had multiple complex medical conditions. The nurse and DON both acknowledged that hand hygiene should have been performed, as required by facility policy.
A resident with a full code status was found unresponsive and staff failed to follow emergency procedures, including immediate activation of code blue, checking vital signs, and use of the AED. The CNA left the resident unattended to notify nurses, and although CPR was started, the AED was not used due to lack of staff training. This resulted in the resident's death and placed other full code residents at risk.
Three residents with significant physical and/or cognitive impairments were found with call lights out of reach, including one with hemiplegia and blindness, another with cerebral ischemia and muscle weakness, and a third with similar dependencies. Staff interviews and facility policy confirmed that call lights should be accessible at all times, but observations showed they were not, requiring staff intervention to correct placement.
A resident with diabetes and a history of refusing blood sugar checks was not monitored for signs and symptoms of hypoglycemia or hyperglycemia, despite physician orders and care plan interventions. Documentation and staff interviews confirmed that required monitoring and documentation were not performed, and the resident was later found in cardiac arrest with a critically high blood sugar level.
A resident with multiple medical conditions did not receive wound care as ordered by the physician, including the application of urea cream and wrapping of both lower extremities. The responsible LVN did not document the treatment in the TAR for several days, and both the LVN and DON confirmed that the care was not provided or recorded as required by facility policy.
A resident with a suprapubic Foley catheter was found to have cloudy, amber urine with sediments in the drainage bag. Nursing staff observed these signs but did not follow established protocols for assessment, physician notification, and specimen collection, resulting in a failure to ensure the resident was free from signs of urinary tract infection.
The facility failed to ensure timely medication administration for two residents due to insufficient staffing. One resident reported delays in receiving pain medication, while another experienced significant delays in scheduled medications. LVNs cited high resident numbers and frequent interruptions as reasons for the delays. The facility's policy requires sufficient staffing, but current levels were inadequate.
The facility failed to administer medications on time and as prescribed to several residents, with some medications being crushed without a physician's order. Staffing issues and frequent interruptions during medication passes contributed to these deficiencies.
A resident's medications were improperly administered by crushing them together without a physician's order, including an extended-release medication, in an LTC facility. The resident, with conditions such as hypertension and atrial fibrillation, preferred crushed medications for easier swallowing. However, the facility's pharmacy consultant confirmed that one medication should not be crushed, highlighting a failure in adhering to medication management protocols.
A facility failed to create a baseline care plan for a resident with diabetes within 48 hours of admission, as required by policy. The resident, admitted with type 2 DM, endocarditis, and chronic kidney disease, did not have a timely care plan, leaving staff without guidelines for managing the resident's diabetes. The DON acknowledged the oversight, which was contrary to the facility's policy.
A resident with diabetes receiving insulin injections did not have physician orders for blood sugar monitoring, as required by their care plan. The resident was admitted with conditions including diabetes and chronic kidney disease, but their medication administration record showed no blood sugar monitoring. The deficiency was noted when the resident became unresponsive with low blood sugar, necessitating hospital transfer. The DON confirmed the absence of monitoring orders and initial assessment, contrary to facility policy.
A resident with Influenza A and asthma was not properly monitored for respiratory rate, temperature, and O2 saturation as required by their care plan. Several entries were missing from the resident's records, which were essential for assessing their condition. An LVN confirmed the absence of these critical measurements, which were necessary to determine if the resident's symptoms were improving or worsening.
A resident in an LTC facility did not receive medications within the prescribed time frame, as required by the facility's policy. The resident's medications, including aspirin, famotidine, and atorvastatin, were frequently administered several hours late, as confirmed by the Medication Administration Audit Report and interviews with the resident and the DON. The facility's policy mandates that medications be given within one hour of the scheduled time, which was not adhered to in this case.
A resident's request for access to medical records was not fulfilled in a timely manner, violating their rights. Despite being alert and oriented, the resident's request to view and send records to a representative was delayed due to a misunderstanding of facility policy and payment requirements. The records were eventually sent after corporate approval, highlighting discrepancies in the facility's handling of such requests.
A resident with knee immobilizers did not receive timely follow-up care from an orthopedic surgeon, leading to a delay in adjusting the knee hinged brace as per the surgeon's instructions. The resident was unable to start bending his knees as scheduled, causing frustration and potential decline in mobility. The facility's Director of Rehabilitation and Director of Nursing acknowledged the importance of timely follow-up to ensure proper care and mobility progression.
A resident requested the influenza vaccine, but the facility failed to administer it, as there was no documentation of communication with the pharmacy or vaccine administration. The resident was alert and oriented, and the facility's policy required offering the vaccine annually to all residents without contraindications. The DON acknowledged the oversight.
A resident at an LTC facility experienced the loss of personal belongings, including a purse, laptop, and checkbook, and expressed feelings of sadness and irritation. Despite the resident's capacity to make medical decisions and need for substantial assistance with daily activities, the facility failed to develop a care plan to address the incident or provide emotional support, as confirmed by staff interviews and contrary to the facility's policy.
Improper Disposal of PPE Outside Resident Room
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program when a CNA did not discard used personal protective equipment (PPE) in a designated trash bin inside a resident room. During observation in the hallway near a specified room, the CNA was seen exiting the room carrying a used gown and discarding it in a trash bin located across the hallway, rather than disposing of it inside the room. In a subsequent interview, the CNA acknowledged that PPE should have been discarded in the room but stated there was no trash bin available there, and further stated that disposing of PPE inside the room helps prevent the spread of infection and that failure to use a designated bin could increase the risk of cross-contamination and make residents sick. The Infection Prevention Nurse confirmed in an interview that PPE is to be discarded in a designated trash bin inside the room to prevent spread of infection from that room and stated that not using dedicated in-room trash bins could increase the risk of spreading infection to other residents. Review of the facility’s undated PPE policy indicated that training on proper donning, use, and disposal of PPE is provided upon orientation and at regular intervals.
Failure to Complete Admission Inventory of Personal Belongings
Penalty
Summary
The facility failed to protect a resident's personal property by not completing an Inventory of Personal Effects upon admission as required. The resident was admitted with diagnoses including a left artificial knee joint, anxiety disorder, and depression. The California Standard Admission Agreement stated that each resident must identify their personal property inventory in writing on a form provided by the facility. The resident's History and Physical and Minimum Data Set documented that the resident had capacity to understand and make medical decisions, had no cognitive impairment, and no change in mental status, delusions, or hallucinations. Review of the resident's progress notes for the admission month did not indicate that the resident brought in personal belongings at the time of admission. The Inventory of Personal Effects form for the resident, dated several weeks after admission, listed multiple belongings including clothing items, blankets, a wallet/purse, laptop with mouse, phone, seated walker, and wheelchair, but did not show that belongings were inventoried upon admission. During an interview and observation, the resident reported arriving with bags of clothing that went missing during the stay, including a favorite t-shirt, striped shorts, other t-shirts, pants, socks, and a jacket, and stated that staff did not label clothing, provide a personal inventory form, or record belongings at admission. No large plastic bags of clothing were observed in the resident's room or closet. A CNA stated that CNAs and licensed nurses were responsible for documenting residents' personal items on the Inventory of Personal Effects form upon arrival and that all inventory changes must be recorded to avoid items going missing or being stolen.
Failure to Ensure Availability of Prescribed PRN Anti-Anxiety Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed PRN anti-anxiety medication, alprazolam, was available and could be administered as ordered for one resident. The resident was admitted with diagnoses including a left artificial knee joint, anxiety disorder, and depression, and was documented on the H&P as having capacity to understand and make medical decisions, with the MDS showing no cognitive impairment or change in mental status. Physician orders dated 12/17/2025 prescribed alprazolam 0.5 mg once daily PRN for anxiety manifested by episodes of inability to relax, with instructions for nurses to monitor episodes every shift, document non-drug interventions, and document effectiveness. Review of the MAR showed no alprazolam administration from 12/17/2025 through 12/29/2025, and progress notes did not show that licensed nurses contacted the pharmacy to obtain the medication during that period. The resident reported requesting alprazolam several times between 12/17/2025 and 12/27/2025 and being told by an LVN that the medication was not available; staff offered non-pharmacological interventions that were not always effective, and the resident stated that not having the medication worsened his anxiety and caused frustration and discouragement. The pharmacist stated she received the alprazolam order on 12/19/2025 but could not dispense it because it lacked the required handwritten physician signature, and that facility staff did not contact the pharmacy about the order from 12/20/2025 through 12/28/2025; a signed order was not provided until 12/29/2025, when the medication was sent. The pharmacist and RN confirmed alprazolam was not stocked in the e-kit, so no emergency supply was available. The DON and RN acknowledged that the resident did not have access to alprazolam as ordered from 12/17/2025 through 12/28/2025, that PRN medications should be in stock within two days of admission, and that the facility’s “Administering Medications” policy requiring safe and timely administration as prescribed could not be followed during that time.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident who had recently undergone left hip hemiarthroplasty following a femur fracture. Documentation review showed that the resident required varying levels of assistance with activities of daily living (ADLs), including being dependent for toileting hygiene, requiring maximum assistance for bathing, and moderate assistance for bed mobility and transfers. Despite these needs being documented in the resident's Minimum Data Set (MDS) and other records, the baseline care plan addressing these needs was not created until more than 48 hours after admission, contrary to the facility's policy and procedure. Interviews with facility staff confirmed that the baseline care plan was delayed, and as a result, the care team may not have been fully informed of the resident's specific needs for supervision, behavioral interventions, and assistance with ADLs during the initial period after admission. The Medication Administration Record indicated ongoing monitoring for pain, anticoagulant therapy, and depression, but these interventions were not incorporated into a baseline care plan within the required timeframe. The lack of a timely baseline care plan was acknowledged by nursing staff, who stated that this could have resulted in the resident's needs not being met appropriately.
Failure to Monitor and Assess Post-Surgical Wound Leading to Infection and Dehiscence
Penalty
Summary
The facility failed to provide care in accordance with professional standards and the resident's person-centered care plan for a resident admitted with a left hip surgical incision following hemiarthroplasty. Upon admission, the resident's care plan required monitoring for signs of infection and skin breakdown at the surgical site, but documentation and interviews revealed that staff did not consistently assess or document the condition of the wound. The Treatment Administration Record (TAR) lacked evidence of daily monitoring for infection, and weekly wound measurements and assessments were not performed as required by facility policy. Additionally, the baseline care plan was not developed in a timely manner, and interventions for monitoring infection were not implemented or documented. The resident experienced multiple episodes of significant pain at the surgical site, which were recorded in the Medication Administration Record (MAR), but the location, quality, and aggravating factors of the pain were not assessed or documented by licensed nurses. Despite repeated reports of pain, there was no indication that the surgical wound was evaluated for changes in condition or signs of infection during these episodes. Both the physician and physician assistant did not assess the wound directly, relying instead on nursing staff, who only observed the dressing and not the underlying incision. This lack of direct assessment contributed to a failure to identify early signs of infection or wound complications. The resident's follow-up appointment with the surgeon was not scheduled in a timely manner as ordered, and the wound was not evaluated by a wound care specialist until after dehiscence occurred. When the resident eventually developed wound dehiscence with drainage and increased pain, the issue was not promptly addressed by staff, leading the resident to call emergency services independently. Subsequent hospital evaluation confirmed infection and required surgical intervention. Interviews with staff and review of facility policies confirmed that required assessments, documentation, and communication regarding the resident's wound status were not performed as outlined in the care plan and facility protocols.
Failure to Implement Physician's Orders for Pain Management
Penalty
Summary
The facility failed to implement the physician's orders for pain management for one resident following a left hip hemiarthroplasty. The resident had a history of left femur fracture, generalized anxiety disorder, and polyneuropathy, and was admitted for aftercare following joint replacement surgery. Physician orders required staff to document non-pharmacological interventions for pain, such as heat, repositioning, relaxation breathing, food/fluid, massage, exercise, and immobilization, and to document the results. The orders also specified that Tramadol 50 mg could be administered every six hours as needed for moderate to severe pain rated 5 to 10 out of 10. The resident's care plan and physician orders further required pain monitoring every shift and documentation of non-pharmacological interventions and their results. Record review revealed that the resident experienced moderate pain on several occasions, but there was no documentation that non-pharmacological interventions were offered or provided as required by the physician's orders. Additionally, the Medication Administration Record (MAR) showed that the resident received Tramadol on multiple occasions when reporting 0/10 pain, which did not meet the prescribed parameters. Interviews with nursing staff confirmed that non-pharmacological interventions were not consistently offered or documented, and that pain medication was administered outside of the physician's order parameters. Further interviews with the resident and medical staff corroborated that non-pharmacological pain management interventions were not offered when the resident reported pain and discomfort. The facility's policies required documentation of non-pharmacological interventions and administration of medications in accordance with prescriber orders, but these were not followed. The deficiency was identified through review of records, interviews with staff and the resident, and examination of facility policies.
Failure to Provide Menu-Specified Protein Item to Residents
Penalty
Summary
The facility failed to provide the pork sausage patty as indicated on the menu and meal tickets for two residents during breakfast service. Both residents had meal tickets and dietary profiles that specified a regular diet with no restrictions or dislikes for pork or sausage, and both were assessed as needing adequate protein and calorie intake due to their medical conditions. Observations confirmed that the breakfast trays delivered to these residents did not include the sausage patty, despite it being listed on their meal tickets and the facility's approved menu. For the first resident, documentation showed diagnoses including generalized muscle weakness, anemia, and chronic kidney disease, with a care goal to maintain optimal oral intake and avoid significant weight change. The resident was cognitively intact and had no dietary restrictions. During the breakfast meal observation, the resident expressed disappointment at not receiving the sausage patty. The Dietary District Manager (DDM) and Registered Dietitian (RD) confirmed that the resident should have received the sausage patty as per the menu and meal ticket, and that staff are responsible for ensuring trays match the meal tickets before delivery. The second resident had diagnoses of muscle weakness, respiratory failure, and COPD, with a care plan to improve nutritional status and tolerate a high-protein diet. The resident's nutrition assessment indicated moderate protein-calorie malnutrition and a goal to gain weight. The breakfast tray delivered did not contain the sausage patty, and the resident expressed feeling disheartened. Staff interviews revealed that the sausage patty was not included as required, and the DDM and RD confirmed this was not in accordance with the resident's dietary order. The failure to provide the specified menu item was observed and acknowledged by dietary and nursing staff.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to ensure that a resident's food preferences were honored during meal service. Despite documentation in the resident's Dietary Profile and Meal Ticket indicating dislikes for orange juice and hot cereal, these items were included on the resident's breakfast tray. The resident, who was cognitively intact and able to express her preferences, reported the issue to a CNA, who removed the orange juice but left the hot cereal. The Dietary Services Supervisor later confirmed that the tray still contained hot cereal, which was on the resident's dislike list. A review of the facility's policy and procedure on Dining and Food Preferences indicated that residents who refuse certain foods should be offered alternative selections of comparable nutritive value. The Registered Dietitian confirmed that the policy was not followed in this instance, as the resident received food items she had specifically indicated she disliked. This failure resulted in the resident feeling angry and distressed, and constituted a violation of her rights.
Inaccurate Documentation of Surgical Site and Wound Assessment
Penalty
Summary
The facility failed to maintain accurate and consistent documentation for a resident who had undergone left hip hemiarthroplasty. Record reviews revealed discrepancies in the resident's medical records, including conflicting information about the location of the surgical site, the presence of hematuria, and the timing and identification of wound dehiscence. For example, the Inter-Facility Transfer Report and admission records indicated a left hip surgical site, but a Daily Body Check incorrectly documented treatment on the right hip. Additionally, a nurse misinterpreted 'hematuria' as bloody discharge from the surgical site, when it actually refers to blood in the urine, leading to inaccurate wound assessment documentation. Further inconsistencies were found in the documentation of the resident's change of condition, with the timing of wound dehiscence being incorrectly recorded as occurring in the morning instead of the afternoon. Interviews with the Treatment Nurse and Director of Nursing confirmed these documentation errors. The facility's policy requires nursing documentation to be accurate and based on the resident's condition, but these standards were not met in this case.
Failure to Provide Timely Incontinent Care Resulting in Resident Left in Soiled Linens
Penalty
Summary
A resident was observed lying in bed with a diaper and bed linen soaked with urine, and was seen scratching her buttocks area while wearing a hand mitten. The Certified Nurse Assistant (CNA) present stated that he had not provided the resident with morning care or a diaper change. The resident's Minimum Data Set (MDS) indicated she was dependent on staff for toileting and personal hygiene and was incontinent of both bowel and bladder. The care plan for the resident specified that staff were to assist with perineal care as needed to maintain dignity, comfort, and prevent complications related to incontinence. During the interview, the CNA admitted to checking on the resident at the start of his shift but did not check her diaper. He acknowledged that failure to provide timely incontinent care could result in skin redness, irritation, and wounds. The facility's policy on perineal care emphasized the importance of cleanliness and comfort to prevent infections and skin irritation. The failure to provide timely incontinent care as outlined in the care plan and facility policy led to the resident remaining in soiled linens and a wet diaper.
Failure to Post Current Nurse Staffing Information Daily
Penalty
Summary
The facility failed to ensure that the Direct Care Service Hours Per Patient Day (DHPPD) information, which includes the updated census and number of staff on duty, was posted daily as required. During an observation and interview at Nursing Station 1, the DHPPD posted was found to be three days old, and the Director of Staff Development acknowledged that the information was not current and should be updated daily. The facility's policy and procedure requires that nurse staffing data for each shift, including the number of licensed and unlicensed nursing personnel responsible for direct care, be posted in a prominent and accessible location within two hours of the beginning of each shift. This deficiency was identified through observation, interview, and review of facility policy.
Improper Labeling and Storage of Medications and Supplements
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals for two residents. For one resident, multivitamin supplements were stored in the medication cart with only the room number as an identifier, lacking the resident's name and date of birth. Both a registered nurse and a licensed vocational nurse confirmed that supplements and medications should be labeled with the resident's name and date of birth, as per facility practice, to prevent potential mix-ups if a resident is moved to another room. For another resident, a box containing morphine sulfate solution was found in the medication cart with a medication label belonging to a different, previously discharged resident. A licensed vocational nurse acknowledged that this labeling error could lead to medication errors. The facility's policy requires that all medications, including nonprescription items, be labeled with the resident's name and that containers with confusing or incorrect labels be returned to the pharmacy or destroyed.
Failure to Update Physician Orders and Complete Admission Skin Assessment
Penalty
Summary
The facility failed to ensure that physician orders were updated for a resident when licensed staff received a telephone order regarding medication administration. Specifically, the physician orders for a resident with a g-tube and swallowing difficulties did not reflect a new order allowing medications to be given by mouth. Despite a physician communicating via text that oral administration was permitted, this change was not transcribed into the resident's official orders. Both a Licensed Vocational Nurse and a Registered Nurse confirmed that the order to administer medications orally was missing from the resident's record, and acknowledged the importance of updating orders to ensure safe medication administration. Additionally, the facility did not complete an initial body check for another resident upon admission, resulting in incomplete documentation of the resident's skin status. The resident, who had multiple diagnoses including muscle weakness, diabetes, and chronic kidney disease, was at risk for pressure ulcers and had a documented deep tissue injury. The required skin assessment was not performed or documented on the day of admission, as confirmed by a Registered Nurse during record review and interview. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and timely, and that newly admitted residents should have their skin examined for existing conditions. In both cases, the lack of timely and complete documentation led to incomplete medical records for the residents involved.
Improper Disposal of PPE Gown Outside Resident Room
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed exiting the room of two residents while still wearing a used PPE gown, which was then removed and discarded in a linen hamper located in the hallway outside the residents' room. According to interviews with the LVN, the Infection Prevention Nurse (IPN), and the Interim Director of Nursing (IDON), the proper procedure is to remove and dispose of used PPE inside the resident's room to prevent cross contamination and the spread of infections. The facility's policy and procedure on PPE gowns, revised in December 2023, also specifies that soiled gowns must be removed and discarded in appropriate receptacles located in the room or work area before leaving. This incident demonstrates a failure to follow established infection prevention and control protocols, as staff did not dispose of used PPE in the designated area within the resident's room. The deviation from policy was confirmed through direct observation, staff interviews, and review of facility procedures, all of which indicated that disposing of PPE in the hallway constitutes a break in infection control practices.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 23 out of 36 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms. During a facility tour and observation, it was noted that residents in these rooms were able to move in and out and had space for their personal property. However, a review of the facility's Client Accommodations Analysis form, completed by the Maintenance Director, confirmed that these rooms did not meet the space requirement. The Administrator acknowledged that the rooms were out of compliance with the square footage standard, although stated that resident care was not affected. Documentation reviewed included a waiver request letter submitted by the administrator, which listed the specific rooms and their square footage, confirming the deficiency.
Failure to Provide Menu Access and Food Choices to Bed or Chair Bound Residents
Penalty
Summary
The facility failed to ensure that all residents, including those who are bed or chair bound, had access to the weekly menu and list of alternative meal choices. Menus were posted only outside the kitchen, making them inaccessible to residents with physical limitations. Two residents with decision-making capacity and varying levels of assistance required for eating reported not being aware of the menu or alternative choices, and stated they had not been offered food options since admission. Both residents indicated they would have liked to know about or choose different food items, but instead ate what was served to them without being informed of alternatives. Interviews with staff confirmed that menus were only available on the wall outside the kitchen, and that Certified Nursing Assistants could bring menus to residents if requested. However, this process relied on residents knowing to ask, which did not occur for the affected individuals. Facility policies indicated that residents have the right to communication and access to services, and that menus should reflect resident choices, but these were not followed in practice for residents with physical limitations.
Call Light Not Accessible to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. The resident in question had diagnoses including dementia, schizoaffective disorder, and gastro-esophageal reflux disease, and was assessed as having severe cognitive impairment with a need for substantial to maximal assistance for activities such as showering, toileting hygiene, and dressing. During an observation, the call light was found hanging behind the resident's bed and not accessible to the resident. Interviews with both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light was not within reach and acknowledged the importance of accessibility for the resident to communicate needs. The facility's policy and procedures require that call lights be accessible to residents when in bed, but this was not followed in this instance, resulting in the deficiency.
Failure to Revise Care Plan After Change in Medication Administration Route
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of dysphagia, GERD, and a g-tube, after the physician authorized a change in medication administration from g-tube to oral route. The resident's care plan continued to reference interventions for swallowing food and drinks, such as maintaining an upright position and encouraging small sips or bites, but did not address the new order for oral medication administration. Additionally, the care plan for dysphagia only included speech therapy interventions and did not specify what actions staff should take when administering medications by mouth, despite the resident's ongoing risk for swallowing difficulties. Interviews with the medical doctor and registered nurse confirmed that the care plan was not updated to reflect the change in medication administration, which could lead to confusion among staff. The facility's policy required comprehensive care plans to be developed and revised based on identified problem areas and changes in resident status, but there was no specific policy for revising care plans when triggers or changes occurred. The deficiency was identified through record review and staff interviews, and it was noted that the lack of care plan revision had the potential for repeat occurrences.
Failure to Follow Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to follow a physician's order regarding the administration of losartan for a resident with a history of syncope and hypertension. The physician's order specified that losartan should be held if the resident's systolic blood pressure (SBP) was less than 110 mmHg. Despite this, documentation showed that the resident received losartan on two occasions when her SBP was recorded as 105 mmHg and 100 mmHg, both below the threshold set by the physician. A review of the resident's records confirmed that the medication was administered contrary to the order, and this was acknowledged by the Licensed Vocational Nurse (LVN) involved, who stated that the medication should not have been given under those circumstances. The facility's policy on medication administration requires that medications be given in accordance with physician orders, which was not followed in this instance.
Failure to Assist Resident Out of Bed for Meals as Ordered
Penalty
Summary
The facility failed to ensure that a resident was taken out of bed during mealtimes as ordered by the physician. The resident, who had diagnoses including epilepsy, cerebral infarction, dysarthria, and diabetes mellitus, was dependent on staff for all activities of daily living and had limited range of motion in both upper and lower extremities. Despite a physician order specifying that the resident should be taken out of bed daily during mealtimes, observations over several days showed the resident remained in bed while eating. The care plan did not include the intervention to remove the resident from bed during meals, and staff interviews revealed a lack of awareness of the physician's order. The resident expressed a desire to be taken out of bed to eat if staff would assist, and staff acknowledged the importance of this intervention for the resident's mobility and well-being. The facility's policy required care and services to maintain or improve residents' ability to carry out activities of daily living, including mobility and dining. However, the failure to follow the physician's order and update the care plan resulted in the resident not being provided the opportunity to eat out of bed, potentially impacting her functional abilities.
Physician Review of Pharmacist Medication Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's recommendation following a monthly Medication Regimen Review (MRR) for a resident with atrial fibrillation and heart failure. The resident was prescribed amiodarone and carvedilol, both of which can affect heart rate, and the pharmacist recommended monitoring for signs of bradycardia due to the combined effects of these medications. However, there was no documentation indicating that the physician had reviewed or responded to the pharmacist's recommendation for the month of May. Interviews and record reviews revealed that the MRR was typically kept in the DON's office, and staff would inform the physician of any recommendations if requested. In this instance, the responsible RN was not asked to review the MRR, and the DON had resigned, resulting in a lack of follow-up. Facility policy required that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with the physician expected to accept, act upon, or reject the suggestion by the next visit. This process was not followed for the resident in question.
Failure to Administer Clonidine as Ordered for Hypertensive Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering clonidine as ordered for high blood pressure. The medication order specified that clonidine 0.1 mg should be given by mouth every six hours as needed for systolic blood pressure greater than 150. Review of the Medication Administration Records (MAR) for March, April, May, and June showed that although blood pressure was checked every six hours as ordered, there were 33 instances where clonidine was not administered when indicated, as evidenced by blank spaces on the MAR where nurse initials should have been recorded after administration. The resident involved had a history of hypertension, cardiac arrhythmia, and hyperkalemia, and required substantial to maximal assistance with activities of daily living. Interviews with the resident revealed that he was not aware of whether clonidine was given and relied on nursing staff for medication administration. An LVN confirmed that the medication was not given as ordered and acknowledged the potential for serious consequences. Facility policy required medications to be administered according to physician orders and for the MAR to be properly documented, which was not followed in this case.
Failure to Prevent Mental Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from mental abuse and did not follow its own Abuse Prohibition Policy and Procedure. One resident, who had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety disorder, reported being subjected to repeated verbal outbursts and threatening behavior from a roommate with a history of psychiatric and mood disorders, including bipolar disorder and PTSD. The roommate exhibited aggressive and verbally abusive behavior, including yelling, using profanity, and, on one occasion, placing a hand on the resident's shoulder and picking up a butter knife in a threatening manner. These actions caused the resident to feel uncomfortable and unsafe. Staff interviews and record reviews revealed that the roommate had a documented history of behavioral issues, including agitation and verbal abuse toward others. The care plan for the roommate included monitoring for aggression and agitation, and the resident was placed on one-to-one supervision to prevent further incidents. However, on the day of the incident involving the butter knife, the assigned CNA stepped away from the room, leaving the roommate unsupervised. This lapse in supervision allowed the altercation to occur, during which the resident was threatened and felt intimidated. The facility's Abuse Prohibition Policy and Procedure explicitly prohibits mental abuse, including threats and conduct that can cause intimidation or fear. Staff acknowledged that the actions of the roommate constituted mental abuse according to the policy and that the lack of supervision contributed to the incident. The failure to maintain required supervision and prevent abusive behavior resulted in the resident experiencing mental abuse and feeling unsafe in their environment.
Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a femur fracture of unknown origin for a resident to the California Department of Public Health (CDPH), resulting in a delay of investigation by the state agency. The resident, who had diagnoses including osteoarthritis of the hip, end stage renal disease, and was on dialysis, was found to have a right femur fracture after complaining of increased pain in her lower back, hips, and right leg. The x-ray confirmed the fracture, and both the family and physician were notified. The resident was cognitively intact and denied any fall, rough handling, or abuse, stating she did not know how the fracture occurred. Nursing staff, upon receiving the x-ray results, questioned the resident about possible causes, all of which she denied. The Director of Nursing and the Administrator were informed of the situation. The Administrator interviewed the resident, who again denied any incident or abuse, and the Administrator relied on the physician's assessment that the fracture was pathological due to the resident's long-term dialysis and underlying medical conditions. Based on this information, the Administrator determined that the incident did not meet the criteria for reporting as an unusual occurrence or injury of unknown origin. A review of the facility's policy indicated that all unusual occurrences are to be reported to the appropriate state agency within 24 hours. Despite this, the incident was not reported to CDPH, as the facility leadership believed the cause of the fracture was known and not suspicious. This decision was made even though the origin of the fracture was not clearly identified by the resident or staff, and the event was not reported as required by policy.
Failure to Follow Safety Protocols During Resident Care on Low Air Loss Mattress
Penalty
Summary
Certified nurse assistant (CNA) 5 failed to follow established safety protocols while providing care to a resident who was dependent on staff for all mobility and had moderately impaired cognition. The resident, who had muscle weakness and encephalopathy, was ordered to use a low air loss mattress (LALM) for skin management. During a routine care activity, CNA 5 changed the resident on the LALM without placing the mattress in static mode and without the required two-person assistance. As a result, the resident rolled off the bed and fell to the floor. Interviews and record reviews confirmed that facility policy and in-service training required the LALM to be set to static mode and a two-person assist to be used when changing immobile residents on this type of mattress. CNA 5 admitted to not being aware of these requirements at the time of the incident. The incident was corroborated by progress notes and staff interviews, which highlighted the deviation from established procedures intended to prevent such accidents.
Failure to Timely Document Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to document the administration of seven scheduled medications for a resident with a history of cerebral infarction, hemiplegia, and diabetes. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had medications scheduled for 9:00 a.m. that were not documented as given in the Medication Administration Record (MAR). During an interview and record review, the LVN confirmed that the medications were administered but not documented due to being busy, and acknowledged that documentation should occur at the time of administration. The facility's policy and procedure for administering medications requires the individual administering the medication to initial the MAR after giving each medication and before administering the next. The lack of timely documentation resulted in no indication that the resident received the medications, as evidenced by the MAR showing the medications in red, which signifies they were late or not given. This failure to document as required constituted the identified deficiency.
Missed Timely Administration of Insulin Dose
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and diabetes was admitted and readmitted to the facility, requiring insulin for diabetes management. The resident's care plan specified insulin dependence and directed staff to administer hypoglycemic medications as ordered. The resident was assessed as having moderately impaired cognition and was dependent on staff for daily activities. On review of the Medication Administration Record (MAR), it was found that the resident's scheduled dose of Lispro, a fast-acting insulin, was not administered at the prescribed time. During an interview and record review, an LVN confirmed that the Lispro dose, scheduled for 1:00 p.m., was not given because the nurse was busy. The MAR indicated the missed dose by displaying it in red, which the LVN explained signified a late or omitted medication. Facility policy required medications to be administered within one hour of the scheduled time, but this was not followed. The LVN acknowledged that this constituted a medication error and that timely administration was necessary according to the prescriber's order.
Failure to Address and Manage Resident Pain Related to Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to relieve pain for a resident with obstructive and reflux uropathy and an indwelling catheter. The resident was admitted with diagnoses including obstructive and reflux uropathy and difficulty walking, and was assessed as able to understand and communicate needs. Orders were in place for acetaminophen as needed for moderate to severe pain, but there was no order to monitor pain levels. The resident's medication administration record showed that pain medication was not administered on several days when the resident reported pain. Multiple observations and interviews revealed that the resident experienced significant penile pain related to the Foley catheter, which was not properly secured, causing pulling and discomfort. The resident reported pain to CNAs and LVNs over several days, but no action was taken to address the pain or administer pain medication. Family members also observed the resident's discomfort and reported that the pain was affecting the resident's ability to participate in physical therapy and daily activities. Staff interviews confirmed that the pain was reported but not addressed, and the resident's pain was only acknowledged and treated after several days of complaints. Physical therapy notes indicated the resident declined therapy sessions due to pain, and staff confirmed that the pain and refusal to participate were reported to nursing staff. The DON acknowledged that the resident's pain was not addressed as required, and the MAR confirmed a lack of pain medication administration during the period of reported pain. The facility's policy required care that promotes resident well-being and dignity, but this was not followed in the resident's case.
Delay in Suprapubic Catheter Care Resulting in Resident Discomfort
Penalty
Summary
The facility failed to provide timely care and services for a resident with a suprapubic catheter, as required by physician orders and the resident's care plan. The resident, who had quadriplegia and neurogenic bladder, was dependent on staff for all activities of daily living and required her suprapubic catheter to be lavaged with 200 cc every Monday, Wednesday, and Friday during the day shift. On the day in question, the resident began requesting the catheter flush at 10:00 a.m., but the procedure was not performed by 3:20 p.m. despite multiple requests. The resident reported increasing abdominal spasms and discomfort due to the delay. Staff interviews revealed that the treatment nurse was absent, and coverage was uncertain. The registered nurse acknowledged being too busy with other admissions and discharges to perform the catheter flush as scheduled. The facility's policy required that residents receive care and services to maintain or improve their ability to carry out activities of daily living, but this was not followed in this instance, resulting in the resident experiencing discomfort and bladder spasms.
Failure to Assess and Manage Pain Related to Indwelling Catheter
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess and manage a resident's pain associated with an indwelling Foley catheter. The resident, who had diagnoses including obstructive and reflux uropathy and difficulty walking, was admitted with an order for acetaminophen as needed for moderate to severe pain. Despite repeated complaints of penile pain related to the catheter, there was no evidence that pain assessments were conducted or that pain medication was administered during several days when the resident reported discomfort. Physical therapy notes documented the resident's refusal to participate in therapy due to increased penile pain from the catheter, and family members also reported the resident's ongoing pain to staff. Observations revealed that the catheter was not secured properly, causing pulling and pain, and redness and white spots were noted at the insertion site. Staff interviews confirmed that the resident's pain was reported to nurses, but there was no documentation of follow-up, pain assessment, or consistent administration of pain medication. The facility's pain management policy required identification, assessment, treatment, and evaluation of pain to maintain resident comfort. However, the lack of timely assessment and intervention for the resident's pain resulted in unaddressed discomfort, refusal of therapy, and delayed recovery. The failure to secure the catheter and respond to pain complaints was directly observed and confirmed by multiple staff and family interviews.
Failure to Ensure Staff Competency in Securing Foley Catheter
Penalty
Summary
Nursing staff failed to demonstrate competency in securing a Foley catheter (FC) for a resident with obstructive and reflux uropathy, resulting in prolonged pain and discomfort. The resident, who was admitted with significant urinary tract issues and required an indwelling catheter, repeatedly reported pain at the catheter insertion site to both CNAs and LVNs over several days. Family members observed that the catheter was pulling and likely causing the pain, and staff confirmed the resident had been complaining of pain whenever the FC was touched or moved. Upon observation, redness and white spots were noted at the insertion site, and the FC was found unsecured. When attempts were made to secure the FC using a device, the assigned RN was unable to do so, admitting a lack of knowledge on how to use the securing device. The Director of Nursing later clarified that the facility did not use the specific securing device present and that staff should have replaced it with the device they were trained to use. The failure to secure the FC appropriately led to ongoing pain and irritation for the resident, as documented in interviews, observations, and record reviews.
Failure to Report Change in Resident Behavior
Penalty
Summary
The facility failed to report a change in behavior for one of three sampled residents. A certified nursing assistant (CNA) observed that the resident appeared more confused than usual and initiated a Stop & Watch notification, which is intended to alert staff to significant changes in a resident's condition. However, the CNA did not inform the charge nurse of these observed changes, and there was no documentation of a Stop & Watch notification in the resident's medical record or on the facility's dashboard. The Social Services Director was also not informed of any behavioral changes, and as a result, no referral to a psychologist or psychiatrist was made. The resident in question had a history of depression and anxiety disorder and was hospitalized for a urinary tract infection (UTI) following the observed change in behavior. The care plan for this resident included monitoring for changes in cognitive status and notifying the physician as needed. Despite these interventions being in place, the required notifications to the physician, resident, and resident representative were not made when the change in behavior occurred, as outlined in the facility's policy and procedures.
Failure to Ensure Nursing Staff Competency in Medication Administration and Monitoring
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to safely administer medications as ordered for two residents. In one instance, an LVN did not check a resident's blood pressure in the supine position as required before administering Droxidopa, a medication prescribed for orthostatic hypotension. Instead, the LVN measured the blood pressure while the resident was upright, despite the physician's order and a black box warning specifying the need for a supine reading. The Director of Nursing confirmed that the correct procedure was not followed, which could have resulted in an inaccurate assessment prior to medication administration. In another case, a resident with orders for insulin administration based on blood sugar levels did not have their blood sugar checked or documented at two specified times. The Medication Administration Record did not show evidence of blood sugar checks on the dates and times required by the physician's order. The DON acknowledged the absence of documentation and emphasized the importance of proper blood sugar monitoring and documentation for residents receiving insulin. Both incidents were identified through observation, interview, and record review. The facility's policy requires all nursing staff to meet specific competency requirements based on resident needs, as determined by assessments and care plans. The failures in these cases demonstrate that the nursing staff did not meet the required competencies for medication administration and monitoring as outlined in facility policy and physician orders.
Failure to Perform Hand Hygiene After Glove Removal
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene after removing gloves and before donning a new pair of gloves while providing care to a resident. The LVN was observed administering medications to a resident, removing her gloves, and then immediately putting on a new pair of gloves without washing her hands or using an alcohol-based hand sanitizer. This action occurred at the resident's bedside and was directly observed by surveyors. The resident involved had multiple medical conditions, including orthostatic hypotension, a gastrostomy tube, diastolic heart failure, and Parkinsonism, and was totally dependent on staff for activities of daily living. The facility's policy required staff to perform hand hygiene after removing personal protective equipment (PPE) and before resident contact, but this protocol was not followed. Both the LVN and the Director of Nursing acknowledged during interviews that hand hygiene should have been performed to prevent the spread of infection.
Failure to Implement Emergency CPR Procedures and AED Use for Full Code Resident
Penalty
Summary
Facility staff failed to implement their policy and procedure for emergency response and cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive in bed. A Certified Nursing Assistant (CNA) observed the resident was not breathing but left the resident unattended to notify Registered Nurses (RNs) instead of activating the code blue system or initiating immediate life-saving measures. The CNA did not check the resident's vital signs or pulse upon finding the resident unresponsive and did not activate the code blue as required by facility policy. When the RNs and a Licensed Vocational Nurse (LVN) responded, they initiated CPR but did not utilize the facility's Automated External Defibrillator (AED), despite the policy requiring staff to be trained in its use. One RN admitted to not knowing how to use the AED and confirmed that staff had not been trained on its use during CPR. The staff also failed to check and document the resident's vital signs and blood sugar during the code, even though the resident had a history of diabetes and other significant medical conditions. The facility's policy required all clinical staff to be trained and certified in Basic Life Support (BLS)/CPR, including the use of defibrillation, and to follow a specific sequence of actions during a code blue. However, interviews and record reviews revealed that staff were not knowledgeable or adequately trained in these emergency procedures, resulting in the failure to provide timely and appropriate life-saving interventions for the resident. This deficiency was identified as having resulted in the resident's death and placed other residents with full code status at risk.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three of nine sampled residents, as observed during multiple room visits. In one instance, a resident with hemiplegia, blindness in one eye, and epilepsy was found unable to reach the call light, which was tangled on the bed's siderail. The resident expressed the need for the call light to be accessible to request assistance, such as for water. A CNA confirmed the call light should be within reach and corrected the placement during the observation. Another resident, who was asleep and had diagnoses including cerebral ischemia and muscle weakness, was found with the call light hanging outside the bed and not accessible. The CNA placed the call light in the resident's hand upon noticing this. Both residents were dependent on staff for activities of daily living, transfers, and bed mobility, with one having cognitive impairment. A third resident, also dependent for ADLs and with cognitive impairment, was observed with the call light placed on top of the nightstand, out of reach. An LVN acknowledged that the call light should have been closer to the resident. Staff interviews confirmed that all facility staff are responsible for ensuring call lights are accessible and for responding to them promptly. Review of facility policy indicated that call lights must be accessible to residents when in bed, on the toilet, or during bathing.
Failure to Monitor Diabetic Resident for Hypo/Hyperglycemia Symptoms
Penalty
Summary
The facility failed to monitor a resident with a history of diabetes mellitus, including diabetic ketoacidosis and hyperglycemia, for signs and symptoms of hypoglycemia and hyperglycemia, despite physician orders and care plan interventions. The resident had documented refusals of blood sugar checks and insulin, and the care plan specifically directed staff to monitor for symptoms of blood sugar abnormalities. However, there was no documentation in the progress notes or other records indicating that staff monitored the resident for these symptoms, even when blood sugar checks were refused. Physician orders required blood sugar monitoring before meals and at bedtime, with insulin administration per sliding scale, and included protocols for managing hypoglycemia. Despite these orders, the resident's blood sugar was not checked at required times, and there was no evidence of staff monitoring for clinical signs of hypo- or hyperglycemia. The resident was later found in cardiac arrest with a critically high blood sugar level, and staff interviews confirmed the lack of monitoring and documentation for symptoms related to blood sugar abnormalities.
Failure to Follow Physician's Wound Care Orders and Document Treatment
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound care and did not document the treatment provided to a resident with hemiplegia, hemiparesis, obstructive and reflux uropathy, and chronic kidney disease. The physician's order specified that urea cream 40% should be applied to both lower extremities after a shower or bed bath, and the legs should be wrapped with kerlix every dayshift for 30 days. Observations and interviews revealed that the treatment nurse did not consistently apply the lotion or wrap the resident's legs as ordered. On multiple occasions, the resident's lower legs were not wrapped, and the resident reported that the treatment was not performed daily as prescribed. Review of the Treatment Administration Record (TAR) for several consecutive days showed no documentation of the wound care treatment. The LVN responsible for the care confirmed that she did not document the treatments on those days and acknowledged that if the treatment was not documented, it was not done. The Director of Nursing also confirmed the importance of following physician orders and documenting wound care in the TAR, as required by facility policy. The facility's policy stated that the name and title of the individual performing wound care should be documented in the clinical record.
Failure to Ensure Proper Catheter Care and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with a suprapubic Foley catheter was observed to have cloudy, amber-colored urine with visible sediments in the drainage bag. During the observation, a Licensed Vocational Nurse (LVN) acknowledged the presence of these signs and stated that the catheter needed to be irrigated. The resident's medical record indicated diagnoses including hemiplegia, obstructive and reflux uropathy, and chronic kidney disease. The resident was noted to have no cognitive impairment and required substantial assistance with activities of daily living. A physician's order was in place to irrigate the Foley catheter with 30ml as needed for maintenance. Further interviews revealed that facility protocol required daily assessment of the Foley catheter, and that any observation of amber urine, sediments, or cloudiness should prompt a change of condition report, physician notification, and urine specimen collection. The Director of Nursing confirmed that Foley catheters must be assessed every shift and that the physician should be notified if sediments are observed. The failure to follow these procedures resulted in the resident not being free from signs of urinary tract infection, as evidenced by the observed condition of the urine and drainage bag.
Medication Administration Delays Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) were able to administer medications timely as ordered by physicians for two of the five sampled residents. Resident 1, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease, reported not receiving her pain medication on time and had to personally request it at the nurses' station. Similarly, Resident 2, with diagnoses including hypertension and atrial fibrillation, experienced delays in receiving scheduled medications, with records showing significant delays on multiple occasions. Interviews with LVNs revealed that they were responsible for a high number of residents, which made it challenging to administer medications on time. LVNs reported interruptions during medication passes, such as responding to call lights and assisting residents, which contributed to the delays. The Director of Nursing stated that staff had not complained about the workload, and overtime was allowed with management approval. The facility's policy indicated that sufficient nursing staff should be provided to meet residents' needs, but the current staffing levels were inadequate to ensure timely medication administration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide medications to four out of five sampled residents in a timely manner and as ordered by the physician. Observations and interviews revealed that medications scheduled for 9:00 a.m. were administered several hours late to Residents 2, 3, 4, and 5. Licensed Vocational Nurse (LVN 1) and LVN 4 both reported difficulties in administering medications on time due to the high number of residents they were responsible for and frequent interruptions during medication passes. The Registered Nurse Supervisor confirmed that the medications were not administered as scheduled, which is against the facility's policy that requires medications to be given within one hour before or after the scheduled time. Additionally, the facility failed to ensure that medications were administered correctly to Resident 2. LVN 1 was observed crushing three medications, including an extended-release medication, and mixing them with applesauce before administering them to Resident 2. This practice was not supported by a physician's order and had the potential to alter the medication's intended release mechanism, potentially affecting its therapeutic efficacy. The facility's pharmacy consultant confirmed that the extended-release medication should not be crushed, as it could lead to immediate release and increased frequency of urination for Resident 2. The facility's policy and procedure on medication administration emphasize that medications should be administered as prescribed by the physician and that long-acting or enteric-coated dosage forms should not be crushed. The policy also states that the facility should have sufficient staff to allow for the administration of medication without unnecessary interruptions. However, the report indicates that staffing issues and interruptions during medication passes contributed to the deficiencies observed in the administration of medications to the residents.
Improper Medication Administration Due to Crushing Without Order
Penalty
Summary
The facility failed to ensure that medications for one of the residents were administered as ordered by the physician. Specifically, the staff crushed three medications together, including an extended-release medication, without a physician's order. This practice was observed during a medication administration session where a Licensed Vocational Nurse (LVN) crushed the medications and mixed them with apple sauce before administering them to the resident. The resident had been admitted with diagnoses including hypertension, atrial fibrillation, and anxiety disorder, and had the ability to make her needs known. The resident stated she preferred her medications crushed for easier swallowing, and the LVN confirmed this practice was followed without obtaining the necessary physician's order. The facility's pharmacy consultant later confirmed that one of the medications, Oxybutynin Chloride extended release, should not be crushed as it could alter its intended release mechanism. The facility's policy requires nursing staff to demonstrate competency in medication management, which includes adhering to physician orders and ensuring medications are administered correctly. The failure to follow these protocols placed the resident at risk of receiving an incorrect dosage and potentially experiencing adverse effects due to the altered release of the medication.
Failure to Create Timely Baseline Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to create a baseline care plan for a resident with diabetes within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, endocarditis, and chronic kidney disease, did not have a baseline care plan that included the necessary healthcare information to properly care for them immediately upon admission. This omission was identified during a review of the resident's records, which showed that the care plan for diabetes was only initiated several weeks after admission. The Director of Nursing acknowledged that the baseline care plan should have been created within the specified timeframe and should have contained the minimum information needed for the resident's care. The absence of a timely baseline care plan meant that staff lacked a guideline for managing the resident's diabetes, potentially impacting the resident's care. The facility's policy, dated August 2021, clearly stated the requirement for a baseline care plan to be developed within 48 hours of admission, but this was not adhered to in this case.
Failure to Monitor Blood Sugar Levels for Insulin-Dependent Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident receiving insulin injections by not obtaining and monitoring a physician order for blood sugar levels, as indicated in the resident's care plan. The resident, who was admitted with diagnoses including endocarditis, type 2 diabetes mellitus, and chronic kidney disease, was found to have no blood sugar monitoring orders despite receiving insulin NPH and insulin lispro. This oversight was identified during a review of the resident's order summary report and medication administration record, which showed no indication of blood sugar level monitoring. The deficiency was further highlighted when the resident experienced a change in condition, becoming pale and unresponsive with a blood sugar level of 64 mg/dL, leading to their transfer to a general acute care hospital. Interviews with the Director of Nursing confirmed the absence of blood sugar monitoring orders and the lack of initial assessment per the facility's policy and procedure. The facility's policy required the physician to order appropriate lab tests and incorporate monitoring parameters into the medication administration record and care plan, which was not done for this resident.
Failure to Monitor Vital Signs for Resident with Influenza A
Penalty
Summary
The facility failed to record the respiratory rate, temperature, and oxygen saturation (O2 sat) for one of two residents, identified as Resident 2. This resident was admitted with diagnoses including Influenza A and asthma, conditions that necessitate close monitoring of respiratory parameters. The care plan for Resident 2, dated 1/24/2025, indicated a risk for respiratory complications due to a positive Influenza A result, with a goal to prevent signs and symptoms of respiratory distress. An order was placed on 1/24/2025 to monitor Resident 2's respiratory rate, temperature, and O2 sat every 6 hours starting on 1/25/2025. However, upon review, it was found that several entries were missing from Resident 2's records. Specifically, there were no O2 sat readings documented on 1/25/2025 and 1/26/2025, and multiple entries were missing on 1/27/2025 and 1/28/2025. Similarly, there were missing entries for respirations and temperature on 1/25/2025 and 1/28/2025. During an interview, LVN 1 confirmed the absence of these critical measurements, which were essential for assessing whether Resident 2's flu symptoms were improving or worsening. The facility's policy on Pulse Oximetry, dated 10/2010, requires that O2 sat readings be documented with the date and time, but this was not adhered to in Resident 2's case.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services to a resident by not ensuring that licensed nurses adhered to the facility's policy and procedure for administering medications within one hour of their prescribed time. This deficiency was identified through interviews and record reviews, which revealed that the resident's medications were frequently administered several hours after the scheduled times. The medications involved included aspirin, famotidine, and atorvastatin, which were prescribed for conditions such as cerebrovascular accident, acid indigestion, and hyperlipidemia, respectively. The resident, who was alert and oriented, required setup assistance for daily activities and had intact cognitive skills for decision-making. Despite this, the Medication Administration Audit Report showed multiple instances where the resident's medications were administered late, ranging from two to six hours past the scheduled times. These delays were consistent over several days and involved both morning and evening doses of the medications. Interviews with the resident and the Director of Nursing confirmed the issue, with the resident expressing that the medications were often given late. The Director of Nursing acknowledged the problem, stating that medications should be administered within one hour of the scheduled time to ensure their effectiveness and minimize side effects. The facility's policy on administering medications also emphasized the importance of timely administration, which was not followed in this case.
Delayed Access to Medical Records Violates Resident Rights
Penalty
Summary
The facility failed to fulfill a request for access to medical records in a timely manner for a resident, which violated the resident's rights. The resident, who was alert and oriented, requested access to his medical records and for them to be sent to his representative. Despite the request being made on 11/18/2024, the records were not sent until 11/26/2024, causing frustration for the resident and his representative. The facility's policy stated that access to records should be provided within 24 hours and copies within two business days, but this was not adhered to. Interviews with the Medical Records Director (MRD), Director of Nursing (DON), and Administrator (ADM) revealed discrepancies in the facility's handling of the request. The MRD stated that records should be released within two business days, but the ADM indicated that no records would be released until payment was received. The DON clarified that electronic records should be free of charge and that the resident should have immediate access to view his records. The delay in releasing the records was attributed to a misunderstanding of the facility's policy and the requirement for payment, which was later waived by the corporate office.
Failure to Follow-Up with Orthopedic Surgeon in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up care from an orthopedic surgeon, which is a professional standard of practice. The resident, who was admitted with a diagnosis of rupture of other tendons and unspecified knee patellar tendinitis, was instructed by the orthopedic surgeon to begin bending his knees two weeks after a visit on 10/30/2024. However, the facility did not follow up with the orthopedic surgeon until 11/25/2024, 18 days after the resident's admission, to clarify the orders regarding the knee hinged brace and knee precautions. The delay in following up with the orthopedic surgeon resulted in the resident being unable to start bending his knees as instructed, leading to frustration and potential decline in mobility and range of motion. The Director of Rehabilitation acknowledged the importance of timely follow-up to adjust the knee hinged brace appropriately, as failure to do so could result in acute tightness and limited mobility. The Director of Nursing also confirmed that the standard of practice was to contact the orthopedic surgeon for treatment recommendations following surgery with a brace.
Failure to Administer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to administer the influenza vaccine to a resident who had requested it, placing the resident at risk for acquiring the influenza virus. The resident, who was alert and oriented, had requested the flu vaccine on November 7, 2024, as documented in their Consent to Administer Influenza Vaccine form. Despite this request, there was no documentation indicating that the facility staff communicated with the pharmacy to order the vaccine or that the vaccine was administered to the resident. During an interview, the Director of Nursing (DON) acknowledged the absence of documentation regarding the administration of the influenza vaccine to the resident. The facility's policy and procedure for the influenza vaccine stated that all residents without medical contraindications should be offered the vaccine annually. However, the facility did not follow through with this policy, as evidenced by the lack of action taken to ensure the resident received the requested vaccine.
Failure to Develop Care Plan for Lost Belongings
Penalty
Summary
The facility failed to complete a care plan for a resident who experienced the loss of personal belongings, including a purse, laptop, and checkbook, from her room. The resident, who was admitted with a fracture of the right femur, muscle weakness, and hypertension, was capable of making medical decisions and required substantial assistance with activities of daily living. Despite the resident expressing feelings of sadness and irritation due to the loss, the facility did not develop a care plan to address the incident or provide emotional support. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that a care plan should have been created to prevent future loss and address the resident's emotional needs. The facility's policy and procedure require the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet residents' needs. However, the facility did not adhere to this policy, resulting in a deficiency related to the lack of a care plan for the resident's lost belongings.
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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