Plaza Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 1209 Hemlock Way, Santa Ana, California 92707
- CMS Provider Number
- 055206
- Inspections on file
- 77
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Plaza Healthcare Center during CMS and state inspections, most recent first.
A resident with hand contractures and no decision-making capacity exhibited ongoing behaviors of swinging their arms at staff during ADL care, as reported by a CNA and an LVN, along with a history of removing Kerlix dressings and scratching/picking at skin. Despite facility policy requiring comprehensive, person-centered care plans to be reviewed and revised after assessments to address medical, nursing, mental, and psychosocial needs, the resident’s care plan did not include a problem or interventions related to these inappropriate behaviors toward staff. The DON confirmed that the care plan had not been updated to reflect these behaviors, and facility leadership acknowledged the findings.
A resident's medical record was found to be incomplete, with multiple required quarterly nursing assessments—including bed rails, bowel and bladder, elopement, falls, lift and transfer, self-administration of medications, smoking, vital signs and pain, Braden, and Section GG of the MDS—not completed as required by facility policy. Staff interviews confirmed the assessments were overdue and should have been completed, regardless of the resident's intermittent absences.
Three residents were not provided with reasonable accommodations for call light access and timely staff response. One resident, with a history of stroke and Parkinson's disease, was left without a urinal and did not receive assistance after activating the call light, resulting in soiled pull-ups. Two other residents, one with upper extremity impairment and another with psychiatric diagnoses, were found with call lights out of reach, preventing them from requesting help.
A resident who lacked decision-making capacity was administered psychotropic medications without proper informed consent. Consent for clonazepam was obtained directly from the resident despite documented incapacity, and the lorazepam consent form was incomplete, missing the reason and duration for use. The required Surrogate IDT Proposal of Medical Intervention was also not completed, and the DON confirmed these omissions.
Surveyors identified several food safety and sanitation issues, including undated and expired food items stored in freezers, a persistent water leak causing pooling near the trayline and stove, and staff failing to follow proper hand hygiene and hair restraint protocols. These deficiencies were confirmed by the Food Services Director and were not in line with the facility's infection control policies.
Staff failed to ensure meals were served according to physician-ordered diets when an LVN did not have access to the current list of resident diet orders during meal service. Another LVN confirmed the list was not available as required, resulting in meals not being properly checked before serving.
Two residents without fluid restrictions did not receive adequate hydration, as one was found without a water pitcher and another had an empty pitcher that was not refilled. Both residents expressed their needs for water, and staff confirmed the lack of available fluids.
The facility did not include specific staff competencies or behavioral training requirements in its assessment for caring for residents with psychiatric disorders. A CNA reported not receiving formal training and relied on instinct during behavioral episodes, with no documentation of behavioral training found in her file or the facility's records.
Surveyors identified multiple failures in kitchen sanitation, including dirty and damaged utensils, improper air drying and storage of food containers and blenders, unsanitary food preparation surfaces, and unclean equipment such as the microwave, can opener, and ice machine. All residents consumed food prepared in these conditions, and staff acknowledged that these practices did not meet required standards, creating potential for cross contamination and foodborne illness.
A resident with severe cognitive impairment and a left hip pressure injury was found lying on a LAL mattress set incorrectly to static mode and a weight range far above their actual weight. The resident was also observed with multiple layers of bedding, an absorbent pad, and an incontinent brief, contrary to facility policy and care plan instructions. Staff interviews confirmed a lack of clarity regarding proper mattress settings and appropriate bedding use, resulting in care that did not align with prescribed wound management protocols.
A resident with decision-making capacity was administered temazepam, a psychotropic medication, on multiple occasions without documented informed consent as required by facility policy. Nursing staff confirmed that new or changed PRN orders for psychotropic medications require new consent, but the medical record lacked evidence of consent for several orders, and one consent form did not indicate who provided consent.
A resident reported feeling harassed and threatened by another resident, but the facility administrator did not report the allegation to required authorities as mandated by facility policy and regulations. Medical records and staff interviews confirmed the incident met the criteria for emotional abuse, and the administrator later acknowledged the failure to report. The deficiency was identified through interviews, record reviews, and policy examination.
A resident was repeatedly observed with long, dirty, and untrimmed fingernails despite expressing a desire for nail care, and staff failed to provide or document this required ADL service as per facility policy. Interviews and record reviews confirmed that nail care was not consistently performed or recorded, and the care plan did not address the resident's preferences or refusals prior to the deficiency being identified.
A resident with orders for weekly orthostatic blood pressure monitoring due to hypertension medications had identical BP readings documented for both lying and sitting positions on two occasions. Facility staff confirmed these readings were not accurate and should have shown variation, indicating a failure to properly monitor and record orthostatic hypotension.
Two residents who experienced unwitnessed falls did not receive the full 72-hour post-fall neurological assessments as required by facility policy. In both cases, staff discontinued the checks early, with one resident receiving 41 hours and another 50 hours of monitoring, despite documentation indicating the need for continued assessments.
A nurse administered G-tube feeding to a resident without checking gastric residuals and without elevating the head of the bed to the required 30 degrees, contrary to facility policy and physician orders. The nurse incorrectly stated the bed was properly elevated, but measurement showed it was only at 20 degrees.
Two residents did not receive proper respiratory care when the facility failed to label and store oxygen tubing as required and did not timely identify or care plan for a resident's respiratory decline, including significant drops in oxygen saturation. Nursing staff and the DON confirmed that facility policies for oxygen therapy and change in condition were not followed.
A resident received hydrocodone-acetaminophen daily at a set time regardless of therapy schedule, contrary to physician orders specifying administration prior to therapy. Nursing staff did not coordinate with therapy staff, and the medication order was incorrectly entered in the MAR. Additionally, two PRN pain medications were administered without pain level parameters, and were given even when the resident reported no pain, resulting in unnecessary medication administration.
A resident receiving dialysis was not kept NPO as ordered prior to a medical appointment, resulting in the appointment being rescheduled. Additionally, required Pre and Post Dialysis Assessment forms were not fully completed on two occasions, with staff confirming the documentation was incomplete and should have been followed up with the dialysis center.
Multiple infection control deficiencies were observed, including an LVN failing to perform hand hygiene during medication administration, another LVN not performing hand hygiene between glove changes during wound care for a resident with a pressure injury, improper handling of clean laundry, and a dressing change on a dialysis access site performed without required PPE, despite Enhanced Barrier Precautions. Facility staff acknowledged these lapses during interviews.
Two residents were involved in a physical altercation during a supervised smoke break, where one resident verbally abused others and was subsequently struck by another, resulting in a skin tear. Staff were unable to intervene in time to prevent the incident, and required monitoring and documentation for the resident who struck the other was not completed as per facility policy and physician order.
The facility did not consistently provide or document required written notifications of transfer or discharge for several residents who were hospitalized or discharged, including failing to notify the Ombudsman and to include necessary information in the medical records. Staff interviews confirmed that the process for completing and documenting these notifications was not followed as required by facility policy.
Staff did not follow the standardized recipe when preparing pureed vegetables for 21 residents on a pureed diet, using three cups of cold milk instead of the required amount and temperature of fluid. This deviation from policy was confirmed by the DDS during meal preparation observation.
Two residents were found with call lights out of reach, preventing them from requesting assistance as needed. One resident with moderate cognitive impairment and functional limitations could not locate the call light, while another cognitively intact resident was unable to reach the call light clipped to the bed. Staff and the DON confirmed the importance of call light accessibility for meeting resident needs.
A resident's administration of hydrocodone-acetaminophen was not properly documented on the MAR, despite being signed out on the narcotic record. An LVN admitted to not recording the administration on the MAR due to habit, and the DON confirmed that both the controlled medication log and MAR should be completed for accountability. This failure to follow policy resulted in inaccurate medication reconciliation for a controlled substance.
A resident's medical record lacked accurate documentation of meal intake for multiple meals, as required by facility policy. Staff interviews confirmed the missing entries and highlighted the importance of this documentation, particularly for residents at risk for weight loss. The deficiency was verified through record review and staff statements.
Surveyors observed that two of three outside garbage dumpsters had lids propped open by trash bags and bulky boxes, preventing proper closure. The Maintenance Supervisor confirmed that dumpster lids should remain closed for infection control, in accordance with facility policy and the FDA Food Code.
The facility failed to complete required post-fall neurological assessments, monitoring, and notifications for two residents after fall incidents. In one case, a resident with cognitive impairment did not receive documented post-fall monitoring or timely notification to the physician and responsible party. In another case, a resident with abnormal neurological findings after a fall did not receive a complete assessment or immediate transfer as required by policy. These failures resulted in a risk of delayed interventions for the residents' post-fall conditions.
A resident who experienced an unwitnessed fall did not have nursing documentation completed for each shift over a 72-hour period as required by facility policy. Staff interviews confirmed the lack of documentation, and the resident was transferred to an acute care hospital before the monitoring period was completed. The DON and Administrator acknowledged the deficiency during record review.
A facility failed to document weekly skin checks for a resident with severe cognitive impairment, as required by its policy. The last recorded skin check was on 2/26/25, despite the resident being under the facility's care. Interviews with an LVN and the DON confirmed the oversight, attributing it to the LVN from a registry agency not completing the checks.
A resident was administered Geodon from another resident's discontinued medication vial, which was improperly stored in the IP's office instead of being disposed of as per facility policy. The DON and Administrator confirmed the medication was not available in the e-kit and acknowledged the improper storage and disposal practices.
A resident received Geodon without proper documentation or consent in a facility. The medication order was not transcribed, informed consent from the conservator was not obtained, and there was no documentation of administration or side effects monitoring. Additionally, no care plan was initiated for the medication use. Staff interviews confirmed these deficiencies, with the DON and NP acknowledging the lack of documentation and care planning.
The facility failed to provide consistent RNA services for two residents, leading to potential decline in their ROM functions. For one resident, RNA services for assisted active ROM and sit-to-stand exercises were not documented on specific dates. Similarly, another resident did not receive RNA services for ambulation on certain dates. RNAs confirmed that they were sometimes reassigned to work as CNAs, resulting in incomplete RNA services.
A facility failed to ensure staff wore appropriate PPE when caring for a COVID-19 resident. A CNA was observed changing bed linens for a resident with COVID-19 while only wearing a regular mask and gloves, without a gown, goggles, or face shield, despite posted instructions. The CNA admitted to forgetting the PPE, and the Infection Preventionist could not locate the facility's PPE policy.
A facility failed to safeguard controlled medications, resulting in missing medications for several residents. The policy required double-lock storage and key possession by the medication nurse, but an LVN left keys unattended, leading to missing Pregabalin, Temazepam, and Zolpidem Tartrate. Despite a search, the facility could not reconcile the missing medications, and the DON confirmed the failure in accounting and safeguarding procedures.
The facility failed to ensure food safety and sanitation guidelines were followed, as evidenced by the serving of undercooked hamburgers to multiple residents, who reported receiving patties that were pink or frozen inside. Despite the facility's policies requiring well-cooked meat, residents had to request replacements multiple times. Additionally, a dishwasher was observed not wearing a beard restraint, violating infection control measures.
The facility failed to follow the recipe for Potato Medley, as the cook used a handful of salt without measuring, deviating from the specified recipe. This was confirmed by the cook and the Dietary Supervisor, highlighting a potential impact on residents' nutritional needs.
A subcutaneous syringe with a needle was improperly disposed of, being found exposed and wedged vertically on the lid of a sharps disposal container attached to a medication cart. An LVN present during the observation confirmed the syringe was easily accessible and acknowledged it should have been properly disposed of. The facility's policy requires used syringes and needles to be placed immediately into puncture-resistant containers to avoid needle stick risks.
The facility failed to follow physician orders for wound care and repositioning for two residents with pressure injuries. One resident was not repositioned every two hours as required, and the prescribed Santyl ointment was not applied to their wounds. Another resident did not receive the updated wound care treatment as ordered by the wound care doctor, with Medihoney used instead of Santyl. These failures risked complications and delayed healing.
A resident with severe cognitive impairment was physically assaulted by another resident, resulting in injuries including a laceration and skin tear. The assault was witnessed by staff, and the aggressor admitted to the attack, citing anger as the cause. The facility failed to adhere to its abuse prevention policy, leading to this deficiency.
The facility failed to follow its abuse prevention policy when a CNA mishandled a report of physical abuse. A resident reported that a staff member hit another resident, but instead of removing the alleged perpetrator from care, the CNA brought the accused staff to the residents for identification. The DON acknowledged the breach in protocol, which posed a potential risk to the residents involved.
A resident was served a meal that included Brussels sprouts, despite their dietary profile indicating a dislike for green vegetables. The Dietary Manager confirmed the oversight, acknowledging that the resident's meal tray-card had not been updated to reflect their current food preferences, as required by the facility's policy.
A resident with Alzheimer's dementia and severe cognitive impairment was physically abused by another resident with schizoaffective disorder in an LTC facility. The incident occurred when the second resident became irritated by the first resident's moaning sounds and hit them with a water pitcher, resulting in a superficial skin tear and scalp bleeding. The facility's abuse prevention policy was not effectively implemented to prevent this incident.
A resident's room was found to have multiple maintenance issues, including a hole in the wall, exposed drywall, and dark stains, which were not logged for repair. The resident expressed dissatisfaction, and staff confirmed the room did not meet homelike standards.
A resident with cognitive impairment struck and bit another resident, who was cognitively intact, in a LTC facility. The incident resulted in visible injuries, highlighting a failure in the facility's abuse prevention policy. A CNA witnessed the altercation, and the facility acknowledged the incident and the resulting injury.
A resident with a physician's order for pain medication was not assessed or offered medication after complaining of severe knee pain. Staff interviews confirmed the oversight, with an LVN admitting to not performing an assessment due to being busy. The DON verified the lack of assessment and documentation.
A resident at high risk for falls did not have the required bilateral floor mats in place as ordered by the physician. Despite a history of multiple falls and a care plan that included floor mats as an intervention, the mats were not provided. This was confirmed through observations and interviews with an LVN and the DON.
The facility failed to administer prescribed medications to two residents. An LVN did not give citalopram hydrobromide to a resident with depression and Austedo XR to another resident with tardive dyskinesia, despite physician orders. These omissions were confirmed by the LVN and acknowledged by the DON.
The facility failed to ensure the safe storage of medications when a medication cart was left unlocked and unattended in a hallway near residents. An LVN confirmed the cart was left in this state, and the DON acknowledged the requirement for carts to be locked when unattended.
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. A heavy-duty blender was not air-dried before use, and various kitchen utensils were found in poor condition, with dry food particles and water spots. The kitchen hood also had blackish dirt residue. These deficiencies, confirmed by the Food Service Supervisor, could lead to cross-contamination and foodborne illnesses.
Failure to Revise Care Plan for Resident’s Inappropriate Behaviors During Care
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive, person-centered care plan to address documented inappropriate behaviors toward staff during ADL care. Facility policy on Person-Centered Care Planning, revised 4/24/25, requires development, implementation, review, and revision of comprehensive care plans with measurable objectives and timeframes after each comprehensive and quarterly assessment to meet residents’ medical, nursing, mental, and psychosocial needs. Medical record review for Resident 5, who was admitted with contractures of both hands and had an H&P dated 5/16/25 indicating no capacity to understand and make decisions, showed that the resident’s plan of care did not contain a problem or interventions addressing inappropriate behavior toward staff during care. During an interview on 2/25/26, CNA 12 reported that Resident 5 occasionally swung his arms toward her once or twice a week when she provided ADL care, and that he would cooperate when she returned later and encouraged him. In a telephone interview the same day, LVN 5 stated that Resident 5 had contracted fingers but could move his arms, had a history of removing Kerlix rolls, scratching and picking his skin, and swinging his arms at staff during care. LVN 5 further stated that the behavior of swinging his arms at staff during care was not documented and should have been included in the care plan. On 2/26/26, the DON confirmed during interview and concurrent record review that Resident 5’s plan of care had not been updated to reflect this inappropriate behavior toward staff during care, and on 2/27/26 the Administrator and DON were informed of and acknowledged these findings.
Failure to Complete Required Quarterly Nursing Assessments
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete, as required by accepted professional standards. Specifically, multiple required quarterly nursing assessments—including those for bed rails, bowel and bladder, elopement, falls, lift and transfer, self-administration of medications, smoking, vital signs and pain, Braden (skin assessment), and Section GG of the MDS—were not completed as scheduled for the resident. Facility policy required these assessments to be conducted quarterly, annually, upon significant change of condition, post-fall, and as needed. Review of the resident's medical record confirmed that the last completion dates for most assessments were several months prior, and some assessments were missing for the current quarter. Interviews with the MDS Coordinator and MDS Nurse confirmed that the assessments were not current and acknowledged that they should have been completed according to facility policy. The MDS Nurse stated that although the quarterly MDS could still be transmitted, the associated nursing assessments were not up to date and were considered to be for facility use. The MDS Coordinator verified the missing assessments and stated that the resident's intermittent absences from the facility did not excuse the lack of quarterly assessments. The Administrator and ADON were informed of and acknowledged these findings.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of three residents regarding call light accessibility and timely response. One resident, who had a history of stroke and Parkinson's disease and was at risk for incontinence, activated his call light to request a urinal but did not receive assistance for over 25 minutes, resulting in soiling his pull-ups. Documentation showed that the assigned CNA was on a scheduled lunch break, and the covering CNA went to lunch late without notifying other staff, leaving the resident's needs unmet. The resident's care plan required regular checks and toileting assistance, but these interventions were not followed during the incident. Additionally, two other residents were observed with their call lights out of reach. One resident, who had an upper extremity impairment and required substantial assistance with ADLs, was unable to access her call light, and the assigned CNA confirmed it was not within reach. Another resident, with diagnoses including schizoaffective disorder and anxiety, also had her call light on the floor and out of reach. In both cases, staff verified the call lights were not accessible to the residents, preventing them from requesting assistance when needed.
Failure to Obtain Proper Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use by not properly obtaining and verifying informed consent for the administration of clonazepam and lorazepam. The resident in question was documented as lacking the mental capacity to make decisions, yet the consent for clonazepam was obtained directly from the resident, and the verification form indicated the resident as the person who provided consent. Additionally, the verification was obtained via telephone, and two nurses signed the form. For lorazepam, the informed consent form did not include the required information regarding the reason and duration for use, and the verification form lacked the name, dosage, and frequency of the medication. Further, the facility did not complete the Surrogate Interdisciplinary Team (IDT) Proposal of Medical Intervention for the resident, despite the absence of a family surrogate and the resident's inability to provide informed consent. The Director of Nursing confirmed that the resident could not make decisions and that the surrogate IDT proposal was not completed. The facility's policies required these steps to be followed to ensure proper informed consent for psychotropic medication use, but these procedures were not adhered to in this case.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food safety and sanitation. Undated pepperoni slices and pizza crust were found in the meat freezer, and an expired gallon of milk was stored in the walk-in freezer, despite posted instructions requiring all food items to be labeled and dated. These findings were confirmed by the Food Services Director, who acknowledged that the items should not have been stored in the freezers. Additionally, a leak under the kitchen sink resulted in water pooling on the floor near the trayline area and stove. Staff reported this issue had been ongoing, but the Food Services Director was unaware of the problem at the time of the survey. Further deficiencies were noted in staff hygiene and use of protective equipment. During trayline service, a staff member picked up a food item from the floor with gloved hands and then returned to handle a clean utensil without performing hand hygiene, which the staff member admitted. Observations also revealed that multiple staff, including a CNA, the Food Services Director, and a Dietary Aide, were either not wearing hair restraints or were wearing them improperly while in the kitchen. These lapses were verified with the Food Services Director and were not in accordance with the facility's infection control policies.
Failure to Verify Resident Diet Orders Prior to Meal Service
Penalty
Summary
The facility failed to ensure that meals were served to residents according to their prescribed diet orders, as required by facility policy and physician directives. During a meal observation, a licensed vocational nurse (LVN) was seen checking diet cards and lifting meal tray lids but did not have access to the current list of residents' diet orders to verify accuracy. When questioned, the LVN stated that the list was at the nurses' station, but upon further inquiry, another LVN confirmed that the list was not available at the station and acknowledged it should have been printed prior to meal service. This lapse meant that meals could not be properly checked against physician orders before being served to residents.
Failure to Provide Sufficient Fluids to Residents
Penalty
Summary
The facility failed to provide sufficient fluids to two residents observed for hydration. One resident, who had no fluid restrictions and was capable of making decisions, was found without a water pitcher in her room and expressed a desire for iced water. She was observed with dryness to her mouth, and a CNA confirmed the absence of a water pitcher. Medical records indicated she had diagnoses including schizoaffective disorder, mood disorder, and anxiety. Another resident, also without fluid restrictions and no cognitive impairment, reported that staff did not refill his water pitcher, which was found empty during observation. An LVN verified the pitcher was empty, and a CNA stated he would refill it when he could. This resident had a history of stroke, Parkinson's disease, and high blood pressure. These observations and interviews confirmed that the facility did not ensure water pitchers were available and refilled as needed for these residents.
Failure to Specify Staff Competencies and Training for Psychiatric Care in Facility Assessment
Penalty
Summary
The facility failed to ensure its facility-wide assessment included a resident-centered staffing plan that addressed the specific competencies required to care for residents with psychiatric disorders. The assessment tool reviewed did not specify the behavioral training staff would receive to manage residents with psychiatric or behavioral symptoms, despite the facility having a significant number of residents with such needs. The Administrator confirmed that the assessment was used as a general overview and did not detail the competencies or training for staff related to psychiatric care. During interviews, a CNA reported relying on instinct and calling for help when managing residents with escalating mental health behaviors, and stated she had not received formal training from the facility. Review of her employee file and the facility's course completion history confirmed the absence of documented behavioral training. The deficiency was identified through interviews and document reviews, which showed a lack of formalized training and documentation for staff responsible for residents with psychiatric disorders.
Widespread Kitchen Sanitation Failures and Unsafe Food Handling Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of dirty and damaged utensils, improper drying and storage of kitchen equipment, and unclean food preparation surfaces. During a kitchen tour, surveyors observed numerous stainless steel knives, spatulas, serving scoops, measuring spoons, and cups with dry crusted food residue, fuzzy films, and watermarks. The DDS acknowledged these findings and confirmed that the utensils should have been properly washed to prevent cross contamination. Additionally, several utensils and equipment were found to be in poor condition, including knives with peeling handles, spatulas and scoops that were partially melted or chipped, and cutting boards that were heavily marred with deep grooves, making them difficult to clean and sanitize. Further deficiencies were noted in the handling and storage of kitchen equipment. Multiple clear plastic containers and blenders used for food and juice preparation were observed to be wet and stacked while still containing visible water, contrary to facility policy and food code requirements for air drying. During puree preparation, a wet blender was used to process food, and the DDS confirmed that equipment should have been air dried before use. The kitchen hood above the stove was found to have black, greasy residue, and the internal panel of the ice machine contained black dirt residue, despite recent servicing. Both the kitchen and ice machine room had drainpipes resting on the ground and touching the drain, lacking the required air gap to prevent backflow. Additional unsanitary conditions included a dirty microwave with dry food residue inside and a countertop-mounted can opener with dry, crusted residue on the blade. The DDS and Maintenance Supervisor acknowledged these findings and stated that the equipment should have been cleaned according to facility policy and manufacturer guidelines. All 133 residents in the facility consumed food prepared in the kitchen, making these deficiencies significant in terms of potential for cross contamination and foodborne illness, as directly stated in the report.
Improper LAL Mattress Settings and Excessive Bedding for Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary care and services to a resident with a pressure injury by not ensuring the proper use and settings of a low air loss (LAL) mattress. During observation, the resident was found lying on a LAL mattress that was set to static mode with a weight range of 200 to 250 pounds, despite the resident's actual weight being 107 pounds. The care plan and physician's orders specified that the mattress should be set to alternate mode when not providing ADL care and adjusted to one bar above 90 pounds. Staff interviews confirmed that the mattress settings were not in accordance with the care plan or the manufacturer's guidelines, and staff were unclear about the correct settings and their responsibilities in ensuring proper mattress function. Additionally, the resident was observed lying on multiple layers of bedding, an absorbent pad, and an incontinent brief while on the LAL mattress. Facility policy and staff interviews indicated that only one layer of sheet and either an incontinent pad or brief should be used to maximize the effectiveness of the LAL mattress. Staff acknowledged that having multiple layers of bedding and pads could defeat the purpose of the mattress and potentially impact wound healing. The resident in question had a history of severe cognitive impairment, was dependent on staff for ADLs and mobility, and had an unstageable pressure injury on the left hip. The wound was documented as healing with no signs of infection, but the improper mattress settings and excessive bedding layers were not in line with the care plan or facility policy, potentially compromising the resident's skin integrity and wound healing.
Failure to Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent prior to administering psychotropic medication (temazepam) to a resident who had the mental capacity to make their own decisions. According to the facility's policy, licensed nurses are required to verify and document informed consent in the resident's medical record before administering the first dose of such medications. Medical record reviews showed that multiple orders for temazepam were initiated and administered over several months, but the records did not contain evidence that informed consent was obtained for these orders. Additionally, one consent form present in the record did not indicate who provided the consent. Interviews with nursing staff confirmed that for each new or changed order of PRN psychotropic medication, a new consent should have been obtained and documented. Both an RN and an LVN reviewed the resident's records and verified the absence of required informed consent documentation for several temazepam orders. This deficiency was identified through interviews, medical record reviews, and review of facility policy and procedures.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who stated she felt harassed and threatened by another resident. According to the facility's own policies and procedures, all allegations of abuse, including those involving intimidation or fear, are to be reported immediately to the appropriate authorities, including the California Department of Public Health (CDPH), Licensing & Certification Program, Ombudsman, and law enforcement. Despite this, the administrator chose not to report the incident, stating it was not considered verbal or physical abuse, even though the resident reported feeling threatened and had called the police herself. Medical record reviews showed that the resident who made the allegation was cognitively intact, alert, and oriented, and had a documented history of reporting feeling threatened by another resident during a supervised activity. Progress notes indicated that both residents involved were placed on behavior monitoring following the incident. Staff interviews confirmed that the facility's abuse protocol required reporting such allegations, and both registered nurses interviewed stated that feeling threatened or harassed should be considered emotional abuse and reported accordingly. The administrator later acknowledged that the incident met the facility's definition of intimidation or fear and should have been reported as required by policy. However, the initial failure to report the allegation as abuse resulted in non-compliance with both facility policy and regulatory requirements. The deficiency was identified through interviews, medical record reviews, and policy review, with staff and administrative acknowledgment that the reporting protocol was not followed in this case.
Failure to Provide and Document Required Nail Care for a Resident
Penalty
Summary
A deficiency was identified when a resident was not provided with necessary care and services to maintain their ability to perform activities of daily living (ADLs), specifically in the area of grooming and personal hygiene. The resident was observed on multiple occasions with long, dirty, and untrimmed fingernails, which included brown discoloration and dirt residue. The resident expressed a desire to have her nails trimmed but reported that staff had not offered or provided this care. Facility policy required nail care to be performed to clean the nail bed and keep nails trimmed, and staff interviews confirmed that nail care should be checked and provided every shift. Review of the resident's medical record and ADL documentation revealed multiple instances where nail care tasks were either marked as 'not applicable' or lacked documentation altogether for several shifts. Staff interviews confirmed that personal hygiene, including nail care, was scheduled to be provided twice daily, and any refusals should be documented and communicated to the charge nurse. However, the care plan did not reflect any documentation of the resident's refusal to have her nails trimmed prior to a certain date, and there was no evidence that refusals were consistently addressed or care was provided as required. The Director of Nursing (DON) and other staff verified that nail care is a required component of personal hygiene and that failure to document care rendered is considered as care not being completed. The DON also confirmed that both CNAs and licensed nurses are responsible for ensuring personal hygiene tasks, including nail care, are performed and documented. The lack of documentation and observed failure to provide nail care resulted in the resident being left with untrimmed and dirty fingernails, contrary to facility policy and the resident's expressed wishes.
Failure to Accurately Monitor Orthostatic Hypotension
Penalty
Summary
The facility failed to ensure accurate monitoring of orthostatic hypotension for one resident. According to the facility's policy, orthostatic vital signs are to be taken and recorded when ordered by a physician and when symptoms such as falls, vertigo, or dizziness occur. The policy defines orthostatic hypotension as a 20 mmHg drop in systolic or a 10 mmHg drop in diastolic blood pressure within three minutes of standing, with even smaller drops being significant in elderly individuals. For this resident, physician orders required weekly monitoring of orthostatic blood pressure in both lying and sitting positions on Saturdays due to the use of hypertension medications. Medical record review showed that on two separate dates, the blood pressure readings recorded for both lying and sitting positions were identical. During interviews, both the LVN and the DON acknowledged that these identical readings were not accurate and that blood pressure values should fluctuate between positions. The failure to accurately monitor and record orthostatic blood pressure could have impacted the adjustment of the resident's hypertension medications as needed.
Failure to Complete 72-Hour Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to complete post-fall neurological assessments for the required 72-hour period for two of five residents reviewed for accidents. According to the facility's Fall Management Program policy, for unwitnessed falls, neurological assessments are to be conducted every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and then every four hours until 72 hours post-fall. For one resident, after a fall from bed while reaching for a dropped water pitcher, neurological checks were only performed for 41 hours, and staff did not realize the assessments had not continued for the full 72 hours as required. The neurological flow sheet was marked as completed, but the checks did not extend to the full duration specified in the policy. For another resident who was found lying on the floor, neurological assessments were conducted for only 50 hours instead of the required 72 hours. Staff interviews confirmed that the post-fall neurological checks were not completed for the full duration as outlined in the facility's protocol. In both cases, the documentation and staff statements verified that the assessments were prematurely discontinued, contrary to the established policy for post-fall care.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow established facility policy and physician orders during the administration of enteral tube feeding for a resident. The facility's policy required that the head of the bed be elevated to at least 30 degrees during feedings and that gastric residuals be checked prior to starting the feeding. The physician's orders also specified the need to elevate the head of the bed to 30-45 degrees during tube feedings and to administer a specific enteral formula at a set rate. During observation, the nurse was seen setting up and administering the tube feeding without checking for gastric residuals and without ensuring the resident's head of the bed was properly elevated. The head of the bed was measured at 20 degrees, below the required minimum. The nurse confirmed that she did not check for gastric residuals and incorrectly stated that the bed was elevated to 30 degrees. These actions were inconsistent with both facility policy and physician orders.
Deficiencies in Respiratory Care and Oxygen Therapy Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who required oxygen therapy. For one resident, the nasal cannula tubing was observed to be neither labeled nor dated as required by the facility's policy and procedures. Additionally, the tubing was not stored in a set-up bag when not in use, but instead was left coiled on top of the oxygen concentrator. The Director of Nursing (DON) confirmed these findings and acknowledged that the tubing should have been labeled and stored properly to maintain cleanliness and infection control. For another resident, the facility did not identify or address respiratory changes in a timely manner. The resident was observed coughing and wheezing, with oxygen saturation levels dropping significantly during the surveyor's presence. Despite these symptoms and a documented drop in oxygen saturation, there was no evidence in the medical record that a care plan was developed to address the resident's desaturation and moist cough. Nursing staff confirmed that documentation of a change in condition was completed, but the care plan was not updated to reflect the resident's current respiratory status. The facility's policies require that oxygen therapy supplies be changed, dated, and stored appropriately, and that any change in a resident's condition be assessed, documented, and care planned. In both cases, these procedures were not followed, resulting in deficiencies in the provision of safe and appropriate respiratory care for the affected residents.
Failure to Follow Pain Management Protocol and Physician Orders
Penalty
Summary
The facility failed to follow its pain management protocol and physician's orders for a resident requiring pain management services. The resident had a physician's order for hydrocodone-acetaminophen to be administered prior to therapy sessions, but the medication was given daily at a set time in the morning, regardless of whether therapy was scheduled or not. Documentation and staff interviews confirmed that the medication was administered even on days when the resident did not receive therapy, and without coordination between nursing and therapy staff regarding therapy schedules. The order was also incorrectly entered in the electronic medication administration record (MAR), leading to routine administration rather than as needed before therapy. Additionally, the resident had two PRN (as needed) pain medication orders—acetaminophen and a lidocaine patch—without specified pain level parameters for administration. Staff interviews revealed that PRN pain medications should have clear pain level guidelines, and the DON confirmed that orders for multiple PRN pain medications should specify the pain level at which each should be administered. Review of the MAR showed that both PRN medications were administered for a documented pain level of zero, which staff acknowledged should not occur, as zero indicates no pain. These failures resulted in the resident receiving unnecessary pain medication and being at risk for inadequate pain control during therapy sessions. The facility's own policies required pain medications to be administered as ordered, and staff confirmed that the observed practices did not align with these requirements. The lack of coordination between nursing and therapy, incorrect order entry, and absence of pain level parameters for PRN medications directly contributed to the deficiency.
Failure to Follow NPO Orders and Complete Dialysis Documentation
Penalty
Summary
The facility failed to follow physician orders and complete required documentation for a resident receiving dialysis services. Specifically, the resident was ordered to be NPO (nothing by mouth) after midnight prior to a scheduled medical appointment related to swelling at the dialysis site. Despite this order, the resident was given breakfast, resulting in the medical appointment being rescheduled. Interviews with nursing staff confirmed that there was a lack of communication between nursing and dietary staff regarding the NPO order, which led to the resident not being properly prepared for the appointment. Additionally, the facility did not ensure that the Pre and Post Dialysis Assessment forms were fully completed for the resident on two separate dates. The required Dialysis Unit Assessment sections were left incomplete, and staff acknowledged that these forms should have been completed, either by the dialysis center or through follow-up by facility staff. The facility's policies required these assessments and documentation to be maintained in the resident's medical record, but this was not done as required.
Infection Control Lapses in Hand Hygiene, PPE Use, and Laundry Handling
Penalty
Summary
The facility failed to maintain infection prevention and control practices as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of clean laundry. During a medication administration observation, an LVN did not perform hand hygiene at required moments, including after removing gloves, after disinfecting equipment, and when moving between residents and their belongings. The LVN acknowledged not following the facility's hand hygiene policy, which requires hand hygiene before and after donning PPE, and when entering or exiting a resident's room. In a separate incident, another LVN performed wound care on a resident with a Stage 3 pressure injury but did not perform hand hygiene between donning and doffing gloves. The LVN was unsure about the requirement for hand hygiene during this process, despite the facility's policy and statements from other staff confirming that hand hygiene should occur to prevent cross-contamination. The resident involved had severe cognitive impairment and required specific wound care interventions as ordered by the physician. Additional deficiencies included a laundry rolling rack with clean residents' clothing that was only partially covered, with clothing touching handrails and walls, contrary to facility policy requiring clean laundry to be fully covered. Furthermore, an LVN was observed performing a dressing change on a resident's dialysis access site without wearing the required PPE, despite the resident being on Enhanced Barrier Precautions due to a dialysis catheter. The LVN confirmed knowledge of the need for PPE but did not comply during the observed procedure. Facility leadership acknowledged these findings during interviews.
Failure to Prevent and Monitor Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during a supervised smoke break. One resident was verbally aggressive, using foul racial slurs and loud language directed at another resident and others present. The situation escalated when the verbally targeted resident struck the verbally aggressive resident above the right eyebrow, resulting in a superficial skin tear. Staff present in the area were unable to intervene in time to prevent the physical altercation, but responded immediately after the incident to separate the residents and provide assessment. The facility's policies require monitoring and documentation following any change in condition, including incidents of abuse or altercations. After the altercation, there was a physician's order to monitor the resident who struck the other for signs and symptoms of emotional distress every day shift for 14 days. However, the facility failed to provide documented evidence of continued monitoring and assessment by licensed nurses for this resident as required by both facility policy and the physician's order. Interviews with staff confirmed that the required monitoring was not completed post-incident. Both residents involved had significant psychiatric histories, with one having schizoaffective-bipolar disorder and the other diagnosed with schizophrenia and moderate cognitive impairment. The care plan for the resident who struck the other included interventions to monitor for aggression and provide feedback, but there was no evidence that these interventions were adequately implemented or documented following the incident. The failure to monitor and document as required had the potential to negatively impact the well-being of the residents involved.
Failure to Provide Required Transfer/Discharge Notifications and Documentation
Penalty
Summary
The facility failed to follow its own protocols and federal requirements for providing written notification of transfer or discharge for multiple residents who were hospitalized or discharged. Specifically, the facility did not consistently complete or provide the Notice of Proposed Transfer and Discharge forms to residents, their responsible parties, or the Ombudsman as required. In several cases, there was no documentation in the medical records to show that these notifications were completed or sent, and fax confirmations to the Ombudsman were missing. This was confirmed through interviews with staff, including the Medical Records Director (MRD) and nursing staff, who acknowledged the absence of required documentation and forms in the residents' records. For example, one resident who was discharged to the community did not receive a discharge summary or a recapitulation of their stay, including important information such as home health services, follow-up appointments, and medication instructions. Other residents who were transferred to acute care hospitals on multiple occasions did not have completed Notice of Proposed Transfer and Discharge forms in their records, and there was no evidence that the Ombudsman was notified as required by facility policy. Staff interviews confirmed that the process of completing and documenting these notifications was not followed consistently. The facility's policies require that before a resident's transfer or discharge, written notification must be provided to the resident, their responsible party, and the Ombudsman, with documentation placed in the medical record. Despite these clear policies, the survey found repeated failures to provide and document these notifications for several residents, both in open and closed records. These deficiencies were acknowledged by facility leadership during interviews.
Failure to Follow Standardized Puree Recipe for Residents on Pureed Diet
Penalty
Summary
The facility failed to follow its standardized recipe for preparing pureed vegetables for 21 residents on a pureed diet. During an observation of meal preparation, a staff member was seen adding three cups of cold milk to cooked broccoli and carrots, instead of the recipe-specified one half cup to one and one-half cups of warm fluid such as milk or low sodium broth for 24 servings. The facility's policy required the use of standardized recipes for all food prepared and served by the dietary department. The Dietary Director confirmed that the staff member did not follow the correct recipe during the preparation of pureed vegetables, which affected the meals provided to the residents receiving pureed diets.
Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of two residents by not ensuring that their call lights were kept within reach, as required by facility policy. For one resident with moderately impaired cognition and functional limitations requiring substantial or maximal assistance with dressing and hygiene, the call light was observed hanging below the bed mattress and not accessible. The resident was unable to locate the call light when asked, and both an LVN and a CNA confirmed that the call light was not within reach, acknowledging its importance for residents to request assistance. A second resident, who was cognitively intact but unable to make medical decisions, was also found with a call light clipped and hung on the side of the bed out of reach. The resident attempted but was unable to reach the call light. An LVN verified the inaccessibility and subsequently moved the call light within the resident's reach. The DON confirmed that call lights must be placed within easy reach, especially on the resident's strong side if there is any weakness or paralysis, and acknowledged that inaccessibility would prevent residents' needs from being met.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for one resident by not ensuring proper reconciliation and documentation of a controlled medication, hydrocodone-acetaminophen. According to the facility's policy, licensed nurses are required to document the administration of controlled medications both on the accountability record and the Medication Administration Record (MAR) at the time of administration. For one resident, the Individual Narcotic Record showed multiple instances where hydrocodone-acetaminophen was signed out and presumably administered, but there was no corresponding documentation on the electronic MAR for those dates. This discrepancy was confirmed during a medication reconciliation conducted with a licensed vocational nurse (LVN), who acknowledged the lack of documentation on the MAR due to personal habit. Interviews with the resident confirmed that pain medication was received as requested, and the DON verified that the correct process requires documentation on both the controlled medication log and the MAR. The failure to document the administration of controlled medications as required by facility policy was acknowledged by both the DON and the Administrator. This lapse in documentation created a risk for improper medication reconciliation and potential diversion of controlled substances.
Incomplete Documentation of Meal Intake in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically regarding the documentation of meal intakes. Review of the resident's nutrition records for several dates showed missing entries for the amount eaten at various meals, including breakfast, lunch, and dinner. The facility's policy required prompt, complete, and accurate documentation of care and services provided, but these requirements were not met for the resident in question. Interviews with facility staff, including an LVN and the DON, confirmed the missing documentation and emphasized the importance of recording meal intake, especially for residents at risk for weight loss. The DON stated that CNAs are responsible for documenting meal intake after each meal and must report refusals to the charge nurse for further action. The absence of this documentation meant there was no proof that the tasks were completed as required by facility policy.
Improper Storage of Garbage in Outside Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in two out of three outside dumpsters, as observed during surveyor inspections. One dumpster was found with its lid fully propped open by bulky boxes, and two dumpsters had lids partially propped open by trash bags and boxes, preventing them from closing completely. These observations were confirmed by the Maintenance Supervisor, who acknowledged that the lids should remain closed at all times for infection control purposes. The facility's own waste management policy requires that waste containers be closable and that garbage be disposed of in covered bins, in alignment with the 2022 FDA Food Code, which mandates tight-fitting lids to prevent pest entry.
Failure to Complete Post-Fall Assessments and Notifications
Penalty
Summary
The facility failed to provide necessary care and services to prevent further falls and injuries for two of four sampled residents. For one resident with severe cognitive impairment, after a fall from bed resulting in a minor injury, there was no documentation of post-fall neurological assessment or monitoring. Additionally, the attending physician and responsible party were not notified of the incident, contrary to facility policy. Interviews with staff revealed that the licensed nurse was not informed of the fall by the CNAs, and as a result, required assessments and notifications were not completed or documented. For another resident, who was cognitively intact and had clear speech, a witnessed fall occurred in which the resident struck her face. The neurological assessment post-fall documented abnormal findings, including unequal and non-reactive pupils, inability to respond to commands, and slurred speech. Despite these findings, the post-fall assessment was incomplete, and the resident was not transferred via paramedics as required by facility policy for abnormal neurological findings. Documentation of contributing factors, medication changes, and clinical suggestions was also incomplete. Facility policies reviewed indicated that after any fall, a licensed nurse must perform a post-fall evaluation, complete neurological checks for 72 hours, and notify the attending physician and responsible party. Staff interviews confirmed that these steps were not followed for both residents. The failures in assessment, documentation, and notification posed a risk that residents would not receive timely interventions to address their post-fall status.
Failure to Document Change of Condition Monitoring After Fall
Penalty
Summary
The facility failed to ensure that nursing documentation was completed for each shift over a 72-hour period following a resident's change of condition (COC) due to an unwitnessed fall. According to the facility's policies, licensed nurses are required to document each shift for at least 72 hours after a COC, including falls, to monitor for changes in the resident's condition. Medical record review for a resident who experienced an unwitnessed fall revealed that this required documentation was missing for the specified period following the incident. Interviews with nursing staff, including an LVN and an RN, confirmed that the documentation was not completed as required and that the resident was transferred to an acute care hospital before the 72-hour monitoring period was finished. Both staff members acknowledged that the facility's policy mandates shift-by-shift documentation for 72 hours post-fall to monitor for any changes in health status. The Director of Nursing and the Administrator also acknowledged the findings during a review of the medical record.
Failure to Document Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that weekly skin checks were completed and documented in the medical record for one of the sampled residents, identified as Resident 8. According to the facility's policy and procedure (P&P) on Pressure Injury Prevention, revised on 6/27/24, weekly skin checks are required to be completed and documented. However, a review of Resident 8's medical record revealed that the last documented skin check was on 2/26/25, despite the resident being admitted and discharged within the facility's care. Interviews with LVN 4 and the Director of Nursing (DON) confirmed the absence of documented skin checks after 2/26/25. The DON acknowledged that the weekly skin checks should have been conducted by the LVN charge nurse, but they were not completed by the LVN from the registry agency responsible for Resident 8's care. Resident 8 had a BIMS score of 2, indicating severe cognitive impairment, which underscores the importance of adhering to the facility's P&P for accurate medical record-keeping.
Improper Medication Administration and Storage
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident by administering Geodon medication from another resident's discontinued medication vial. The medication was not available in the medication e-kit, and the Licensed Vocational Nurse (LVN) administered it as a one-time dose ordered by the Nurse Practitioner (NP) when the resident was exhibiting disruptive behavior. The Director of Nursing (DON) confirmed that the Geodon medication was stored in the Infection Preventionist's (IP) office, which was against the facility's policy and procedures (P&P) for medication storage and administration. Additionally, the facility did not adhere to its P&P regarding the disposal of discontinued medications. The IP acknowledged storing the Geodon vial in her office instead of disposing of it in the designated waste disposal bin in the medication room. This oversight was confirmed during interviews with the DON and the Administrator, who acknowledged the findings. The failure to properly store and dispose of medications as per the facility's P&P had the potential to lead to unsafe administration and handling of medications.
Failure to Document and Monitor Antipsychotic Medication Administration
Penalty
Summary
The facility failed to properly monitor and document the administration of Geodon, an antipsychotic medication, for a resident. The resident, who was under the care of a conservator, received Geodon via intramuscular injection following a verbal order from a nurse practitioner. However, the order was not transcribed into the resident's medical record, and there was no documentation of informed consent from the conservator. Additionally, the administration of the medication and monitoring for side effects were not recorded in the Medication Administration Record (MAR), and no care plan was initiated to address the use of Geodon. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and the Nurse Practitioner (NP), confirmed these deficiencies. The LVN admitted to not documenting the medication order, side effects monitoring, or obtaining consent, assuming the Registered Nurse (RN) would handle it. The DON and NP acknowledged the lack of documentation and care planning, with the DON expressing an expectation for licensed nurses to transcribe orders, document, obtain consent, and initiate care plans. These failures were acknowledged by the facility's Administrator and DON.
Failure to Provide Consistent Restorative Nursing Services
Penalty
Summary
The facility failed to provide necessary interventions and services to maintain or improve the range of motion (ROM) for two residents, leading to a potential decline in their ROM functions. For Resident 1, the facility did not consistently provide Restorative Nursing Assistant (RNA) services as ordered by the physician. The medical records showed gaps in the documentation of RNA services for assisted active ROM and sit-to-stand exercises with a front wheel walker on specific dates in July, August, and September 2024. During an interview, RNA 1 confirmed that the services were not provided on those dates because RNAs were sometimes reassigned to work as Certified Nursing Assistants (CNAs), leaving the RNA services incomplete. Similarly, for Resident 2, the facility failed to provide RNA services for ambulation with a front wheel walker as per the physician's order. The medical records indicated missing documentation for RNA services on certain dates in July and September 2024. RNA 2 verified that the services were not provided on those dates due to RNAs being pulled to work on the floor as CNAs. This lack of consistent RNA services posed a risk of further decline in the residents' ROM functions.
Inadequate PPE Use for COVID-19 Resident
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) when providing care for a resident diagnosed with COVID-19. During an observation on October 7, 2024, at 0900 hours, a certified nursing assistant (CNA) was seen changing the bed linen for Resident A, who was diagnosed with COVID-19, while only wearing a regular mask and gloves, without a gown, goggles, or face shield. The CNA then proceeded to check another resident's bed for linen changes. A sign was posted with precaution instructions requiring staff to wear a gown, gloves, and a procedure mask with eye protection when within two meters of the resident. Interviews conducted on the same day revealed that Resident A confirmed being moved to the room due to a COVID-19 diagnosis. The CNA admitted to forgetting to wear the required PPE. Additionally, the Infection Preventionist (IP) was unable to locate the facility's policy and procedure (P&P) for PPE use but confirmed that staff should wear a gown, gloves, goggles/face protection, and an N95 mask. The IP stated that these items were provided in front of each room designated for COVID-19 isolation.
Failure to Safeguard Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmacy services to safeguard controlled medications for several residents, leading to the risk of medication diversion. The facility's policy required Schedule II-V medications to be stored under double lock, with the medication nurse maintaining possession of the key. However, during a shift, LVN 1 left the keys unattended on top of a medication cart, which was against the facility's policy. This lapse in protocol resulted in the inability to locate controlled medication bubble packs for four residents during a shift change. The missing medications included Pregabalin for one resident, Temazepam for two residents, and Zolpidem Tartrate for another resident. Despite a facility search and review of inventory records, the facility could not reconcile the missing medications. The Director of Nursing confirmed that the facility failed to ensure proper accounting and safeguarding of the controlled medications, as the required reconciliation by two licensed nurses at each shift was not adequately performed.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed, specifically in the preparation and serving of hamburgers. On multiple occasions, residents reported receiving hamburgers that were not well-cooked, with patties that were pink or even frozen inside. This issue was reported by several residents, including Residents 1, 2, 3, 4, A, and B, who expressed concerns about the potential health risks of consuming undercooked meat. Interviews with residents revealed that they often chose not to eat the hamburgers due to their condition, and some residents had to request replacements multiple times before receiving a properly cooked hamburger. The facility's policies and procedures (P&P) for meat cookery and storage, revised on 7/1/24, were not adhered to, as evidenced by the repeated serving of undercooked hamburgers. Interviews with Certified Nursing Assistants (CNAs) and dietary staff confirmed that the hamburgers were not consistently cooked to a safe temperature, and there were multiple instances where residents had to request replacements. The Dietary Supervisor verified that hamburgers were served on 7/20/24 and acknowledged that all meat products should be well-cooked, yet the issue persisted. Additionally, the facility failed to enforce proper infection control measures in the kitchen. An observation on 8/15/24 revealed that a dishwasher was not wearing a beard restraint while working in the kitchen, contrary to the facility's P&P for dietary department infection control. This lapse in personal cleanliness and sanitary food preparation further contributed to the potential risk of foodborne illness for residents, staff, and visitors consuming food prepared in the facility's kitchen.
Failure to Follow Recipe for Potato Medley
Penalty
Summary
The facility failed to ensure that the menu was followed, specifically in the preparation of Potato Medley. During an observation and interview, it was noted that the cook, identified as [NAME] 1, did not adhere to the recipe while preparing the dish. Instead of using the specified amount of salt, [NAME] 1 used her hand to pour a handful of salt into the potatoes without measuring it, which deviated from the recipe's instructions. This action was verified by [NAME] 1 during the observation. An interview with the Dietary Supervisor (DS) confirmed that the cook should have used measuring tools such as a spoon, scoop, or cup to measure the seasoning. The DS acknowledged the findings and agreed that [NAME] 1 should have followed the recipe as outlined. This failure had the potential to impact the nutritional needs of the residents who received food prepared in the kitchen.
Improper Disposal of Subcutaneous Syringe
Penalty
Summary
The facility failed to ensure the proper disposal of a subcutaneous syringe in the sharps container, posing a safety risk to residents, staff, and visitors. During an observation and interview, a subcutaneous syringe with a needle was found exposed and wedged vertically on the lid of a sharps disposal container attached to Medication Cart A. The lid of the container had instructions to place the sharp horizontally and lift to ensure proper disposal. LVN 1, who was present during the observation, did not know who disposed of the syringe and confirmed that the used syringe with needle was easily accessible. LVN 1 acknowledged that the syringe should have been properly disposed of after use. The facility's policy and procedure for the disposal of medications and medication-related supplies, revised in April 2008, requires that used syringes and needles be disposed of safely and in accordance with applicable laws and safety regulations to avoid the risk of needle sticks. The policy specifies that needles should not be recapped after use and should be placed immediately into puncture-resistant, one-way containers designed for that purpose. These containers should have lids that prevent reaching into the container, whether kept in the medication room or affixed to the medication cart.
Failure to Follow Wound Care Orders and Repositioning Protocols
Penalty
Summary
The facility failed to provide necessary care and services to promote wound healing for two residents with pressure injuries. For the first resident, the facility did not follow the physician's orders for wound care, specifically failing to apply the prescribed Santyl ointment to the left ischium wound and not repositioning the resident every two hours as required. The resident, who had a Stage 4 pressure injury and was unable to move his legs, was observed in the same supine position multiple times over a day, indicating a lack of repositioning. Interviews with staff confirmed that the resident needed assistance to turn and that there was no order for repositioning in the care plan. The second resident also did not receive the prescribed wound care as per the physician's orders. The facility failed to apply Santyl to the resident's right shoulder and hip wounds as directed by the wound care doctor. Instead, Medihoney was used, which was not in accordance with the updated treatment orders. The new orders from the wound care doctor were not carried out, and the licensed nurses did not document the changes in the progress notes. These deficiencies in following physician orders and ensuring proper wound care and repositioning posed risks for complications and delayed wound healing for both residents. The facility's policies and procedures required treatments to be provided as ordered by the physician, but these were not adhered to in these cases.
Resident Assault and Injury Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 7, who has severe cognitive impairment and a history of psychosis, non-Alzheimer's dementia, anxiety disorder, depression, and a psychotic disorder, was physically assaulted by Resident 8. Resident 8, who is cognitively intact and has a medical history of schizoaffective disorder, anxiety disorder, schizophrenia, and autistic disorder, was observed screaming and yelling in the hallway before approaching and pushing Resident 7 to the floor. This incident resulted in Resident 7 sustaining a laceration to her left outer eye and a skin tear to her right elbow. The incident was witnessed by staff members, including RN 2, LVN 2, and CNA 1, who provided detailed accounts of the event. RN 2 heard Resident 8 screaming and observed the assault, while LVN 2 and CNA 1 noted the injuries sustained by Resident 7, including a laceration, hematoma, and skin tears. Resident 8 admitted to hitting Resident 7, stating he was upset and mad. The facility's policy on abuse prevention and management defines abuse as the willful infliction of injury, which was not adhered to in this case, leading to the deficiency.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policies and procedures for abuse prevention when a report of physical abuse was mishandled. A certified nursing assistant (CNA 4) received a report from a resident (Resident 9) that another staff member (CNA 5) had hit a different resident (Resident 4). Instead of following the facility's policy to immediately remove the alleged perpetrator from resident care, CNA 4 brought CNA 5 to Residents 4 and 9 to identify the alleged staff member. This action was contrary to the facility's abuse prevention program, which mandates the immediate suspension of the suspected employee pending investigation. Resident 4, who could make needs known but not medical decisions, and Resident 9, who was alert and oriented, were involved in the incident. The Director of Nursing (DON) confirmed awareness of the situation and acknowledged that CNA 4's actions were inappropriate and not in line with the facility's policy. The failure to remove CNA 5 from the care environment immediately after the allegation was reported created a potential risk for the residents involved.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 1, which was documented in their dietary profile. During a dining observation, Resident 1 was served a meal that included Brussels sprouts, despite their dietary profile indicating a dislike for green vegetables. This oversight was confirmed by the Dietary Manager, who acknowledged that the resident's meal tray-card had not been updated to reflect their current food preferences. The facility's policy and procedure for dietary profiles and resident preference interviews, revised in April 2022, requires the Dietary Manager to complete a dietary profile for residents within 72 hours of admission. This profile should capture and update information regarding nutritional needs and preferences, which should be reflected in the resident's medical records and tray cards. However, in this instance, the Dietary Manager failed to update Resident 1's tray card, resulting in the resident being served food they had expressed a dislike for, potentially impacting their well-being.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's rights to be free from physical abuse by another resident. The incident involved two residents, where one resident, diagnosed with Alzheimer's dementia and severe cognitive impairment, was unable to understand and make decisions. This resident was involved in a verbal and physical altercation with another resident who had schizoaffective disorder and unspecified dementia. The altercation resulted in the first resident sustaining a superficial skin tear on the hand and bleeding from the scalp. The incident occurred when the second resident became irritated by the first resident's moaning sounds and physically aggressive when the moaning did not stop. The second resident, who was alert and oriented, hit the first resident with a water pitcher after a verbal exchange. The facility's investigation revealed that the altercation was due to the second resident's demand for the bed by the window and the first resident's refusal to be quiet. The facility's policy on abuse prevention and management was not effectively implemented to prevent this incident.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for one of the residents, identified as Resident 20. During an observation and interview, it was noted that Resident 20's room had several maintenance issues, including a hole in the wall with a napkin stuffed into it, exposed drywall, and dark stains on the walls. The restroom attached to the room also had significant issues, such as a crack behind the sink, an unpainted area above the sink, a crack on the door connecting to the adjacent room, and dark stains on the floor and walls near the toilet. Resident 20 expressed dissatisfaction with the room's condition, stating it did not feel homelike and that they had requested repairs for the hole in the wall. Further investigation revealed that the necessary repairs for Room A were not logged in the Maintenance Book, which is kept at the nurse's station. This was confirmed during a concurrent interview and observation with LVN 4, who acknowledged the room's condition did not meet the standards of a homelike environment. The Director of Nursing, Acting Administrator, and Maintenance Supervisor also verified these findings during their observation and acknowledged that the room did not represent a homelike environment, as required by the facility's policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck and bit her. The incident involved two residents, one of whom was cognitively intact with a history of schizophrenia, bipolar disorder, and anxiety, while the other had moderate cognitive impairment and a history of schizophrenia and anxiety disorder. The incident occurred when the resident with cognitive impairment approached the other resident, who was sitting in her wheelchair, and struck her with open hands and bit her thumb, resulting in visible teeth marks and redness. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the failure to prevent the physical altercation between the two residents. A CNA witnessed the incident and observed blood on the floor and the resident after the altercation, although she did not see the biting occur. The facility's documentation acknowledged the incident and the resulting injury, indicating a lapse in ensuring a safe environment free from abuse.
Failure to Assess and Manage Resident's Severe Pain
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable well-being. Specifically, the facility did not assess or offer pain medication to a resident who complained of severe left knee pain. The resident had a physician's order for hydrocodone-acetaminophen to be administered as needed for severe pain, but the medical record showed no assessment or offer of pain medication on the day the complaint was made. Interviews with staff confirmed the resident's complaint of severe pain and the lack of assessment and documentation. An LVN admitted to not performing a complete assessment due to being busy and did not document offering pain medication. The DON verified these findings and acknowledged that an assessment should have been conducted and pain medication offered when the resident complained of severe pain.
Failure to Provide Required Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 10, was free from accident hazards by not providing bilateral floor mats as ordered by the physician. This deficiency was identified through observations, interviews, and record reviews. Resident 10 had a history of multiple falls and was at high risk for falls due to factors such as impaired physical mobility, impaired balance/coordination, unsteady gait, sensory deficits, and non-compliance with using call lights. The care plan for Resident 10, which was revised on January 22, 2024, included the use of floor mats as an intervention to mitigate fall risks. On June 4, 2024, during an observation, it was noted that Resident 10 was in bed without the required floor mats. Interviews with LVN 4 and the DON confirmed that there was an active physician order for bilateral floor mats, which were not in place. Both LVN 4 and the DON acknowledged the oversight and the necessity of the floor mats for Resident 10, given the resident's history of falls and the physician's order.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, as observed during a medication administration review. For Resident 8, the facility did not administer citalopram hydrobromide, an antidepressant medication, as ordered by the physician. During a medication administration observation, an LVN administered other medications to Resident 8 but omitted the citalopram hydrobromide. This oversight was confirmed during a subsequent interview and medical record review with the LVN, who acknowledged the error. The Director of Nursing (DON) also confirmed that the medication should have been administered as per the physician's order. Similarly, the facility failed to administer Austedo XR, a medication used to treat tardive dyskinesia, to Resident 9 as ordered by the physician. During the medication administration observation, the LVN administered several other medications to Resident 9 but did not include Austedo XR. This was verified during an interview and medical record review with the LVN, who confirmed the physician's order and acknowledged the failure to administer the medication. The DON also acknowledged that the medication should have been given as prescribed.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the safe storage of medications, as evidenced by an unlocked and unattended medication cart. On two separate occasions, Medication Cart A was observed parked in the hallway near Station 2, unlocked and unattended, with its drawer open and containing multiple prescription medications. This occurred in an area where multiple residents were ambulating, creating the potential for unauthorized access to the medications. During a concurrent observation and interview, an LVN confirmed that the medication cart was left unlocked and acknowledged that it should not be left unattended in such a state. The Director of Nursing was later informed of these findings and acknowledged the requirement for medication carts to be locked when unattended.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as observed during a survey. The heavy-duty blender used for puree preparation was not air-dried before use, contrary to the facility's policy and USDA Food Code 2022, which requires equipment and utensils to be air-dried after cleaning and sanitizing. During an observation, the Food Service Supervisor confirmed that the blender was dried with a paper towel instead of being air-dried, which could lead to cross-contamination. Additionally, the facility did not maintain kitchen utensils in a clean and good condition. Observations revealed a stainless spatula with a worn-off handle, a basting brush with frayed bristles, and a discolored wooden handle, all of which should have been discarded to prevent cross-contamination. The facility's policy requires the discarding of chipped or cracked dishes and utensils, aligning with the USDA Food Code 2022, which mandates that utensils be maintained in a state of good repair and cleanliness. The facility also failed to maintain the cleanliness of the kitchen hood and other equipment. The kitchen hood had blackish dirt residue, and various utensils, including knives and spoons, were found with dry food particles and water spots. The Food Service Supervisor acknowledged these findings, stating that the hood should be cleaned monthly and that utensils should be cleaned after each use to prevent cross-contamination. These deficiencies were verified during the survey and had the potential to cause foodborne illnesses among the residents.
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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.
Trusted data from CMS and state health departments
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