Primrose Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 515 Centinela Ave., Inglewood, California 90302
- CMS Provider Number
- 055608
- Inspections on file
- 43
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Primrose Post-acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, urinary retention, and an indwelling catheter, and her responsible party repeatedly requested to speak directly with the attending MD about the resident’s medical condition. An RN documented that the MD and NP were notified and told the responsible party she would ensure the MD made contact, but there was no documented follow-up. The MD later stated he and his office were never contacted about the request, and the NP reported she was not informed and had never spoken with the responsible party on the MD’s behalf. Review of nursing notes by the RN and DON confirmed there was no evidence of follow-up to ensure the communication occurred, despite facility policy stating residents have the right to communicate with and access people and services inside and outside the facility.
A resident with moderate cognitive impairment, urinary retention, obstructive/reflux uropathy, and an indwelling Foley catheter was hospitalized twice for UTI-related complications and readmitted each time. Despite being able to make medical decisions and having a history of active participation in assessments, no readmission IDT meetings were documented after either hospitalization. Progress notes showed only an invitation to a later quarterly IDT, and the resident and her RP reported they were not informed of the care plan to prevent further hospitalizations and UTIs. The SSD, LVN, and DON confirmed that facility policies require IDT meetings within one week of readmission with resident/representative participation, and acknowledged these policies and the resident’s rights to be informed and involved in care planning were not followed.
A resident with an indwelling Foley catheter, urinary retention, and obstructive/reflux uropathy had a care plan intervention directing nursing staff to monitor and document urine output, but facility records and MARs over several months showed that this monitoring was not performed. The DON confirmed that the intervention, initiated in mid-summer, was not implemented, the physician was not contacted at that time, and an order for intake and output every shift was not obtained until months later, despite acknowledging that standard nursing care for a catheterized resident includes measuring and recording output.
A resident with urinary retention, obstructive and reflux uropathy, and a chronic Foley catheter had a physician order and documented plan for urology follow-up that nursing staff did not clarify, order, or schedule. Review of progress notes over multiple months showed no coordination of the urology consultation, and the MD and NP were unsure whether any urology visit occurred or whether recommendations were obtained. An RN acknowledged that licensed nurses are responsible for reviewing MD notes and implementing planned interventions, and that failure to follow up could result in the resident not receiving physician-directed care.
A resident with moderate cognitive impairment, dependent on staff for personal care and using an indwelling catheter, and her responsible party wished to be informed and involved in IDT meetings and care planning. However, the IDT meeting for this resident was rescheduled three times at their request, and these changes were not documented in the progress notes. The SSD acknowledged that the rescheduling, including new dates, reasons, and notification of the IDT, should have been recorded, and the DON confirmed the medical record was incomplete due to this lack of documentation.
Five boxes containing invoices with resident names, DOBs, MRNs, and medical information were left unattended in a parking lot by a maintenance supervisor, exposing the personal and medical information of three residents with significant health conditions. The DON was unaware of the incident, and facility policy required confidential handling and shredding of such documents.
Surveyors found that the emergency dry food storage room was being monitored with an incorrect thermometer intended for cold food handling and freezer use, which did not provide accurate room temperature readings. The Dietary Services Supervisor acknowledged the error and stated that this could impact the safety of stored food, as the actual room temperature was unknown.
The facility did not maintain documentation or provide evidence of effective QAPI activities or governing oversight, as confirmed by the Administrator. This failure led to repeat deficiencies in resident assessments and food and nutrition services, with no records showing that these issues were addressed in QAPI meetings.
Three residents had inaccurate MDS assessments, including failure to code an anticonvulsant medication, omission of a stage 2 pressure ulcer, and not documenting the use of an anticoagulant. These errors resulted in incorrect data being sent to CMS and did not align with facility policy requiring accurate attestation of MDS information.
A resident at moderate risk for pressure ulcers, who was bedfast and required total assistance, developed a stage 2 sacral pressure ulcer after nursing staff failed to apply barrier cream and perform daily skin checks as outlined in the care plan. The omission of these interventions was confirmed by both the treatment nurse and DON, and was contrary to facility policy.
A resident with moderate cognitive impairment and total dependence on staff for personal care was transferred to a hospital without a completed inventory of personal belongings. The Social Service Director and a nurse confirmed that the inventory was not done as required by facility policy, which mandates documentation of resident property upon admission and updates as needed.
A resident with multiple diagnoses and total dependence on staff was found in bed with their call light out of reach, despite care plan instructions and facility policy requiring accessibility. Both an LVN and a CNA confirmed the importance of keeping the call light within reach to allow the resident to request assistance.
A resident with major depressive disorder was admitted without the facility completing and resubmitting a required PASARR Level I screening, despite the diagnosis qualifying as a mental illness. The previous screening from another facility did not identify a serious mental illness, and no Level II evaluation was conducted. The Case Manager confirmed that the omission meant the resident was not referred for appropriate mental health evaluation as required.
A resident with bipolar disorder and schizoaffective disorder did not receive a required PASARR Level II assessment due to the facility's failure to respond to state agency communications and timely resubmit the Level I screening, potentially resulting in unmet psychiatric care needs.
A resident with multiple chronic conditions did not have her Life Vest battery changed at the time ordered by the physician. Instead, an LVN reported only changing the battery when it beeped, rather than following the scheduled order, resulting in the device not being properly monitored as required.
A resident with a history of falls and multiple medical conditions was observed on two occasions with their bed not in the lowest position, despite care plan and physician orders requiring this as part of fall precautions. Both CNA and LVN staff acknowledged the bed should have been lowered, and the DON confirmed this protocol during interviews.
A resident with multiple medical conditions and at risk for nutritional imbalance was served a cold hard-boiled egg at breakfast, which she reported was unappetizing and inedible. Both an LVN and the Dietary Services Supervisor confirmed the egg was cold and should have been reheated before serving, in accordance with dietary service expectations.
A resident with documented lactose intolerance and a preference for Lactaid was repeatedly served low-fat milk instead of lactose-free milk, despite her care plan and dietary records specifying her needs. The resident's tray card did not reflect her dietary restriction, and the Dietary Services Supervisor confirmed the oversight, acknowledging the risk of stomach problems from the provided milk.
Staff did not follow enhanced barrier precautions for a resident with a gastric tube, as a CNA provided care without wearing a gown as required. In a separate case, a CNA failed to perform hand hygiene before and after feeding a dependent resident, despite facility policy and staff acknowledgment of the requirement.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Clindamycin for a sacral wound infection, but the IPN did not complete the required McGeer Criteria Infection Screening Evaluation form within the specified timeframe. This omission meant the appropriateness of the antibiotic order could not be validated, contrary to facility policy.
A resident with dementia and moderate cognitive impairment was the subject of a financial abuse allegation involving their representative. The Social Service Director reported the incident to APS and the DON, but failed to notify CDPH, the Ombudsman, or law enforcement as required. The facility did not conduct or submit the mandated follow-up investigation report to CDPH within five business days, instead submitting it approximately seven months later, in violation of facility policy.
Six resident rooms were found to have less than the required 80 square feet of usable living space per resident, as confirmed by facility staff and policy review. Observations showed that while residents could move about and there was space for necessary equipment, the rooms did not meet regulatory size standards.
The facility failed to report an allegation of physical abuse within the required two-hour timeframe. A resident with severe cognitive impairment was allegedly hit by another resident. The incident was not reported to the CDPH and Ombudsman until the following day, delaying the investigation and potentially placing the resident at risk for further abuse. The LVN did not report the incident to the Administrator, who is responsible for reporting such allegations. The facility had a history of late reporting of abuse allegations.
A resident at high risk for falls did not have floor mats installed as required by their care plan, despite having conditions like metabolic encephalopathy and hemiplegia. An LVN confirmed the absence of mats, and the DON acknowledged that nursing staff were responsible for implementing such interventions. The facility's policy emphasized maintaining residents' well-being through care plan adherence, yet this was not followed.
A resident with dementia reported an alleged abuse incident to a family member, which was overheard by an Activities Assistant and reported to the Social Services Director and DON. However, the allegation was not reported to the State agency within the required 24-hour timeframe, as the family member dismissed the claim as hallucination. The facility's policy mandates immediate reporting, but the incident was not reported until several days later, posing a risk of further abuse.
A facility failed to report a resident abuse incident within the required two-hour timeframe. An altercation occurred between two residents, one with heart failure and the other with schizoaffective disorder. The DON delayed reporting to the state agency to conduct an investigation, resulting in a 14-hour delay. The Administrator acknowledged the delay, citing the need to gather statements and nurses' lack of awareness about reporting procedures.
A resident with a full code status was found unresponsive in bed, and although CPR was initiated, the facility staff failed to call 911, which is a critical step in the emergency response protocol. The resident, who had a history of severe cognitive impairment and required extensive assistance, was pronounced deceased by the physician over the phone without an in-person assessment. Interviews with staff confirmed that the standard procedure was not followed, resulting in the resident's death and placing other residents at risk.
The facility failed to update its Facility Assessment to reflect the accurate resident census, with 64 residents present but only 52-53 accounted for in the assessment. The DON acknowledged the discrepancy, which could lead to the appearance of inadequate care. CMS guidelines emphasize the need for accurate census data to ensure proper resource allocation for resident care.
Two residents in a facility experienced psychological harm due to inadequate restroom access, as their room's layout obstructed the path to the restroom. Both residents, dependent on staff for toileting due to medical conditions, faced challenges as staff had to move a roommate's bed or use an adjacent room to assist them. The facility's policy allowed for adaptations to accommodate residents' needs, but the current setup did not reflect this, leading to the deficiency.
The facility failed to develop care plans for three residents, leading to potential inadequate care. A resident with multiple sclerosis and Huntington's disease lacked a care plan for a fall. Another resident with epilepsy and dyspnea had no plan for oxygen administration. A third resident with Parkinson's disease and a gastrostomy tube lacked a care plan for enteral feeding. Staff acknowledged the importance of care plans in guiding care.
The facility failed to properly label and dispose of medications, leading to potential medication errors. Unlabeled medications for a discharged resident were found in storage, and multi-dose medications for two residents lacked open dates. Staff interviews confirmed these oversights, which violated facility policies on medication storage and disposal.
The facility failed to maintain safe food storage and preparation practices, with several food items not labeled or dated, and staff not adhering to hand hygiene protocols. These deficiencies could lead to confusion about food safety and increased risk of foodborne illnesses.
The facility failed to maintain sanitary conditions in the dumpster area, as observed during an inspection with the Dietary Service Supervisor (DSS). A garbage dumpster was overfilled, preventing the lid from closing, which the DSS acknowledged could attract pests. This violated the 2022 FDA Food Code and the facility's policy on garbage disposal.
A facility failed to document a change of condition and notify the responsible party for a resident transferred to the hospital. The resident, with conditions like acute kidney failure and dementia, had no documented change of condition, violating policy and potentially worsening their condition. Interviews with staff confirmed the oversight, highlighting a breach in communication protocols.
A facility failed to ensure an accurate MDS assessment for a resident with osteoarthritis and contractures, leading to an incorrect recording of no impairment in lower extremities. The MDS nurse acknowledged the error, stating the assessment should have reflected impairment, which is crucial for proper interventions and reimbursement. The DON confirmed the importance of accurate assessments for quality care.
The facility failed to follow physician orders for a resident requiring floor mats as a fall precaution and did not properly administer medications for another resident with a g-tube. The absence of floor mats posed a risk of injury, while improper medication administration could lead to safety issues. The DON emphasized the importance of following orders and procedures to ensure resident safety.
A resident with a history of epilepsy, dyspnea, hemiplegia, and encephalopathy was administered oxygen without a physician's order, contrary to facility policy. Observations showed the resident receiving oxygen on two occasions, but a review of physician orders confirmed no authorization. Interviews with the LVN and DON highlighted the requirement for a physician order to prevent medication errors.
A facility failed to communicate a fluid restriction for a resident receiving hemodialysis to the physician, as recommended by the dialysis center. The resident, admitted with end-stage renal disease and hyperkalemia, had a fluid restriction order of 1200 cc per day, which was not conveyed to the physician. Interviews with staff revealed that the facility did not adhere to the standard of practice for managing the resident's care, leading to a deficiency.
A resident with severe cognitive impairment and serious medical conditions was found unresponsive. Despite initiating CPR, LVNs failed to call 911, contrary to the facility's emergency procedures. Interviews confirmed that staff understood the importance of calling 911 during a Code Blue, yet it was not done, leading to the resident's death.
The facility failed to document quality control checks for glucometers in two medication carts, potentially leading to inaccurate blood sugar measurements. An LVN was unable to find the necessary test solutions, and the Quality Control Records lacked documentation of calibration indices. The DON confirmed the absence of daily calibration documentation, which is required by both facility policy and manufacturer instructions.
A facility failed to report a resident's CMP results to the physician in a timely manner. The resident, with end-stage renal disease and hyperkalemia, had a physician order for a CMP, but the results were not communicated. The resident was taking Lokelma, which should have been discontinued as the potassium level was normal. The facility's policy required documentation of communication, which was not done, leading to a deficiency.
The facility failed to provide the required 80 square feet per resident in multiple rooms, leading to psychosocial harm for two residents. The inadequate space resulted in difficulties accessing restrooms, causing feelings of being rushed and fear of soiling themselves. Despite these issues, staff care was not negatively impacted.
Failure to Facilitate Resident and Responsible Party Communication With Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and her responsible party were able to communicate with the attending physician as requested, thereby not upholding their rights to communication and access to services. The resident was admitted with cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, had an indwelling catheter, and was always incontinent of bowel movements. Her history and physical indicated she was capable of making medical decisions, and the MDS showed moderate cognitive impairment but an ability to understand and be understood, with active participation by the resident and family in the assessment process. On one date, nursing progress notes documented that the physician and nurse practitioner were notified about the responsible party’s request for communication regarding the resident’s medical condition and that the clinical team would follow up. Later that same day, at the nursing station, the responsible party directly requested to speak with the physician, and the RN stated she would notify the physician and ensure contact was made. The resident also stated she wanted to speak with the physician and had requested that the RN have the physician call her or the responsible party, and she was still awaiting that call. In a subsequent interview, the physician reported that neither he nor his office had been contacted by the facility about the responsible party’s request and that he had not spoken with the responsible party. The NP stated she had not been notified of the request and had never spoken with the responsible party on the physician’s behalf. Review of the nursing progress notes with the RN and the DON showed documentation that the physician was notified of the request but no documentation of any follow-up to ensure the request was honored, and the RN acknowledged she did not know if the physician responded and stated she did not have time to follow up. The facility’s resident rights policy stated that residents have the right to communicate with and access people and services inside and outside the facility and to be supported in exercising their rights.
Failure to Conduct Readmission IDT Meetings and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct required readmission Interdisciplinary Team (IDT) meetings and include a resident and her responsible party (RP) in the development and implementation of her person-centered plan of care following hospitalizations. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and had an indwelling Foley catheter. A History and Physical dated 7/5/2025 documented that the resident could make her own medical decisions, and a Minimum Data Set (MDS) dated 7/9/2025 showed moderate cognitive impairment but indicated she was able to understand and be understood, did not reject care, and that she and her family were active participants in the assessment process. Record review showed that the resident was admitted with a Foley catheter and later hospitalized in September 2025 and again in December 2025 for complications related to a UTI, after which she was readmitted to the facility. Progress notes for September 2025 contained no indication that a readmission IDT meeting was planned or held. For December 2025, the census tab confirmed a readmission, and progress notes documented that on 12/31/2025 an invitation was sent to the resident and her RP for an IDT meeting; however, this was identified by the Social Services Director as an invitation for a quarterly IDT in January, not a readmission IDT. The progress notes did not show that any readmission IDT meeting occurred in December 2025. During interviews, the resident and her RP stated that after the December hospitalization, facility staff did not inform them about the plan of care to prevent future hospitalizations and UTIs and that they wanted to be involved in the care planning process. The Social Services Director and an LVN both stated that IDT meetings must occur for every readmission to review the resident’s condition, plan care, and uphold the resident’s right to be informed and involved in care planning. The Director of Nursing and Social Services Director confirmed that facility policies titled “Resident Rights” and “Care Planning – Interdisciplinary Team” required that residents and/or their representatives be part of IDT meetings, that such meetings occur within one week of readmission, and that any inability to participate be documented. They acknowledged that these policies were not followed for the resident’s readmissions, and that the resident’s and RP’s rights to be informed of and participate in care planning were not upheld.
Failure to Implement Care Plan Intervention for Foley Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident with an indwelling Foley catheter. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and was documented as having moderate cognitive impairment but able to understand and be understood, without disorganized thinking, acute mental status change, or rejection of care. The resident’s MDS indicated dependence on staff for toileting hygiene, bathing, and personal hygiene, and that the resident and family were active participants in the assessment process. A care plan dated 7/16/2025 for the resident’s indwelling Foley catheter included an intervention for nursing staff to monitor and document the resident’s urine output. Record review of progress notes from 7/2025 through 9/2025 showed no indication that urine output was monitored during that period. The DON confirmed that the care plan intervention to monitor urine output, initiated on 7/16/2025, was not implemented and that the physician was not contacted at that time regarding urine output monitoring. The DON also confirmed that the MARs for 7/2025, 8/2025, and 9/2025 did not show urine output monitoring and that an order to monitor intake and output every shift was not obtained until 10/20/2025, at which point total fluid output monitoring began. The DON stated that standard nursing care for a resident with an indwelling catheter should include measurement and recording of output, and that the failure to implement the care plan intervention from 7/16/2025 until 10/20/2025 placed the resident at increased risk of urinary infection and catheter-related complications. The facility’s policy on comprehensive person-centered care plans indicated that care plans are to describe services furnished to help residents attain or maintain their highest practicable physical well-being.
Failure to Clarify and Implement Physician-Directed Urology Consultation
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that a physician’s documented plan for a urology consultation for one resident was clarified, ordered, and scheduled. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and had an indwelling catheter with complete bowel incontinence. The History and Physical indicated the resident could make medical decisions, and the MDS showed moderate cognitive impairment but the ability to understand and be understood, with no rejection of care and active participation by the resident and family in the assessment process. Physician progress notes dated 9/22/2025 and 10/6/2025 documented a plan for follow-up with urology for urinary retention, and a prior physician order dated 1/27/2025 already indicated a urology consultation for obstructive and reflux uropathy and Foley catheter dependence. Despite these documented plans and orders, review of nursing progress notes for September and October 2025 showed no evidence that nursing staff clarified the physician’s progress notes or coordinated the urology follow-up. During interviews, the physician was unsure whether a urologist had been consulted, and the nurse practitioner stated that she had never reviewed any urology notes or recommendations and did not know if the appointments referenced in the progress notes occurred. The NP stated the resident’s medical history and chronic indwelling catheter placed the resident at high risk of UTIs, sepsis, and hospitalization. An RN acknowledged that licensed nurses are responsible for reviewing physician progress notes, clarifying, and carrying out planned interventions, and stated that nurses should have spoken with the physician to clarify whether a urology appointment was desired, noting that failure to follow up could result in the resident not receiving physician-directed care. The DON reviewed the records and progress notes in conjunction with surveyors, confirming the absence of documentation that the urology consultation was carried out.
Failure to Document Rescheduled IDT Meetings in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record for one resident when an Interdisciplinary Team (IDT) meeting was rescheduled multiple times. The resident was admitted with a cognitive communication deficit but was documented in the History and Physical as able to make medical decisions and, per the MDS, had moderate cognitive impairment, could understand and be understood, and did not reject care. The MDS also showed the resident was dependent on staff for toileting hygiene, bathing, and personal hygiene, had an indwelling catheter, was always incontinent of bowel, and that the resident and family were active participants in the assessment process. The resident stated she wanted herself and her responsible party to be informed and involved in IDT meetings and care planning decisions. Record review of the resident’s progress notes for the relevant month showed no indication that the IDT meeting had been delayed, rescheduled, or cancelled. The Social Services Director later stated that the resident’s IDT meeting had actually been rescheduled three times at the request of the resident and responsible party, but these changes were not documented in the progress notes. The Social Services Director acknowledged that scheduling or rescheduling of IDT meetings should have been documented in the clinical record, including the new date, the reason for the change, and whether the IDT was informed. The DON stated that the resident’s medical record was incomplete because the cancellations and rescheduling of the IDT meeting, and notification of the care team, were not documented.
Unattended Resident Records with PHI Left in Parking Lot
Penalty
Summary
The facility failed to protect resident-identifiable, personal, and medical information for three sampled residents. During an observation with the Maintenance Supervisor (MS) and the Director of Nursing (DON), five boxes containing invoices with resident names, dates of birth, room numbers, and medical record numbers were found unattended in the facility parking lot. These invoices included information from dietary, lab, intravenous, and equipment services. The MS stated that he had removed the boxes from storage and left them outside in the parking lot approximately two weeks prior, intending to dispose of them later. The DON was unaware of the boxes and stated that documents containing resident information should not have been left outside and should have been shredded. The records reviewed for the three residents included admission records, Minimum Data Set (MDS) assessments, and invoices from pathology and radiology services, all containing sensitive personal and medical information. The residents involved had significant medical conditions such as dysphagia, diabetes mellitus, acute kidney failure, hemiplegia, hypertension, Parkinson's disease, COPD, and major depression, and were all dependent on staff for activities of daily living. The facility's policy required compliance with privacy laws, including HIPAA, and specified that resident information must be kept confidential and properly disposed of, which was not followed in this instance.
Incorrect Thermometer Used in Emergency Food Storage Room
Penalty
Summary
During an observation and interview in the emergency dry food storage room with the Dietary Services Supervisor (DSS), a thermometer labeled for cold food handling and freezer use, with a range of -20 to 70 degrees Fahrenheit, was found in use. The thermometer's gauge was past the 70-degree mark, and the DSS confirmed that it was not the correct type of thermometer for monitoring the room's temperature. The DSS acknowledged that without the correct thermometer, the actual temperature of the room could not be accurately determined, which could affect the safety of the stored food. A review of the DSS job description indicated responsibility for maintaining the food storage area in a safe manner.
Lack of QAPI Documentation and Oversight Results in Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes and evidence of sufficient governing oversight to demonstrate the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) Program for the last recertification survey of 2024. During an interview, the Administrator confirmed there was no documentation of QAPI activities addressing previous deficiencies in nutrition services and resident assessments. Review of the facility's QAPI policy indicated that the QAPI committee is responsible for helping departments and services implement systems to correct quality of care issues, but there was no documentation to show these responsibilities were fulfilled. This lack of documentation and oversight resulted in repeat deficiencies in resident assessments and food and nutrition services.
Inaccurate MDS Assessments for Medications and Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with a history of cerebrovascular accident, congestive heart failure, and hypertension, Gabapentin was ordered for neuropathic pain, but the MDS assessment did not encode this medication as an anticonvulsant under section N0415. The MDS nurse confirmed that Gabapentin should have been classified as an anticonvulsant based on its pharmacological class, regardless of the prescribed reason, and acknowledged the assessment was completed inaccurately. Another resident, diagnosed with cerebrovascular accident, left elbow contracture, and osteoarthritis, developed a stage 2 pressure ulcer on the sacrum prior to discharge. However, the discharge MDS assessment failed to record the presence of this stage 2 pressure ulcer in section M0300. The MDS nurse stated that the assessment reference date for skin conditions was seven days and admitted to providing incorrect information in the discharge assessment sent to CMS. A third resident, with diagnoses including hypertension, diabetes mellitus, and hyperlipidemia, was prescribed Eliquis, an anticoagulant, as documented in the order summary and care plan. Despite this, the MDS assessment did not reflect the resident's use of an anticoagulant. The MDS nurse confirmed the omission and stated that inaccurate assessments could affect the interventions provided to residents. Facility policy required all staff completing any portion of the MDS to attest to the accuracy of the information, but this was not adhered to in these cases.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Nursing staff failed to implement the care plan interventions for a resident who was admitted with intact skin and identified as being at moderate risk for pressure ulcer (PU) development. The resident's care plan included applying barrier cream and performing daily skin checks to prevent skin breakdown, but these interventions were not carried out. Documentation showed that the resident was bedfast, had limited mobility, and required total assistance with personal care, placing them at increased risk for PU. Despite these risk factors, there was no evidence that barrier cream was applied or that daily skin assessments were documented. As a result of these omissions, the resident developed a stage 2 pressure ulcer on the sacral area, which was identified when the resident was transferred to the hospital. Interviews with the treatment nurse and DON confirmed that the prescribed interventions were not followed, and the facility's policy required daily skin inspections and use of barrier products for residents at risk. The lack of adherence to the care plan and facility policy directly led to the development of the pressure ulcer.
Failure to Complete Inventory of Personal Belongings Upon Resident Transfer
Penalty
Summary
The facility failed to complete an inventory of personal belongings for a resident who was transferred to a General Acute Care Hospital (GACH). The resident, who had a history of cerebrovascular accident with hemiplegia, left elbow contracture, and osteoarthritis, was dependent on staff for daily activities such as oral hygiene, dressing, and personal hygiene. The resident's cognitive skills were moderately impaired, requiring cues and supervision for decision-making. Upon review, it was found that the Inventory of Personal Effects form was not completed or signed by a facility representative at the time of the resident's transfer to the hospital. Interviews with the Social Service Director (SSD) and a Registered Nurse (RN) confirmed that it was the SSD's responsibility to track and safeguard residents' personal belongings, and that the inventory should be completed immediately at the time of transfer or discharge. The facility's policy required that residents' personal belongings be inventoried and documented upon admission and updated as necessary. The SSD acknowledged the importance of this process to prevent loss or theft and to protect residents' rights, but the required documentation was not completed for this resident.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, cerebral vascular accident, hypertension, and generalized muscle weakness was found to have their call light out of reach while in bed. The resident was assessed as being dependent on staff for all activities and was care planned as being at risk for falls, with specific instructions to keep the call light within reach. During an observation, the call light was found hanging behind the resident's head, making it inaccessible. Interviews with both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light should be within the resident's reach to allow them to call for assistance and prevent accidents. Review of the facility's policy also indicated that call lights must be accessible to residents in various settings, including in bed. The failure to ensure the call light was within reach constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Complete and Resubmit PASARR Screening for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident who had a diagnosis of major depressive disorder (MDD). The resident was admitted with diagnoses including MDD, cerebrovascular accident with hemiplegia, and hypertension. Review of the resident's Minimum Data Assessment indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities. The PASARR Level I screening, completed by another facility prior to admission, indicated no serious mental illness and the case was closed without a Level II evaluation. During an interview and record review, the Case Manager acknowledged that a new PASARR Level I screening should have been completed and resubmitted due to the resident's diagnosis of MDD, which is considered a mental illness. The Case Manager stated that a positive Level I screening would have triggered a Level II mental health evaluation and referral to the state mental health agency. The PASRR reference manual also indicated that a significant change in a resident's mental condition requires prompt notification to the state authority for re-evaluation.
Failure to Complete Required PASARR Level II Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a required Pre-Admission Screening and Resident Review (PASARR) Level II assessment was completed for a resident with mental health diagnoses. The resident was admitted with diagnoses including hypertension, bipolar disorder, and schizoaffective disorder, and was dependent on staff for several activities of daily living. Documentation from the Department of Health Care Services indicated that a Level II mental health evaluation was required for this resident. Despite receiving notification from the state agency, the facility did not respond to multiple attempts at communication regarding the Level II evaluation. The Medical Records Director acknowledged that the Level I screening was not resubmitted within the required timeframe after the case was closed due to lack of response. As a result, the resident may not have received the necessary psychiatric care as mandated by federal requirements.
Failure to Change Life Vest Battery as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a history of hypertension, diabetes mellitus, and congestive heart failure had the battery in her Life Vest changed according to the physician's order. The resident was dependent on staff for several activities of daily living and had a care plan indicating the need for Life Vest checks as ordered. The physician's order specified that the Life Vest battery should be changed every morning at 6:00 a.m. On the day of the survey, it was found that the night shift did not change the Life Vest battery at the ordered time. A Licensed Vocational Nurse stated that he only changed the battery when it beeped, indicating a low battery, rather than following the scheduled order. The nurse acknowledged that the physician had specified the time for the battery change and that failure to do so could result in the device not monitoring the resident's heart rhythm.
Failure to Maintain Bed in Lowest Position for Resident on Fall Precautions
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed was maintained in the lowest position as required by the care plan and physician orders for fall precautions. The resident, who had diagnoses including dementia, epilepsy, repeated falls, and muscle weakness, was admitted with a history that placed them at increased risk for falls. The care plan specifically directed that the bed be kept in the lowest position to mitigate this risk. Observations on two separate occasions found the resident's bed not in the lowest position while the resident was in bed. Certified Nursing Assistant 1 and a Licensed Vocational Nurse both acknowledged during interviews that the bed should have been lowered in accordance with fall precaution protocols. The Director of Nursing also confirmed that beds should be kept in the low position to reduce harm from falls. These findings were based on direct observation, record review, and staff interviews.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hypertension, diabetes mellitus, and hyperlipidemia was served a hard-boiled egg at breakfast that was cold and unappetizing. The resident, who was cognitively intact and at risk for nutritional imbalance, reported to surveyors that she frequently received cold food and was unable to eat the cold egg provided. Observations confirmed that the egg was cold to the touch, as verified by both a Licensed Vocational Nurse and the Dietary Services Supervisor, who acknowledged that the egg felt as if it had just come out of the refrigerator and should have been reheated. The Dietary Services Supervisor further stated that eggs are stored in the refrigerator but are expected to be reheated before serving. The job description for the Dietary Services Supervisor included responsibility for ensuring food is appetizing and meets residents' needs. The failure to provide food at an appetizing temperature resulted in the resident being unable to consume the requested protein item at breakfast.
Failure to Accommodate Lactose Intolerance in Dietary Service
Penalty
Summary
The facility failed to honor a resident's preference and medical need for lactose-free milk, despite clear documentation of lactose intolerance and a stated preference for Lactaid at all meals. The resident's admission record, history and physical, and dietary pre-screen all indicated lactose intolerance and a preference for Lactaid. The resident's care plan also specified that the facility would cater to her food preferences. However, during observation, the resident was served low-fat milk with her meal, and her tray card did not indicate her lactose intolerance or preference for Lactaid. The resident reported experiencing abdominal pain and diarrhea when consuming regular milk and stated that she continued to receive low-fat milk with every meal, contrary to her requests. The Dietary Services Supervisor confirmed the resident's lactose intolerance and acknowledged that the provided milk could cause her stomach problems. Facility policy required that resident preferences be detailed on tray cards and that trays be checked for accuracy before delivery, but these procedures were not followed in this case.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) and proper hand hygiene protocols for two residents. For one resident with multiple diagnoses including dementia, epilepsy, unspecified immunodeficiency, dysphagia, and a gastric tube, staff did not wear a gown while providing care, despite physician orders and facility policy requiring EBP for residents with medical devices. The Certified Nursing Assistant (CNA) involved acknowledged not wearing the required gown, and both the Director of Nursing and Infection Preventionist Nurse confirmed that gowns and gloves are necessary under EBP to prevent the spread of multidrug-resistant organisms. In a separate incident, another resident who was dependent on staff for all activities did not receive care in accordance with hand hygiene protocols. The CNA failed to perform hand hygiene before and after feeding the resident and after leaving and re-entering the room, contrary to facility policy. The CNA admitted forgetting to perform hand hygiene, and the Infection Preventionist Nurse confirmed the requirement to wash or sanitize hands before and after resident contact to prevent infection transmission.
Failure to Complete Infection Screening Evaluation Prior to Antibiotic Use
Penalty
Summary
The facility failed to complete the McGeer Criteria Infection Screening Evaluation for one of two sampled residents who was prescribed antibiotics. Specifically, a resident with a history of cerebrovascular accident with hemiplegia, congestive heart failure, and hypertension was admitted and later readmitted to the facility. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. A physician ordered Clindamycin for a sacral wound infection, but the Infection Preventionist Nurse (IPN) did not complete the required McGeer Criteria Infection Screening Evaluation form within three days of the antibiotic order. During a review of the resident's clinical records, the IPN confirmed that the form, which serves as a guide to determine if the resident meets the criteria for antibiotic use, was not filled out. The facility's policy and procedure on infection surveillance requires the use of standard definitions and criteria for infections, but this was not followed in this case. The IPN acknowledged that without completing the evaluation, she could not validate the appropriateness of the antibiotic prescribed.
Failure to Timely Report and Investigate Alleged Financial Abuse
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policy by not submitting the results of an investigation into an allegation of financial abuse to the California Department of Public Health (CDPH) within five working days of the incident. The incident involved a resident with dementia, osteoarthritis, and acute kidney failure, who was moderately cognitively impaired and dependent on staff for daily care. The Social Service Director (SSD) reported the suspected financial abuse by the resident's representative to Adult Protective Services (APS) and informed the Director of Nursing (DON), but did not notify CDPH, the Ombudsman, or law enforcement as required by facility policy and state regulations. A review of records showed that the initial report to APS was made on the day of the incident, but the required report to CDPH was not submitted until approximately seven months later. The facility's policy mandates that a follow-up investigation report be provided to CDPH within five business days of the incident, but this was not done. The SSD acknowledged during interviews that she was a mandated reporter and that the facility did not conduct or submit the required investigation findings to CDPH in a timely manner.
Resident Bedrooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of usable living space per resident in multiple resident bedrooms for six out of 30 resident rooms. During a facility tour, it was observed that residents in the affected rooms were able to move in and out of their rooms, and there was space for beds, side tables, and resident care equipment. However, the Maintenance Supervisor confirmed that these rooms did not meet the 80 square feet per resident requirement. A review of the facility's policy indicated that bedrooms should measure at least 80 square feet per resident in double rooms and at least 100 square feet in single rooms. The specific rooms identified had between three and four beds each, with total square footage ranging from 181 to 286 square feet, resulting in less than the required space per resident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy by not reporting an allegation of physical abuse within the required two-hour timeframe. This incident involved two residents, where one resident allegedly hit another. The incident occurred on the evening of December 5, 2024, but was not reported to the California Department of Public Health (CDPH) and the Ombudsman until the following day, December 6, 2024, at 12:29 p.m. This delay in reporting resulted in a delay in the investigation by the CDPH and had the potential to place the affected resident at risk for further abuse. The affected resident, who was allegedly hit, had a history of unspecified dementia, cerebral infarction with hemiplegia, and metabolic encephalopathy, and was assessed to have severely impaired cognitive skills for daily decision-making. The resident required moderate assistance with personal care activities. The resident who allegedly committed the abuse had intact cognitive skills and required supervision for personal care activities. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for incidents involving abuse or serious bodily injury. During interviews, it was revealed that the Licensed Vocational Nurse (LVN) who was aware of the incident did not report it to the Administrator, who is the designated abuse coordinator. The Administrator was responsible for reporting such allegations to the CDPH and Ombudsman. The LVN acknowledged that the allegation should have been reported sooner to ensure the safety of the resident and to allow for a timely investigation. The facility had been cited in the past for late reporting of abuse allegations, indicating a pattern of non-compliance with reporting requirements.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to install floor mats for a resident who was identified as high risk for falls, as indicated in the resident's care plan. The resident, who had a history of metabolic encephalopathy, hemiplegia, dementia, and cerebral infarction, was assessed as high risk for falls. The care plan specifically required floor mats to be placed on both sides of the resident's bed to prevent injury from falls. However, during an observation, it was noted that the floor mats were not in place, which was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the absence of the mats and the potential risk of injury to the resident. The Director of Nursing (DON) stated that it was the responsibility of the nursing staff to implement care plan interventions, including the provision of floor mats for the resident. The facility's policy on care plans emphasized the importance of providing services to maintain the residents' highest practicable level of well-being, which includes adhering to the care plan interventions. Despite this policy, the failure to provide the necessary floor mats as outlined in the care plan was observed, indicating a lapse in the implementation of prescribed safety measures for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State agency within the required 24-hour timeframe. The resident, who had diagnoses including dementia, urinary tract infection, hemiplegia, and cerebral infarction, reported to a family member over the phone that someone attempted to crawl into her bed and rape her. The family member dismissed the claim as hallucination and confusion. The Social Services Director was informed of the allegation by the Activities Assistant, who overheard the conversation, and subsequently reported it to the Director of Nursing. Despite being informed, the Director of Nursing did not report the allegation to the State agency, citing the family member's dismissal of the claim as the reason. The Administrator was only informed of the incident several days later. The facility's policy requires immediate reporting of such allegations, defined as within two hours for serious bodily injury or within 24 hours for other allegations. The failure to report the allegation in a timely manner was acknowledged by the staff involved, recognizing the potential risk of further abuse to the resident.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to implement its abuse Policy and Procedure (P&P) regarding the timely reporting of an abuse incident to the State Licensing/Certification Agency. The policy required that any allegation of abuse be reported immediately, but no later than two hours. However, an incident involving physical assault between two residents was reported to the state agency approximately 14 hours after it occurred. The Director of Nursing (DON) was informed of the altercation shortly after it happened, but delayed reporting to conduct an investigation first. Resident 1, who had diagnoses including heart failure, end-stage renal disease, and hypertension, was physically assaulted by Resident 2, who had schizoaffective disorder, diabetes, and hypertension. Despite the facility's policy, the DON and Administrator acknowledged the delay in reporting the incident, attributing it to the time taken to gather statements and a lack of awareness among nurses about completing the report. This delay in reporting had the potential to hinder the state agency's investigation and placed residents at risk for further abuse.
Failure to Call 911 During CPR for Unresponsive Resident
Penalty
Summary
The facility failed to implement its emergency procedures for cardiopulmonary resuscitation (CPR) by not calling 911 when a resident, who had a full code status, was found unresponsive in bed. The resident, identified as Resident 65, was observed by a Certified Nurse Assistant (CNA) to be flaccid, cool to touch, and nonresponsive. Despite initiating CPR, the facility staff did not call 911, which is a critical step in the emergency response protocol. Resident 65 had a medical history that included encephalopathy, sepsis, acute respiratory failure, and pneumonia. The resident was severely cognitively impaired and required extensive assistance with activities of daily living. On the day of the incident, the resident was found unresponsive at 4:00 a.m., and CPR was performed by two Licensed Vocational Nurses (LVNs) for 20 minutes. However, 911 was not called, and the resident's physician was notified instead, who pronounced the resident deceased over the phone without an in-person assessment. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), confirmed that the standard procedure during a code blue is to initiate CPR and call 911 immediately. The facility's policy also indicated that staff should continue CPR until emergency medical personnel arrive. The failure to call 911 during the emergency for Resident 65 resulted in the resident's death and placed other residents with full code statuses at risk of not receiving timely life-saving measures.
Removal Plan
- Cardio-Pulmonary Emergencies/CPR in-services were initiated for all licensed staff and certified nurse assistants (CNAs).
- Physician Orders for Life-Sustaining Treatment (POLST) in-services was initiated by the DSD to licensed nurses. Training referred to the section titled Directions for Healthcare Provider.
- The Director of Staff Development (DSD) conducted a review of the employee files pertaining to the nursing dept, specially checking for CPR certifications. The DSD did not find any expired CPR certificates.
- The DON conducted an in-service informing licensed nurses about the notification procedures following a death in the facility which included prompt notification to the DON and Administrator.
- An annotated provider was invited to provide the nursing staff an in-service regarding emergency response during CPR.
- During daily clinical meetings, the DON will review all reported changes in condition to ensure comprehensive assessment of changes, evaluation of initial interventions, identification of additional needs, implementation of adjustments, follow-up, and thorough documentation.
- The Registered Nurse Supervisor will review admissions with a particular focus on POLST and their accurate completion. Any review findings will be completed by the RN, and a summary will be submitted to the DON.
- The RN Supervisor will review any changes of a resident's condition and report any concerns to the DON to ensure adequate interventions were provided.
- The DSD will provide weekly reports on the emergency response CPR review for newly hired staff, if applicable. For employees who undergo annual reviews, the DSD will report monthly to the DON.
- The emergency response system will be reviewed during the annual competency evaluation by the DSD and reported to the DON for acknowledgement.
- The Administrator will update the Quality Assessment & Assurance (QA&A) committee during Quality Assurance (QA) meetings for progress of action plan or if revisions are necessary.
Inaccurate Resident Census in Facility Assessment
Penalty
Summary
The facility failed to update and provide an accurate resident census in its Facility Assessment, which is crucial for determining the resources necessary to care for residents competently. On May 7, 2024, the facility census indicated there were 64 residents, but the Facility Assessment, last revised on January 1, 2024, accounted for only 52-53 residents. This discrepancy was identified during a review on May 10, 2024, when it was noted that the Facility Assessment did not match the current census for the provision of Activities of Daily Living (ADL). During interviews, the Director of Nursing (DON) acknowledged the mismatch between the recorded census and the actual number of residents receiving care. The DON admitted responsibility for maintaining an accurate census and expressed uncertainty about the cause of the error. The Administrator also confirmed that the Facility Assessment should reflect all metrics of care provided to residents, emphasizing the risk of appearing as if some residents were not being cared for. The Centers for Medicare and Medicaid Services (CMS) guidelines require facilities to evaluate their resident population and identify necessary resources for person-centered care, highlighting the importance of accurate census data.
Inadequate Restroom Access for Residents
Penalty
Summary
The facility failed to provide adequate space for two residents, Resident 28 and Resident 39, to access their room's restroom, resulting in psychological harm due to the fear of soiling themselves. Both residents were dependent on staff for assistance with toileting due to their medical conditions, which included dementia, polyneuropathy, hemiplegia, and severe cognitive impairments. Observations revealed that the restroom access was obstructed by a roommate's bed, requiring staff to move the bed or take the residents through an adjacent room to use the restroom. Interviews with the residents and staff highlighted the challenges faced due to the inadequate space. Resident 28 expressed feeling rushed and afraid of soiling herself, while Resident 39 felt frustrated and feared not reaching the restroom in time. Staff members, including a CNA and an LVN, confirmed the need to move the roommate's bed to assist the residents, although the LVN was unaware of the specific procedures used by staff at that station. The Director of Nursing acknowledged the difficulty in accessing the restroom and the potential risks involved, such as limiting residents' ability to use the restroom freely and increasing the risk of falls. The facility's Administrator did not initially believe that the inadequate space reduced the quality of care but recognized the challenges it posed for both staff and residents. The facility's policy on accommodating individual needs indicated that adaptations could be made to the physical environment, such as moving furniture to prevent obstruction. However, the current room arrangement did not align with this policy, leading to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which could potentially lead to inadequate care. Resident 44, who has multiple sclerosis, Huntington's disease, and insomnia, did not have a care plan addressing a fall that occurred on March 22, 2024. Despite being dependent on staff for activities of daily living, there was no documented plan to guide staff in providing appropriate care following the fall. Both the Registered Nurse and the Director of Nursing acknowledged the absence of a care plan and emphasized its importance in ensuring residents receive the necessary care and interventions. Resident 16, diagnosed with epilepsy, dyspnea, hemiplegia, and encephalopathy, also lacked a care plan for oxygen administration. The resident, who is dependent on staff for daily activities and lacks decision-making capacity, did not have a documented plan to guide staff in managing their care needs. The Licensed Vocational Nurse confirmed the absence of a care plan and highlighted the risk of improper care without it. Similarly, Resident 53, with Parkinson's disease, asthma, congestive heart failure, and adult failure to thrive, did not have a care plan for their gastrostomy tube. The resident, who is dependent on staff for daily activities and lacks decision-making capacity, had a physician's order for enteral feeding but no care plan to guide staff in its administration. The Licensed Vocational Nurse and the Director of Nursing both recognized the importance of care plans in guiding staff and ensuring proper care for residents.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications, leading to potential medication errors. For one resident who was discharged, nine medications were found unlabeled in the medication storage closet. The medications included Mirtazapine, Metoprolol, Atorvastatin, Famotidine, Eliquis, and Carbidopa-Levodopa. The Registered Nurse (RN) responsible for collecting and labeling these medications did not follow the facility's policy, which requires labeling with the resident's name, discharge location, and date of transfer. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the absence of labeling and acknowledged the risk of medication errors due to improper storage. Additionally, the facility failed to label multi-dose medications with an open date for two residents. One resident was receiving lactulose for constipation, and another was receiving insulin lispro for diabetes management. During an observation, it was noted that the multi-dose vial of insulin lispro and the container of lactulose did not have open dates. The Licensed Vocational Nurse (LVN) stated that the open date is crucial for determining the expiration of the medication, and the absence of this information could lead to the administration of expired and potentially ineffective medication. The facility's policies on medication storage and disposal were not adhered to, as evidenced by the lack of labeling and proper disposal of medications. The facility's policy requires that discontinued or outdated medications be returned to the pharmacy or destroyed, and that multi-dose containers be labeled with the date opened. The failure to comply with these policies was confirmed by the DON, who acknowledged that such oversights could result in medication errors and ineffective treatment for residents.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Several food items in the dry storage area, Refrigerator 1, Freezer 1, Freezer 2, and Freezer 3 were not dated and labeled, which could lead to confusion about the freshness and safety of the food. The Dietary Service Supervisor acknowledged that all food items should be labeled and dated according to the facility's policies. The facility's policies from 2018 require labeling and dating of all food items upon delivery and during storage to ensure proper rotation and usage. Additionally, there were multiple instances of inadequate hand hygiene and glove use among the dietary staff. Dietary Aide 1 did not wash hands or wear gloves while cleaning a stainless-steel table, and another staff member handled a scooper with bare hands. Dietary Aide 2 failed to wash hands after picking up a dirty towel from the floor. These actions were contrary to the facility's hand hygiene policy and the 2022 U.S. Food and Drug Administration Food Code, which emphasize the importance of handwashing to prevent cross-contamination and foodborne illnesses.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster area in a sanitary manner. During an observation and interview with the Dietary Service Supervisor (DSS), it was found that one garbage dumpster was overfilled, preventing the lid from closing. The DSS acknowledged that the open lid was due to the overfilled trash and stated that open trash bins attract unwanted pests. This situation was in violation of the 2022 U.S. Food and Drug Administration Food Code, which requires outside receptacles to have tight-fitting lids to prevent the scattering of garbage and entry of pests. Additionally, the facility's policy and procedure on food-related garbage and refuse disposal, revised in 2017, mandates that outside dumpsters be kept closed and free of surrounding litter.
Failure to Document Change of Condition and Notify Responsible Party
Penalty
Summary
The facility failed to ensure a change of condition was documented and the responsible party was notified for a resident who was transferred to the hospital. The resident, who had diagnoses including acute kidney failure, cerebral infarction, dementia, and hypertension, was admitted to the facility with the capacity to understand and make decisions. Despite this, there was no documentation of a change of condition for the hospital transfer, which is a requirement according to the facility's policy. Interviews with the LVN and the DON revealed that the lack of documentation meant there was no way to confirm if the physician or responsible party was notified, potentially leading to the resident's condition worsening. The facility's policy mandates that a nurse must notify the resident's representative of significant changes in the resident's status, including hospital transfers, within twenty-four hours, except in emergencies. This deficiency violated the resident's rights and the responsible party's right to be informed.
Inaccurate MDS Assessment for Resident's Range of Motion
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, specifically regarding functional limitation in range of motion. The resident, who was admitted with diagnoses including osteoarthritis and contractures, had a Rehab Joint Mobility Screen Assessment indicating severe impairment in range of motion in multiple joints. However, the MDS assessment inaccurately recorded no impairment in the lower extremities, which was acknowledged as incorrect by the MDS nurse during a review. The MDS nurse admitted that the assessment should have been coded to reflect impairment on both sides of the lower extremity, emphasizing the importance of accuracy for proper interventions and facility reimbursement. The Director of Nursing confirmed that the standard practice is to provide accurate MDS assessments to ensure adequate and quality care. The facility's policy requires individuals completing portions of the MDS to certify the accuracy of their assessments, which was not adhered to in this instance.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper care and adherence to physician orders for two residents, leading to deficiencies in care. For Resident 44, who has multiple sclerosis, Huntington's disease, and insomnia, the facility did not follow physician orders to place floor mats beside the bed as a fall precaution. During an observation, it was noted that no floor mats were present, and the CNA confirmed their absence, acknowledging the potential risk of injury to the resident. The Director of Staff Development and the Director of Nursing both emphasized the importance of following physician orders to prevent potential harm to residents. For Resident 8, who has acute kidney failure, type 2 diabetes mellitus, hypertension, and dementia, the facility failed to check g-tube residuals before medication administration and used the same syringe to stir multiple medication cups. During an observation, LVN 3 did not check the residuals, which is crucial to ensure the resident is absorbing food properly. The DON highlighted the safety issue, noting that failure to check residuals could lead to overfeeding and vomiting. Additionally, using the same stirring utensil for different medications could obscure the cause of any adverse reactions. The facility's policy requires each medication to be administered separately with purified water, which was not followed in this instance.
Oxygen Administration Without Physician Order
Penalty
Summary
The facility failed to ensure that respiratory care was consistent with professional standards of practice for a resident who was administered oxygen without a physician's order. Resident 16, who had a medical history including epilepsy, dyspnea, hemiplegia, and encephalopathy, was observed receiving oxygen via nasal cannula on two separate occasions. However, a review of the resident's physician orders revealed no authorization for oxygen administration. Interviews with the LVN and the DON confirmed that a physician order is required for oxygen administration, as it is considered a medication. The absence of such an order poses a risk of medication error, as staff would not know the appropriate amount of oxygen to administer. The facility's policy on oxygen administration, which mandates verification of a physician's order, was not followed in this instance.
Failure to Communicate Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis received treatments in accordance with standards of practice. Specifically, the facility did not communicate the fluid restriction recommended by the hemodialysis center to the resident's physician, nor did they monitor the resident for signs and symptoms of fluid overload. This oversight involved Resident 216, who was admitted with diagnoses including end-stage renal disease and hyperkalemia. The resident had a physician order for hemodialysis treatment three times a week and was on a fluid restriction of 1200 cc per day, which was not communicated to the physician. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the facility did not follow the standard of practice in managing the resident's care. The Director of Nursing acknowledged the failure to collaborate with the hemodialysis center and communicate the fluid restriction to the physician. A Registered Nurse confirmed that the fluid restriction order was present upon the resident's admission but was not communicated to the physician, which is essential for managing a resident receiving dialysis treatment. The facility's policy on caring for residents with end-stage renal disease was not adhered to, leading to this deficiency.
Failure to Call 911 During Code Blue Results in Resident's Death
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to provide emergency care, resulting in the death of a resident. The incident involved a resident with severe cognitive impairment and multiple serious medical conditions, including encephalopathy, sepsis, acute respiratory failure, and pneumonia. The resident was found unresponsive by a CNA, who then notified an LVN. Despite initiating CPR, the LVNs did not call 911, which was a critical step in the emergency response protocol. Interviews with various staff members, including CNAs, LVNs, an RN, and the DON, revealed a consistent understanding that 911 should be called immediately during a Code Blue to provide advanced cardiac life support. The facility's policy also mandated calling 911 in such situations. However, in this case, the LVNs performed CPR for 20 minutes without contacting emergency services, and the resident's death was pronounced by the primary physician over the phone. This failure to call 911 was identified as a deficiency in the facility's emergency response procedures.
Failure to Document Quality Control Checks for Glucometers
Penalty
Summary
The facility failed to document quality control checks for two medication carts in Nursing Station 1, which could lead to inaccurate blood sugar measurements for residents requiring such checks. During an observation and interview with an LVN, it was found that the glucometer test solutions were missing from both medication carts, and the LVN was unable to locate them. The LVN acknowledged that the glucometer's results could be inaccurate if not calibrated daily, a task typically performed by the night shift. Further review of the Quality Control Records for May 2024 revealed that there was no documentation of blood sugar calibration quality control indices, such as test strip lot numbers and expiration dates, for both carts. The Director of Nursing confirmed the absence of documentation for calibration on a specific date and emphasized the importance of daily calibration to ensure accurate blood sugar results. The facility's policy and the manufacturer's instructions both require daily calibration checks, which were not documented.
Failure to Report Laboratory Results to Physician
Penalty
Summary
The facility failed to ensure that the laboratory test results of a Comprehensive Metabolic Panel (CMP) for a resident with end-stage renal disease and hyperkalemia were reported to the physician in a timely manner. The resident was admitted with these diagnoses and had a physician order to check the CMP. The test was conducted, but there was no documentation indicating that the results were communicated to the physician. The Director of Nursing (DON) confirmed that the results were available in the resident's chart but had not been reported. The resident was taking Lokelma, a medication for high potassium levels, which should have been discontinued as the resident's potassium level was within the normal range. The facility's policy required staff to document when, how, and to whom the laboratory results were communicated, but this was not done. The lack of communication and documentation regarding the laboratory results constituted a deficiency in the facility's care for the resident.
Inadequate Room Space Leads to Psychosocial Harm
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in several rooms, specifically rooms 1, 2, 3, 5, 22, and 31. These rooms did not meet the regulatory requirement of 80 square feet per resident, with room sizes ranging from 181 to 286 square feet for three to four residents. This deficiency was identified through observation and record review, and it was noted that the facility had previously submitted a waiver request acknowledging the non-compliance. The inadequate space in these rooms led to psychosocial harm for two residents. One resident, who was unable to walk, reported feeling rushed and afraid of soiling herself due to the need for staff assistance to access the restroom, which was obstructed by a roommate's bed. Another resident expressed frustration and fear of not reaching the restroom in time, as she also required staff assistance and was sometimes taken to other residents' rooms to use the facilities. Despite these issues, the observations did not indicate that the space constraints interfered with the provision of care or services by the staff.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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