Royal Palms Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 630 W. Broadway, Glendale, California 91204
- CMS Provider Number
- 055899
- Inspections on file
- 59
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Royal Palms Post Acute during CMS and state inspections, most recent first.
A resident with DM, a left BKA, and on dialysis, who required substantial assistance with ADLs and was cognitively intact, was assessed as high risk for falls based on a fall risk evaluation. Despite this, no fall risk care plan was developed or implemented. The resident later called for help and was found on the floor in a kneeling position by the bed with severe left hip pain, and was subsequently diagnosed with a left intertrochanteric femur fracture. The MDSC acknowledged the fall risk assessment had been wrongly coded and that a high fall risk care plan should have been initiated, and the DON confirmed that a fall risk care plan should have been completed in accordance with facility policy.
A resident with advanced dementia, severe cognitive impairment, and a low BIMS score was known by staff to be profoundly confused, disoriented, and frequently wandering into other residents’ rooms, including both female and male rooms, requiring frequent redirection. Despite an altercation in which the resident entered a roommate’s personal space at the bedside and was struck, and despite complaints from other residents, RNs and the SSD reported there were no specific care plan interventions or assigned staff monitoring to address the wandering behavior. The MDS did not code the resident as significantly intrusive wandering, and the MDS coordinator confirmed that no individualized, person-centered care plan had been developed to manage the resident’s behavior, contrary to facility policy requiring comprehensive care plans with measurable objectives and timetables.
A resident with UTI, pneumonia, sepsis, multiple pressure injuries, impaired skin integrity, and an indwelling urinary catheter had physician-ordered Enhanced Barrier Precautions (EBP) and care plan interventions requiring staff to use gowns and gloves for high-contact care. Surveyors found that no EBP signage or PPE was placed outside the resident’s room, and a CNA provided hands-on care, including handling the Foley catheter bag and bedding, without PPE, stating they were unaware EBP was required. An RN and the Infection Preventionist confirmed that EBP should have been implemented per the physician’s order and facility infection control policy, but it was not.
The facility failed to implement its IPCP for suspected scabies by not initiating a line list for affected residents and staff, not updating infection surveillance logs to include residents with suspicious rashes treated with Permethrin, and not performing skin scrape tests before prophylactic scabies treatment. A resident with neuropathy and DM developed a rash and was treated with Permethrin months earlier without a skin scrape or surveillance tracking, and later experienced a recurrent generalized rash that was again treated before testing. Three additional residents with multiple comorbidities developed generalized rashes, were placed on contact precautions, and received Permethrin (and for some, Ivermectin and Hibiclens) before skin scrapes were obtained, with specimens left at the front desk for two days before lab pickup. Despite multiple symptomatic residents and reports of staff rashes, the IP did not maintain a current surveillance log or line list and delayed reporting a suspected scabies outbreak to public health until several days after multiple residents were already on contact precautions.
Surveyors found that staff failed to follow facility policy for timely medication administration and documentation for three residents. Multiple medications scheduled for a specific morning time were documented as given outside the required one-hour window, and an LVN admitted she had pre-signed the MARs before actually administering the medications and was late giving them. The affected residents had conditions including alcoholic cirrhosis with ascites, diabetes, heart disease, and sequela of cerebral infarction, with varying levels of cognitive function and ADL dependence. One resident reported that medications were sometimes not given on time, especially on the night shift. A supervising RN confirmed that facility policy required medications to be given within one hour of the ordered time and documented immediately after administration. The report states that this practice resulted in delayed medication administration and had the potential to compromise residents’ health.
Three residents at high risk for falls were not adequately supervised or provided a hazard-free environment. One resident with cognitive impairment and mobility deficits was left unsupervised in the bathroom and suffered a head injury after a fall. Another resident's bed was not kept in the lowest position as required, and a third resident was found on the floor with the call light out of reach while the assigned CNA was on break and had not arranged for coverage. These deficiencies resulted in actual harm and placed all three residents at risk for serious injury.
A resident who was fully dependent for ADLs and had severe cognitive and physical impairments was left in a wet and soiled incontinence brief for several hours, contrary to their care plan. The CNA responsible had not checked or changed the resident since the morning, resulting in observed skin irritation. Facility staff acknowledged that incontinence care should have been provided more frequently.
A resident with ESRD, diabetes, and dementia was discharged as 'against medical advice' after failing to return from a scheduled dialysis appointment, without proper documentation, care planning, or evidence of communication with the resident or their contacts. The facility did not follow its own policies for discharge preparation or documentation, and there was no physician discharge order or interdisciplinary review.
A resident with end stage renal disease, diabetes, and dementia repeatedly left the facility without permission and missed dialysis appointments, yet the facility did not implement or document behavioral interventions, care plan revisions, or interdisciplinary team involvement as required. The facility also failed to communicate with the resident's family or emergency contacts and did not initiate a psychiatric evaluation as ordered.
A resident diagnosed with impetigo was not placed on contact isolation after a physician's order for hospital transfer, and two roommates exposed to the infection were also not placed on isolation or enhanced barrier precautions. Staff did not post isolation signage or use PPE, and no care plans or physician orders for isolation were initiated, contrary to facility policy and CDC guidelines.
A resident tested positive for CRAB, a rare multidrug-resistant organism, but the facility did not promptly initiate surveillance, notify CDPH, or inform the primary and attending physicians of the affected and exposed residents. The DON delayed recommended screenings and failed to document the exposure or notify medical staff, contrary to facility policy.
The facility failed to properly dispose of garbage, with one dumpster found without a lid and overflowing, and the garbage area littered with waste and rubbish. The DON, HKS, MS, and DSS acknowledged the oversight, which could attract pests and spread infection. Facility policy requires food waste to be contained and dumpsters to be closed, which was not followed.
A resident's call light was found inaccessible, stuck behind the bed and on the floor, preventing the resident from calling for assistance. The resident, with conditions including difficulty in walking and muscle weakness, was unable to reach the call light, as confirmed by staff and the Director of Nursing. The facility's policy requires call lights to be accessible and functioning at all times.
A resident with mental health diagnoses was not referred for a required PASRR Level II evaluation after a positive Level I screening. The facility's oversight was discovered during a record review, revealing no documentation of the necessary referral. Staff interviews confirmed the lapse in following up on the PASRR requirement, highlighting the absence of a system to ensure compliance.
A resident with quadriplegia developed a Stage 1 pressure injury due to the facility's failure to update the care plan. Despite existing care plans for skin integrity, the plan was not revised when the injury was identified, as confirmed by staff interviews. The DON acknowledged the oversight, which left the resident at risk for further complications.
A resident's care plan was not updated to include Febuxostat, a medication prescribed for gout, despite being on the medication since late 2024. This oversight was confirmed by facility staff, who acknowledged the importance of updating care plans to monitor treatment effectiveness. The facility's policy requires care plans to be revised with new resident information, which was not followed in this case.
A facility failed to provide a communication tool for a resident with dementia and Alzheimer's who did not speak the facility's formal language. The resident, with severely impaired cognition and dependent on care, lacked translation materials in their room, hindering communication with staff. A CNA and the DON acknowledged the absence and necessity of such tools, contrary to the facility's policy on language access.
A resident with communication difficulties and at risk for falls did not have their call light within reach, as observed during a room visit. Facility staff confirmed the importance of call light accessibility for timely assistance, as per facility policies. The deficiency had the potential to prevent the resident from receiving necessary care.
Two residents in a facility experienced deficiencies in pressure ulcer care and prevention. One resident's low air loss mattress was not set to their correct weight, contrary to guidelines, risking skin breakdown. Another resident developed a Stage 1 pressure injury that progressed to Stage 2 due to the care plan not being updated with necessary interventions. These failures in adhering to facility policies and procedures resulted in inadequate care and increased risk for the residents.
Two residents in an LTC facility experienced deficiencies in oxygen administration. One resident, with a history of respiratory issues, was found with their nasal cannula on the floor, not receiving prescribed oxygen. Another resident was administered oxygen without a physician's order, contrary to facility policy. These lapses in following protocols had the potential to impact the residents' health.
A resident with benign prostatic hyperplasia did not receive their prescribed Finasteride due to the facility's failure to reorder the medication in a timely manner. The LVN responsible did not document the refill request, and the medication was unavailable during a scheduled administration. The DON confirmed that the facility's policy requires timely reordering and documentation of medication orders.
The facility failed to ensure that two residents signed their POLST forms before placing them in their medical charts. Despite having intact cognition, the residents' POLST forms were prepared but not signed, leading to incomplete documentation. Staff interviews revealed a lack of adherence to the process for completing and filing POLST forms, with signed forms not being placed in the residents' charts as required.
The facility failed to maintain a safe and clean environment in two bathrooms, where paint was peeling, and grout was discolored, posing potential infection risks. The Maintenance Supervisor confirmed these issues, which contradicted the facility's policy for a homelike environment.
Two residents with cognitive impairments were found with cigarette lighters, violating the facility's smoking policy. Despite requiring supervision, staff failed to enforce the policy, posing a fire risk, especially with oxygen present. Interviews revealed staff were unaware of the residents' possession of lighters, highlighting a lapse in safety practices.
The facility failed to meet the required square footage for 40 out of 54 resident rooms, with 5 two-bedroom and 35 three-bedroom configurations not providing the minimum space per resident. Despite this, residents reported adequate space for mobility and care, and no deficits in care or safety were observed during the survey.
A facility failed to notify a resident's representative of a diabetic ulcer, violating the policy requiring prompt notification of changes in medical condition. The resident, with severe cognitive impairment and type 2 diabetes, had a documented ulcer upon readmission, but the representative was not informed, preventing timely medical intervention. Interviews revealed the representative was unaware of the ulcer until the resident's transfer to a hospital, and the Social Services Director confirmed the lack of documentation of communication.
A facility failed to develop a person-centered care plan for a resident's Prevalon boots, lacking instructions on cleaning and maintenance. The resident, with conditions like encephalopathy and diabetes, had a care plan mentioning the boots but no maintenance guidance. Staff interviews revealed a lack of documentation and understanding of boot care, posing an infection risk. The facility's policy required care plans to maintain resident well-being, but this was not followed, leading to potential infection control issues.
A resident with end-stage renal disease and severely impaired cognition repeatedly refused medications and supplements, but the LTC facility failed to develop a comprehensive care plan or inform the responsible party. Despite requests for an IDT meeting, none was held, leading to the resident's hospitalization due to severe weakness and abnormal lab values.
A resident with a recent tooth extraction was not provided the prescribed pureed diet, leading to frustration and meal refusal. Despite the resident's requests and communication with staff, the facility continued to serve a regular diet due to a breakdown in communication and oversight in updating dietary orders.
A resident with diabetes mellitus had a new order for Lantus insulin that was not updated in their care plan, despite high Hemoglobin A1C levels. This oversight was confirmed by nursing staff and the DON, indicating a failure to provide timely treatment for the resident's condition.
A resident's care was compromised when a facility failed to notify the physician about a medication alert for Lantus, resulting in a dose below the usual range. Additionally, an endocrinology consult was not completed due to a lack of communication among staff, despite an elevated hemoglobin A1C result. These oversights were contrary to the facility's policies and procedures.
A resident with diabetes and a high hemoglobin A1C level did not receive a timely endocrinology consult due to a communication breakdown in the facility. The physician's order for the consult was not followed up, as the social worker was not informed, leading to a delay in treatment. Staff interviews confirmed the oversight, highlighting a failure to adhere to the facility's policy on social services involvement.
A resident with diabetes and ileus reported a grievance about an improperly administered enema to an RN, who informed the ADON. However, the ADON did not follow up, and the grievance was neither documented nor resolved, violating the facility's grievance policy.
A resident with severe cognitive impairment and aggressive behaviors was prescribed Trileptal, but the facility failed to monitor the effectiveness of the medication. Despite daily administration, there was no documented evidence of behavior monitoring, as confirmed by the ADON and DON, placing the resident at risk for unnecessary medication.
A resident missed two dialysis treatments due to transportation issues, and the facility failed to promptly notify the attending physician and the resident's emergency contact. The missed treatments were not documented in the resident's medical records, leading to a delay in addressing the issue. The resident was later transferred to a hospital for severe complications.
The facility failed to arrange transportation for a resident to attend scheduled dialysis treatments on two occasions, resulting in missed treatments and the resident's transfer to an acute hospital for severe health risks. The staff was aware of the transportation issue but did not take timely action to resolve it, and the resident's family was not informed until the resident's condition worsened.
A CNA in a LTC facility tied a resident to a wheelchair with a bed sheet to prevent the resident from getting up while attending to another resident. The resident, who had severe cognitive impairment and was at high risk for falls, expressed feelings of helplessness and fear. The CNA did not seek help or inform the LVN on duty, and the restraint was discovered by a ST who reported it to the DOR. The DON confirmed the use of the bed sheet as a restraint was inappropriate.
A resident with severe cognitive impairment was found tied to a wheelchair by a CNA, who admitted to using a bed sheet to prevent falls. The incident was reported to a charge nurse but not to the facility's abuse coordinator until the next day, resulting in an 18-hour delay in notifying authorities. This violated the facility's policy requiring immediate reporting of abuse allegations.
A resident with severe cognitive impairment received medications from a CNA, who was not licensed or trained to administer them. An LVN improperly delegated this task, violating facility policy and placing the resident at risk. Interviews with staff confirmed that CNAs are not permitted to administer medications, as outlined in the facility's policy and job descriptions.
Failure to Develop and Implement Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing fall risk for a resident who was at high risk for falls. The resident was admitted with diagnoses including diabetes mellitus, a left below-knee amputation, and was receiving dialysis. An MDS dated 3/3/2026 showed the resident was cognitively intact with a BIMS score of 15, and required substantial/maximal assistance for personal hygiene, dressing, toileting hygiene, and putting on/taking off footwear, and partial/moderate assistance with oral hygiene and eating. A Fall Risk Evaluation dated 2/20/2026 was completed, but the MDS Coordinator later stated it was wrongly coded and that the resident was actually at high risk for falls. The DON also stated that the fall risk evaluation showed a high-risk fall score of 16. On 2/20/2026 at approximately 9:00 PM, the resident called for help and staff found the resident on the floor in a kneeling position next to the end of the bed, facing the bathroom, unable to get up without assistance and reporting severe left hip pain. A Change of Condition Evaluation documented this event at 10:03 PM. A subsequent hospital orthopedic surgery history and physical dated 2/22/2026 indicated the resident had sustained a left intertrochanteric femur fracture after the injury on 2/20/2026. During interviews, the MDS Coordinator confirmed that no fall risk care plan had been completed for this resident despite the high fall risk, and the DON confirmed that a care plan for risk of falls should have been completed. The facility’s policy on comprehensive person-centered care stated that care plan interventions are to be based on thorough assessment and are intended to prevent or reduce decline in residents’ functional level.
Failure to Care Plan for Resident Wandering and Room Intrusions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with specific, measurable interventions to address a resident’s wandering behavior, particularly entering other residents’ rooms. The resident was originally admitted with dementia with behavioral disturbance, anxiety disorder, vascular dementia, and confusional arousals. An MDS dated 1/22/2026 documented severely impaired cognitive skills and a need for moderate assistance with ADLs, but did not code the resident as wandering in a manner that significantly intruded on others. An IDT note dated 02/09/2026 described an altercation on 02/08/2026 in which the cognitively impaired, disoriented resident independently ambulated to a roommate’s bedside, attempted to pull up the roommate’s blanket, and entered the roommate’s personal space, leading the roommate to become verbally upset and strike the resident in the left eye. A psychiatric assessment dated 02/12/2026 documented that the resident was profoundly confused, severely disoriented, had limited insight, functioned at an extremely low cognitive level consistent with advanced dementia, and did not understand boundaries or the seriousness of certain behaviors. The Social Services Director reported that the resident had a low BIMS score, could not answer simple questions such as name and time, and required staff redirection because the resident always wandered into other residents’ rooms. RN staff confirmed the resident was very confused, wandered into both female and male residents’ rooms, and required redirection, and also stated there were no care plan interventions or specific interventions in place to address this wandering behavior and no staff member assigned to monitor it, despite complaints from female residents. The MDS coordinator confirmed that no care plan had been developed to address the resident’s wandering into other residents’ rooms and that there were no individualized interventions in place, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents’ needs.
Failure to Implement Physician-Ordered Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered Enhanced Barrier Precautions (EBP) for a resident with multiple infection risks. The resident was readmitted with diagnoses including a UTI, pneumonia, and sepsis, and had multiple lower pressure injuries, impaired skin integrity, and an indwelling urinary catheter. The resident’s care plan identified risks for infection, catheter-associated UTI, and transmission of MDROs, and included goals and interventions requiring compliance with EBP, including the use of clean gowns and gloves during all high-contact care activities. A physician’s order dated 11/18/2025 directed continuation of EBP for infection control. Surveyors’ review of records and interviews with staff confirmed that the EBP order and related care plan interventions were not implemented. On review of the resident’s order summary with an LVN, it was confirmed that EBP should have been in place, including posting of an EBP sign and provision of PPE for staff. The LVN stated that implementing physician orders was important so residents and visitors would know what protective equipment to wear to limit infection transmission. The care plan for risk of healthcare-associated infection, dated 11/20/2025, specified that all direct care staff were to demonstrate and document 100% compliance with EBP protocols, but this was not carried out in practice. Direct observations showed that staff were providing hands-on care without PPE and without any visible indication that EBP was required. A CNA was observed touching the resident’s blanket, repositioning the Foley catheter bag, and assisting the resident without wearing any PPE, and the CNA stated they did not know the resident required PPE under EBP. On a separate observation, there was no EBP signage or PPE available outside the resident’s room. An RN verified that no EBP sign was posted and no PPE was available, despite acknowledging that EBP had been ordered by the physician to decrease infection transmission. The Infection Preventionist also stated that the resident should have been placed on EBP with appropriate PPE available and that the physician’s order should have been implemented. The facility’s infection prevention and control policy required implementation of appropriate enhanced barrier and transmission-based precautions when necessary, consistent with CDC guidelines, but these were not followed for this resident.
Failure to Implement Scabies Surveillance and Timely Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program (IPCP) and follow county scabies guidelines for four residents with suspected scabies. The Infection Preventionist (IP) did not initiate or maintain a line list for residents or staff with suspected scabies, despite multiple residents and some staff developing generalized rashes and being placed on contact precautions. The IP acknowledged that some staff reported rashes and concern for scabies but stated he did not create a list and was unsure how many staff were affected. Infection surveillance logs from 10/2025 to 1/2026 did not include residents with suspicious rashes treated with Permethrin, including a resident who was suspected of having scabies and treated with Permethrin cream in 10/2025. The IP stated he did not consider rashes treated with Permethrin as infections requiring monitoring and only tracked infections requiring antibiotics. One resident, admitted with neuropathy and diabetes mellitus, complained of mild itchiness and localized rash in 10/2025. The IP documented that the rash was of unknown etiology with potential for transmission, and the resident and roommates were placed on contact isolation and treated with Permethrin cream, Hydroxyzine, and Hydrocortisone. However, no skin scrape test was performed at that time to rule out scabies, and this episode was not entered into the infection surveillance log. The same resident later developed a generalized rash again in 2/2026, was placed on contact precautions, and was prophylactically treated with Permethrin before a skin scrape was performed. The IP and a licensed nurse confirmed that the skin scrape for this resident was done after Permethrin treatment, and the IP stated that residents should have been tested with a skin scrape prior to treatment. In early 2/2026, three additional residents with significant comorbidities (including COPD, CHF, Parkinson’s disease, CVA, hemiplegia, DM, adult failure to thrive, and kidney stones) were identified with generalized body rashes. Dermatology consultations were obtained, and all four residents were placed on contact precautions, had environmental cleaning measures implemented, and were prophylactically treated with Permethrin cream; two residents also received oral Ivermectin and Hibiclens. Physician orders for skin scraping were written for these residents, but the scrapes were performed only after Permethrin treatment and after the arrival of collection kits. The IP’s notes show that skin scrape specimens for multiple residents were completed and then left at the front desk until picked up by the lab two days later. Despite having at least four residents on contact precautions for suspicious rashes and staff reporting rashes, the IP did not maintain an updated infection surveillance log for 2/2026 and did not prepare a line list of symptomatic residents and staff. The facility also failed to recognize and timely report a suspected scabies outbreak to the local public health department. The county guidance available in the facility defined an outbreak as two or more clinically suspected or confirmed cases of scabies in residents, healthcare workers, volunteers, or visitors within a six-week period and directed facilities to report healthcare-associated scabies outbreaks. The IP stated he did not report a potential outbreak when the four residents were placed on contact precautions and tested for scabies because skin scrape results were still pending, and he chose to wait until a positive result was obtained. A fax to the county department of public health reporting a possible scabies outbreak was not sent until eight days after the residents were placed on contact precautions. The IP later acknowledged that, based on the county guideline, he should have reported a potential outbreak earlier and that he should have recommended scabies testing before Permethrin treatment from an infection prevention standpoint.
Failure to Administer and Document Medications per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for timely medication administration and proper documentation for three of five sampled residents. The facility’s policies required medications to be administered within one hour before or after the scheduled time and documentation to occur immediately after, and never before, administration. Review of the Medication Administration Audit Reports showed that multiple medications scheduled for 9:00 AM for three residents were documented as given at times outside the required one-hour window, and a nurse later admitted to pre-signing the MARs before actually administering the medications. One resident with alcoholic cirrhosis with ascites and diabetes, cognitively intact but dependent for most ADLs, had several 9:00 AM medications (including metolazone, furosemide, gabapentin, lactulose, rifaximin, midodrine, and spironolactone) documented as administered between 9:38 AM and 9:41 AM. Another cognitively intact resident with diabetes and heart disease, requiring maximal assistance with dressing and toileting hygiene, had 9:00 AM medications (ferrous sulfate, diltiazem, metoprolol, and hydralazine) documented as administered between 9:30 AM and 9:31 AM. A third resident with sequela of cerebral infarction and moderately impaired cognition, requiring supervision for most ADLs, had 9:00 AM medications (amlodipine and clopidogrel) documented as administered at 9:27 AM and 9:28 AM. During observation and interviews, an LVN was seen at the medication cart well after the scheduled 9:00 AM medication time and stated that the 9:00 AM medications for the three residents in the same room had not yet been administered. The LVN later confirmed that on that date she was late in administering the medications and had pre-signed the MARs for those residents before actually giving the medications, acknowledging that this was not the facility’s practice. A resident also reported that medications were sometimes not administered on time and that this depended on which nurse was working, noting that medications were especially late on the night shift. A registered nurse confirmed that the standard was to “pour, pass, and sign,” and that medications must be given as ordered within the one-hour before/after window, consistent with the written policies reviewed by surveyors. The report states that this deficient practice resulted in delayed medication administration for the three residents and had the potential for residents’ health to be compromised.
Failure to Prevent Falls and Maintain Safe Environment for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and maintain a hazard-free environment for three residents at risk for falls. One resident with a history of metabolic encephalopathy, hemiplegia, and hemiparesis following a stroke was left unsupervised in the bathroom by an RN, despite care plan interventions requiring frequent visual checks due to poor decision-making and inability to use the call light. This resident subsequently fell, sustaining a 4 cm hematoma on the right forehead and was diagnosed with a non-traumatic intracranial hemorrhage after transfer to an acute care hospital. Another resident, also with hemiplegia and hemiparesis following a cerebral infarction and classified as high risk for falls, was observed with their bed in a high position, contrary to care plan instructions and staff knowledge that the bed should be kept in the lowest position to prevent falls. The resident was not informed by staff about the risks associated with the bed's position and was not reminded to keep it low, despite documentation in nursing progress notes indicating this requirement. A third resident, with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, and dementia, required total dependence for mobility and was at high risk for falls. This resident was found on the floor with the call light out of reach while the assigned CNA was on break and had not endorsed coverage to another staff member. The care plan required the call light to be within reach and frequent visual checks, but these interventions were not followed, and the resident was not monitored during the CNA's absence.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was unable to perform activities of daily living (ADLs) independently was not assessed or changed in a timely manner for a wet and soiled incontinence brief, as required by the resident's care plan. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, metabolic encephalopathy, and dementia, was observed at 2 PM with a brief soaked in urine and feces. The certified nurse assistant (CNA) responsible stated the last incontinence check and change had occurred at 8 AM, and was unsure when the resident had last had a bowel movement. The CNA acknowledged that the resident should have been checked more frequently and that care was not provided as needed. Further observation and interviews revealed that the resident was dependent on staff for nearly all ADLs, including toileting hygiene. A registered nurse (RN) noted the presence of blanchable redness near the resident's left medial buttock and sacrococcyx, which could have resulted from prolonged exposure to urine and feces. The director of nursing (DON) confirmed the importance of timely incontinence and perineal care, stating that failure to maintain good hygiene could lead to skin breakdown and other complications. Review of facility policy indicated that residents unable to perform ADLs independently should receive necessary support and assistance with elimination in accordance with their care plan.
Failure to Ensure Accurate Discharge Documentation and Resident Preparation
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate discharge procedures for a resident who was assessed as cognitively intact and capable of making decisions. The resident, who had diagnoses including end stage renal disease, diabetes, dementia, and dependence on renal dialysis, was admitted with orders for regular dialysis and a limited out-on-pass privilege. On the day of the incident, the resident was observed leaving for a scheduled dialysis appointment but did not arrive at the dialysis center. The facility was notified by the dialysis center that the resident was missing, and subsequent attempts to contact the resident were unsuccessful. The police were notified later that evening, and a missing person report was filed. Despite the resident's absence, the facility documented the discharge as 'against medical advice' (AMA) without evidence of a physician discharge order, care plan, interdisciplinary team documentation, or any indication that the resident was informed of or participated in a planned discharge. The facility's policy required detailed documentation and communication for transfers or discharges, including preparation of a post-discharge plan and notification of the resident and their representative. None of these steps were documented in the resident's medical record. Interviews with facility staff and the physician revealed that the decision to discharge AMA was based on the resident exceeding the out-on-pass time limit, but there was no formal documentation of behavioral concerns, care plan interventions, or interdisciplinary review regarding the resident's history of leaving without notice. The resident was later found by a security guard at a local hotel and returned to the facility, after which the facility arranged for transfer to an acute care hospital for missed dialysis treatments. The resident was subsequently readmitted to the facility. Throughout the incident, there was a lack of documentation regarding the basis for discharge, communication with the resident or their emergency contacts, and adherence to facility policies and procedures for safe and appropriate discharge planning.
Failure to Implement Behavioral Health Interventions and Care Planning for Resident with Repeated Unauthorized Absences
Penalty
Summary
The facility failed to develop and implement resident-centered care plan interventions and involve the interdisciplinary team (IDT) for a resident with a known history of leaving the facility without permission and failing to return from out on pass, as required by physician's orders. Despite repeated incidents where the resident left the facility without authorization, there was no evidence that behavioral interventions were initiated or that strategies were documented to address the resident's non-compliance and unsafe behaviors. The facility also did not document the resident's status upon return after these episodes, nor did they ensure timely notification of the physician regarding missed dialysis appointments and the resident's whereabouts. The resident in question had multiple complex medical diagnoses, including end stage renal disease requiring regular dialysis, diabetes, and dementia, but was assessed as cognitively intact and able to make decisions. The resident had physician orders specifying dialysis schedules and limitations on out-on-pass privileges, which required accompaniment by a family member and a maximum duration of four hours. However, the facility did not document the rationale for these restrictions, nor did they involve or communicate with the resident's family or emergency contacts as indicated in the orders. Additionally, a psychiatric evaluation was ordered but not initiated or scheduled, and there was no documentation explaining the reason for the psychiatric referral. Multiple progress notes and interviews revealed that the resident missed scheduled dialysis appointments after leaving the facility without permission, and the facility was often unaware of the resident's whereabouts until notified by external parties such as the dialysis center or police. The facility's own policy required behavioral health assessments, individualized interventions, and IDT involvement, but these steps were not documented or implemented. Staff interviews confirmed a lack of formal care planning, IDT review, or revision of privileges in response to the resident's repeated behaviors, and there was no evidence of family involvement in care planning as required.
Failure to Implement Infection Control Precautions for Residents Exposed to Impetigo
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for three residents who shared a room, following a physician's diagnosis of impetigo in one of the residents. After the diagnosis, the resident with impetigo was not immediately placed on contact isolation, despite a physician order for transfer to a hospital and a text message from the Infection Preventionist indicating the need for isolation. The resident remained in the shared room for approximately eight hours after the need for isolation was identified, without any isolation signage or precautions in place. The two roommates who were exposed to the resident with impetigo were also not placed on isolation or enhanced barrier precautions during or after the exposure. Staff interviews revealed that neither the Director of Nursing nor the assigned nurses and CNAs were aware of the need to implement isolation or enhanced barrier precautions for the exposed residents. No isolation signage was posted outside the room, and staff did not use personal protective equipment (PPE) when providing care to any of the three residents during the period of exposure. Record reviews confirmed that there were no physician orders or care plans initiated for isolation or contact precautions for the affected residents. The facility's own policies, as well as CDC guidelines, require contact precautions for suspected or confirmed cases of impetigo to prevent transmission. The Infection Preventionist and Director of Nursing acknowledged during interviews that the facility did not follow these guidelines or their own policies, and that the necessary precautions were not implemented in a timely manner.
Failure to Implement Infection Control Program and Timely Notification for CRAB Exposure
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program (IPCP) for 27 residents following notification from the Local Health Officer's Public Health Nurse (PHN) that a resident tested positive for Carbapenem-Resistant Acinetobacter baumannii (CRAB) Tier 2, a rare and communicable multidrug-resistant organism. Despite receiving an email with recommendations from the PHN, the Director of Nursing (DON) did not initiate surveillance tracking or interventions for the 26 potentially exposed residents, nor did the facility notify the California Department of Public Health (CDPH) within the required 24-hour period. The DON acknowledged being too busy and covering for the infection preventionist at the time, resulting in a delay of 11 days before screening exposed residents was initiated. Additionally, the facility did not notify the primary medical doctor of the resident who tested positive for CRAB, nor did it notify or coordinate with the attending physicians of the 26 other residents who were potentially exposed and recommended for rectal swab screening. There was no documentation in the affected residents' medical records regarding the exposure, the positive CRAB result, or the recommended screenings. The infection preventionist, who started after the initial notification, confirmed that attending physicians were not informed and that there was no documentation or change of condition forms completed for the exposed residents. The facility's own policies and procedures require immediate notification of attending physicians for significant changes in condition, surveillance and data reporting for infection control, and reporting of unusual occurrences to appropriate agencies within 24 hours. These policies were not followed, as evidenced by the lack of timely surveillance, physician notification, and reporting to CDPH. Interviews with facility staff and the PHN confirmed these failures, and the DON admitted that the lack of action could have allowed the communicable disease to spread and prevented residents from receiving appropriate medical recommendations.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. One of the four metal dumpsters was found without a lid and overflowing with boxes, while the garbage area was littered with food waste and various rubbish, including dirty crates, broken chairs, carts, and shelves. This situation was identified during an observation with the Director of Nurses (DON), who acknowledged the issue and stated she was unaware of the missing lid. The DON recognized the potential for attracting pests and spreading infection due to the improper disposal of waste. Interviews with the Housekeeping Supervisor (HKS), Maintenance Supervisor (MS), and Dietary Service Supervisor (DSS) revealed that they were responsible for ensuring the trash bins were covered and the area was clean. However, they admitted to missing this oversight. The HKS and MS acknowledged the environmental concerns associated with uncovered and overflowing trash, which could lead to infestations and infections. The DSS also stated that the dietary staff used the trash bin for food waste and was unaware of the overflowing condition. The facility's policy on food-related garbage and refuse disposal emphasized the importance of keeping food waste in containers and ensuring dumpsters are closed and free of surrounding litter, which was not adhered to in this instance.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the resident's call light was within reach, as required by the resident's care plan. The resident, who was admitted with diagnoses including difficulty in walking, muscle weakness, and diabetes type 2, was observed unable to reach the call light, which was stuck behind the bed and on the floor. This was confirmed during an interview with the resident, who stated he needed help but could not find the call light. Further observations and interviews with the facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the call light was not accessible to the resident. The facility's policy and procedure on answering call lights, revised in September 2022, mandates that call lights must be accessible to residents and functioning at all times. The failure to ensure the call light was within reach could potentially prevent the resident from asking for assistance, leading to accidents such as falls.
Failure to Follow Up on PASRR Level II Evaluation
Penalty
Summary
The facility failed to follow up on a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident who had a positive Level I screening indicating the need for further mental health evaluation. The resident, who was originally admitted in 2021 and readmitted later, had diagnoses including psychotic disorder and schizoaffective disorder. Despite the positive PASRR Level I screening on 11/15/2023, which required a Level II evaluation, the facility did not refer the resident for this necessary assessment. This oversight was identified during a review of the resident's records, which showed no documentation of a Level II referral. The resident's medical records indicated significant assistance needs with daily activities and ongoing treatment for mental health conditions, including medications for schizoaffective disorder and depression. Interviews with facility staff, including the MDS Nurse and Assistant Director of Nurses, revealed that the responsibility for following up on the PASRR Level II requirement was missed. The Director of Nurses acknowledged the lack of a system to ensure PASRR II follow-ups, emphasizing the importance of such evaluations to meet the resident's comprehensive care needs.
Failure to Update Care Plan for Pressure Injury
Penalty
Summary
The facility failed to update and implement a resident-centered care plan for a resident who developed a Stage 1 pressure injury on the left upper buttock. The resident was readmitted to the facility with diagnoses including quadriplegia and contractures of the lower extremities, and was dependent on care for various activities of daily living. Despite having a care plan in place to prevent skin breakdown, the plan was not updated when the pressure injury was identified. Interviews with facility staff, including a Treatment Nurse and a Registered Nurse, confirmed that the care plan was not revised to address the new pressure injury. The Director of Nursing acknowledged that the care plan for skin breakdown was not updated, which could have prevented the development of the pressure injury. The facility's policy and procedure for comprehensive, person-centered care plans require the identification of problem areas and the development of interventions, which was not adhered to in this case. The lack of an updated care plan left the resident at risk for further complications, such as infection, due to the pressure injury.
Failure to Update Care Plan for Gout Medication
Penalty
Summary
The facility failed to update and revise the care plan for a resident, identified as Resident 11, to include the use of Febuxostat, a medication prescribed to manage gout. Despite the resident being on Febuxostat since December 31, 2024, the care plan, initiated on November 12, 2024, did not reflect this medication as part of the interventions for managing the resident's pain related to gout. This oversight was identified during a review of the resident's records, which showed that the care plan had not been updated to include the medication, potentially affecting the monitoring of the medication's effectiveness. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the care plan should have been revised to include the new medication. The staff acknowledged that care plans are essential for monitoring the effectiveness of treatments and ensuring that the resident's goals and needs are met. The facility's policy on care plans, revised in March 2022, mandates that care plans be updated as new information about the resident's condition becomes available, highlighting a lapse in adherence to this policy.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or device for a resident who did not speak the formal language used in the facility. This deficiency was identified for a resident who was readmitted with diagnoses of dementia and Alzheimer's disease, and whose primary language was different from the facility's formal language. The resident's cognitive abilities were severely impaired, and they were dependent on care for eating and toileting hygiene. Despite these needs, there was no communication tool or translation material available in the resident's room to facilitate communication with the staff. Observations and interviews revealed that the lack of communication tools prevented the resident from effectively communicating their needs, which could delay the provision of appropriate care and treatment. A Certified Nursing Assistant (CNA) confirmed the absence of translation materials in the resident's living area and emphasized the importance of such tools for residents who do not speak English. The Director of Nursing (DON) acknowledged the necessity of communication tools for residents who speak a different language and confirmed that the resident required such a tool to communicate their needs. The facility's policy on translation and interpretation services, last revised in 2017, indicated that individuals with limited English proficiency should have meaningful access to information and services, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide necessary care and services to a resident who was dependent on staff for activities of daily living (ADL). The resident, who had communication problems due to slurred speech and was at risk for falls, did not have their call light within reach. This deficiency was observed during a room visit where the call light was found wrapped around the bottom of the right siderail, out of the resident's reach. The resident was noted to be frowning and attempting to pull the string for the overhead light, indicating a need for assistance. Interviews with facility staff, including a CNA, RN, and the Director of Nurses, confirmed that the call light should always be within reach to ensure the resident can request assistance, especially in emergencies. The facility's policies on ADLs and answering call lights emphasize the importance of accessibility and timely response to residents' needs. The failure to ensure the call light was within reach had the potential to prevent the resident from receiving timely care and assistance.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident 9, who had a history of pressure injuries and was using a low air loss (LAL) mattress, did not have the mattress settings adjusted to their current weight of 117 pounds, as required by the manufacturer's guidelines. This oversight was confirmed through observations and interviews with the treatment nurse, licensed vocational nurse, registered nurse, and director of nursing, all of whom acknowledged the importance of setting the LAL mattress correctly to prevent pressure injuries. The facility's policy and procedure, as well as the manufacturer's guidelines, emphasized the need for proper mattress settings to prevent skin breakdown. Resident 29, who was admitted without any pressure injuries, developed a Stage 1 pressure injury on the left upper buttock, which progressed to a Stage 2 injury within two days. The care plan for Resident 29 was not updated to address the new pressure injury, and the necessary interventions were not implemented in a timely manner. Interviews with the treatment nurse and registered nurse revealed that the care plan and treatments were not adjusted when the Stage 1 pressure injury was identified, contributing to its progression to Stage 2. The director of nursing acknowledged that the lack of timely updates and interventions in the care plan could have prevented the progression of the injury. The facility's failure to adhere to its policies and procedures for pressure ulcer prevention and management resulted in inadequate care for both residents. The lack of proper mattress settings for Resident 9 and the failure to update and implement interventions for Resident 29's pressure injury highlight deficiencies in the facility's care practices. These deficiencies placed both residents at risk for further skin breakdown and complications, as noted in the facility's policies and procedures for pressure ulcer risk assessment and management.
Deficiencies in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident 116, who had a history of pneumonia, sleep apnea, heart failure, and respiratory failure, was found with their nasal cannula on the floor, not receiving the prescribed oxygen treatment. The resident required substantial assistance for self-care and moderate assistance for mobility. During an observation, it was noted that the nasal cannula was not in place, and the resident was not receiving oxygen, which could have caused difficulty in breathing. The facility's policy required staff to ensure the nasal cannula was correctly placed and to periodically check on the resident, which was not adhered to. Resident 69, diagnosed with Huntington's disease, atherosclerotic heart disease, and diabetes, was administered oxygen without a physician's order. The resident's cognitive status was moderately impaired, and they required supervision or assistance with daily activities. During an observation, the resident was receiving oxygen at 3 liters per minute without an order, and the electronic health records did not indicate any physician's order for oxygen. The facility's policy required a physician's order before administering oxygen, which was not followed, leading to the potential risk of oxygen toxicity. The facility's policies on oxygen administration and physician orders were not followed in both cases. The Director of Nursing and other staff acknowledged the lapses in ensuring the nasal cannula was correctly placed for Resident 116 and the lack of a physician's order for Resident 69. These deficiencies in following established protocols for oxygen administration had the potential to adversely affect the residents' health and safety.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to implement its policy on Transmitting Medication Orders by not reordering a scheduled medication, Finasteride, in a timely manner for a resident with benign prostatic hyperplasia (BPH). The resident was initially admitted on 11/10/2022 and readmitted on 9/23/2024, with a physician's order to administer Finasteride 5 mg daily. On 2/26/2025, during a medication pass observation, the medication was not available in the cart, and the resident did not receive the prescribed dose. LVN 1, responsible for administering the medication, stated that the last dose was given the previous day, and a refill request was made to the pharmacy, but no documentation was provided to confirm this action. The Director of Nursing (DON) confirmed that licensed nurses should request medication refills when only three doses remain, as per the facility's policy. The facility's policy also requires nurses to reorder medications when a three to five-day supply remains and to document the order details in the resident's medical record. The failure to reorder Finasteride in a timely manner resulted in the medication not being available for administration, potentially compromising the resident's health.
Failure to Obtain Resident Signatures on POLST Forms
Penalty
Summary
The facility failed to implement its policy and procedure on charting and documentation by not ensuring that the POLST forms for two residents were signed by the residents before being placed in their medical charts. Resident 24, who was admitted with peripheral vascular disease, and Resident 179, who was admitted with type 2 diabetes and a foot ulcer, both had intact cognition according to their Minimum Data Set assessments. Despite this, the facility prepared the POLST forms for these residents but did not obtain their signatures before filing them in their charts. Interviews with facility staff revealed a lack of adherence to the process for completing and filing POLST forms. The Medical Records Director and Social Services Director indicated that the admission nurse was responsible for offering the POLST to residents, and the Medical Records Assistant maintained a binder with signed POLST forms. However, the signed forms were not placed in the residents' charts as required. The Director of Nursing emphasized the importance of having a complete and accurate POLST in the resident's chart to prevent delays in treatment during emergencies. The facility's policy on charting and documentation mandates that medical records be complete and accurate, which was not followed in these instances.
Deficient Maintenance of Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and clean homelike environment in two observed bathrooms. During observations, it was noted that the paint was bubbling and peeling off the walls behind the sinks in both bathrooms. Additionally, there was a light brown discoloration on the grout sealer around the sinks and a white residue around the faucet heads. These conditions were observed on February 27, 2025, at 9:31 AM and 9:39 AM, respectively. During a concurrent observation and interview with the Maintenance Supervisor at 11:30 AM, it was confirmed that the paint was indeed bubbling and peeling in both bathrooms. The Maintenance Supervisor acknowledged that these conditions posed a potential source for infection control issues, as the peeling paint and discolored grout could come into contact with residents' hands during handwashing, potentially leading to illness. The facility's policy and procedure titled 'Homelike Environment,' revised in February 2021, emphasized the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inadequate Supervision of Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision of residents who smoke, leading to a deficiency in safety practices. Two residents, both with moderate cognitive impairments and requiring assistance with daily activities, were found in possession of cigarette lighters, contrary to the facility's smoking policy. Resident 104, with a history of hemiplegia, hemiparesis, and diabetes, was observed with a lighter on his bedside table, which he claimed as his own. Similarly, Resident 79, diagnosed with Parkinson's Disease and diabetes, was seen with a lighter on his walker while smoking in the patio area. The facility's smoking policy and risk evaluations clearly stated that these residents should not have cigarette lighters in their possession and required supervision while smoking. Despite these guidelines, staff failed to enforce the policy, as evidenced by the residents' access to lighters. Interviews with staff, including a registered nurse and the Director of Activities, revealed a lack of awareness and enforcement of the policy, acknowledging the potential hazards posed by residents having lighters, especially in a facility where oxygen is used. The facility's policies on safety and supervision emphasize the importance of preventing accidents and ensuring a hazard-free environment. However, the failure to supervise residents adequately and prevent them from possessing lighters represents a significant oversight. This deficiency poses a risk of fire or accidents, particularly given the presence of oxygen in the facility, which could endanger both residents and staff.
Deficiency in Resident Room Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 40 out of 54 residents' rooms met the square footage requirement of 80 square feet per resident in multi-resident rooms. The deficiency involved 5 two-bedroom and 35 three-bedroom configurations, which did not provide the minimum required space per resident. The facility's policy and procedure, revised in 2017, stated that all resident rooms should meet federal and state requirements, including providing at least 80 square feet per resident in multi-bed rooms. Despite this policy, the rooms in question did not meet these standards, as detailed in a room waiver request submitted by the facility's administrator. During the recertification survey, observations indicated that nursing staff's duties were not hindered by the space provided, and there were no observed deficits in care, privacy, or safety for the residents. Interviews with residents revealed that they felt their rooms were spacious enough to accommodate their needs, including the use of wheelchairs and walkers, and did not report any difficulties for staff in providing care. However, the facility's failure to comply with the square footage requirements represents a deficiency in meeting regulatory standards for resident living space.
Failure to Notify Resident's Representative of Diabetic Ulcer
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in condition for a resident with a diabetic ulcer. The facility's policy and procedure required prompt notification of changes in a resident's medical condition to the resident, their attending physician, and their representative. However, the RR was not informed about the resident's diabetic ulcer, which was documented upon the resident's readmission to the facility. The lack of notification prevented the RR from requesting necessary medical treatment and care for the resident, potentially leading to a serious condition. The resident, who was admitted with diagnoses including encephalopathy, quadriplegia, and type 2 diabetes mellitus, had a diabetic ulcer on the left lateral malleolus. Despite the presence of the ulcer being noted in the Admission Data Collection and subsequent physician's orders for treatment, there was no documentation indicating that the RR was informed of the ulcer. The facility's records, including Nursing Progress Notes and Weekly Wound Notes, failed to show that the RR was updated about the resident's wound condition. Interviews with the RR and the Social Services Director (SSD) revealed that the RR was unaware of the diabetic ulcer until the resident was transferred to a General Acute Care Hospital for further evaluation. The SSD acknowledged the absence of documentation regarding communication with the RR about the wound and stated that there should have been records of attempts to reach the RR. This deficiency violated the RR's right to be informed of the resident's medical condition changes.
Failure to Develop and Implement Care Plan for Prevalon Boots
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, specifically regarding the use and maintenance of Prevalon boots. The resident, who was admitted with conditions including encephalopathy, quadriplegia, and type 2 diabetes mellitus, had a care plan that mentioned the use of bilateral Prevalon boots but did not include instructions on how to clean or maintain them. This omission was noted during a review of the resident's care plan, physician's orders, and treatment administration records, none of which provided guidance on the maintenance of the boots. Interviews with facility staff, including a CNA, LVN, and the Treatment Nurse, revealed a lack of documentation and understanding regarding the cleaning and maintenance of the Prevalon boots. The CNA admitted there was no place to document when the boots were cleaned, and the LVN acknowledged that a care plan should have been in place to ensure proper maintenance. The Treatment Nurse confirmed that without documentation, there was no evidence of the boots being maintained, which could lead to infection. The facility's policy and procedure on comprehensive person-centered care plans required that care plans describe services to maintain the resident's well-being and be updated as conditions change. However, the Director of Nursing confirmed that the facility did not follow these procedures, as there was no specification on how to clean the Prevalon boots. This lack of adherence to policy posed an infection control issue, potentially affecting the resident's existing conditions.
Failure to Implement Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was dependent on dialysis and repeatedly refused prescribed medications, vitamins, and supplements. This resident, who had diagnoses including end-stage renal disease, anemia, and hypertension, was admitted to the facility with severely impaired cognition. Despite the resident's refusal of essential medications and supplements, the facility did not create a care plan to address these refusals or explore alternative measures to ensure the resident's compliance with their treatment regimen. The facility also failed to inform the resident's responsible party about the repeated refusals of medications and supplements. The responsible party was not made aware of the resident's non-compliance, nor was there any documented evidence that the facility staff communicated the resident's status to the dialysis center. This lack of communication and failure to hold an interdisciplinary team (IDT) meeting, despite requests from the dialysis center and the responsible party, contributed to the resident's deteriorating health condition. As a result of these deficiencies, the resident was admitted to a generalized acute care hospital due to severe muscle weakness and abnormal laboratory values, including a critically low hemoglobin level. Interviews with facility staff revealed that there was no documented evidence of attempts to address the resident's refusals or to inform the medical doctor and family. The facility's policies and procedures regarding care plans and resident rights were not followed, leading to significant health complications for the resident.
Failure to Provide Prescribed Pureed Diet
Penalty
Summary
The facility failed to serve a therapeutic pureed textured diet to a resident as prescribed by the physician and in accordance with the resident's plan of care and preference. The resident, who had a tooth extraction resulting in soreness of the gums, was supposed to receive a pureed diet but was instead served a regular textured diet. This oversight led to the resident's frustration and refusal to eat meals due to discomfort. The resident had been admitted with diagnoses including congestive heart failure, diabetes, and anemia, and had intact cognitive skills. Despite the resident's clear preference and request for a pureed diet following the tooth extraction, the facility continued to serve a regular diet. The dietary supervisor acknowledged being informed of the resident's preference but failed to communicate this to the nursing staff, resulting in the continuation of the regular diet order. Interviews with staff revealed a breakdown in communication and oversight in updating the resident's dietary orders. The dietary supervisor and the Director of Nursing admitted to not extending the pureed diet order, which was initially set for only two days. The facility's policies emphasize the importance of accommodating resident preferences and ensuring accurate diet orders, but these were not followed in this case.
Failure to Update Diabetes Care Plan with New Insulin Order
Penalty
Summary
The nursing staff at the facility failed to revise the care plan for a resident diagnosed with diabetes mellitus, following a new order for long-term acting insulin, Lantus. The order, dated 6/11/2024, was not incorporated into the resident's active care plan. This oversight was identified through observation, interview, and record review, indicating a deficiency in updating the care plan to reflect the resident's current medical needs. The resident, who was readmitted to the facility on 8/3/2023, had a history of cerebral vascular accident/stroke and diabetes mellitus. Despite having an intact cognition as per the Minimum Data Set dated 4/8/2024, the resident's Hemoglobin A1C levels were significantly high at 13.5% as of 6/5/2024, necessitating the insulin order. The failure to update the care plan was acknowledged by both a registered nurse and the Director of Nursing, who confirmed that the omission could have delayed treatment for the resident's high blood sugar levels.
Failure to Notify Physician and Complete Endocrinology Consult
Penalty
Summary
The facility failed to meet professional standards of quality for a resident by not notifying the physician about a medication alert for Lantus, a medication used to lower blood sugar. On June 11, 2024, the daily dose of Lantus prescribed was below the usual dose, which could have rendered the medication ineffective in managing the resident's blood sugar levels. Despite an electronic alert being sent to the pharmacist and medical doctor, there was no follow-up or documentation indicating that the physician or pharmacist were notified, and no order was made to adjust the dose. The registered nurse acknowledged the oversight and the potential for the resident to become ill and require hospitalization due to high blood sugar levels. Additionally, the facility did not ensure that an endocrinology consult was ordered for the resident after an elevated hemoglobin A1C result was recorded on June 5, 2024. Although a nurse practitioner wrote an order for the consult on June 6, 2024, the social worker was not informed, and the consult was not authorized or completed. The director of nursing confirmed that the failure to notify the social worker and follow up on the order resulted in a delay in treatment for the resident's high blood sugar levels. The facility's policies and procedures, including the Nursing Services Policy and Procedure Manual and the Telephone Orders policy, were not adhered to in these instances. The manual emphasizes that services should be performed according to acceptable clinical standards, and the Telephone Orders policy requires that verbal orders from physicians be properly documented. The lack of adherence to these protocols contributed to the deficiencies observed in the care of the resident.
Failure to Follow Up on Endocrinology Consult Order
Penalty
Summary
The facility failed to provide necessary social services for a resident by not following up on a physician's order for an endocrinology consult after an elevated hemoglobin A1C result was recorded. The resident, who had been readmitted with diagnoses including a stroke and diabetes mellitus, had a hemoglobin A1C level of 13.5%, significantly above the normal range of 4% to 6%. Despite the physician's order for an endocrinology consult on the following day, the consult was not arranged, leading to a delay in treatment. Interviews with facility staff revealed a breakdown in communication and procedure. The social worker was not informed of the endocrinology consult order, which was necessary for the resident under custodial care. The Director of Nursing and other staff acknowledged that the failure to notify the social worker resulted in the consult not being ordered, potentially delaying treatment for the resident's high blood sugar levels. The facility's policy indicated that the social services department should have been involved in authorizing and ordering the consult, but this step was missed, leading to the deficiency.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to respond to a grievance filed by Resident 2, who had intact cognition and was dependent on various activities of daily living. Resident 2 reported to RN 1 that LVN 1 did not correctly administer an enema, and RN 1 informed the ADON via text message. However, the ADON did not follow up on the grievance, and no further action was taken to address Resident 2's complaint. This resulted in the grievance not being documented or resolved, as confirmed by the review of the facility's Grievances/Complaint Log and Resident 2's Progress Notes. Resident 2's medical history included diabetes mellitus type 2 and ileus, and the resident had been readmitted to the facility with a distended abdomen. Despite Resident 2's clear communication of the grievance, the facility's staff failed to adhere to the established grievance policy, which mandates prompt efforts to resolve grievances. Interviews with the involved staff members, including RN 1, CNA 1, LVN 1, and the ADON, corroborated the lack of follow-up and documentation regarding the grievance, highlighting a significant lapse in addressing resident concerns as per the facility's policies and procedures.
Failure to Monitor Behavior for Medication Effectiveness
Penalty
Summary
The facility failed to monitor the behavior of a resident prescribed Trileptal for poor impulse control, which included behaviors such as hitting staff and throwing objects. Despite the medication being administered daily since it was ordered, there was no documented evidence in the Medical Administration Record (MAR) or Progress Notes that the resident's behavior was being monitored for the effectiveness of the medication. This lack of monitoring was confirmed during interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who both acknowledged that the resident's behavior should have been monitored to ensure the medication's efficacy. The resident in question had severe cognitive impairment and diagnoses of schizophrenia and bipolar disorder, which contributed to their aggressive behaviors. The facility's policies and procedures required that the effectiveness and effects of medications be evaluated and documented, but this was not done in this case. The failure to monitor the resident's behavior placed them at risk for unnecessary medication and potentially worsening aggressive behavior, as noted by the DON during the interview.
Failure to Notify Physician and Family of Missed Dialysis Treatments
Penalty
Summary
The facility failed to immediately contact and communicate with the attending physician regarding significant changes in a resident's status that impacted the dialysis portion of the care plan. Specifically, the licensed nurse did not notify the physician after the resident missed two dialysis treatments due to transportation issues. The first missed treatment occurred on 4/13/2024, and the second on 4/16/2024, but the physician was not informed until 4/17/2024 at 1 am. Additionally, the facility staff did not promptly inform the resident's emergency contact about the missed treatments as required by the facility's policy on changes in the resident's condition or status. The resident, who was dependent on dialysis, was admitted to the facility on 4/11/2024 with diagnoses including chronic kidney disease, type 2 diabetes mellitus, and hypertension. The resident's dialysis schedule was set for Tuesdays, Thursdays, and Saturdays. Despite the importance of these treatments, the facility's internal communication records and nursing progress notes did not document the missed dialysis treatments or any notification to the attending physician. This lack of documentation and communication led to a delay in addressing the resident's missed treatments. As a result of the missed dialysis treatments, the resident was transferred to a General Acute Care Hospital on 4/17/2024 for weakness and lethargy. The hospital's emergency department report indicated that the resident was at risk for severe complications and required aggressive intervention. Interviews with facility staff revealed that the licensed nurses were aware of the missed treatments but failed to follow the proper protocol for notifying the physician and documenting the incidents in the resident's medical records. The interim Director of Nurses confirmed that the physician should have been informed immediately after each missed treatment, and a change in condition form should have been completed.
Failure to Arrange Dialysis Transportation
Penalty
Summary
The facility failed to ensure the resident's needs related to dialysis treatments were met for a resident who was to receive scheduled dialysis treatments as ordered by the physician. The facility did not arrange transportation for the resident to and from the off-site certified dialysis facility on two occasions, resulting in missed dialysis treatments on 4/13/2024 and 4/16/2024. Consequently, the resident was transferred to the General Acute Care Hospital Emergency Department for weakness and lethargy, where it was noted that the resident was at risk for central nervous system, cardiopulmonary, metabolic, and renal demise and required aggressive intervention. The resident was admitted to the facility on 4/11/2024 with diagnoses including chronic kidney disease Stage 3, Type 2 diabetes mellitus, dependence on renal dialysis, and hypertension. The resident had dialysis orders with chair time scheduled every Tuesday, Thursday, and Saturday. However, the facility's internal communication records indicated that no transportation was arranged for the resident on 4/13/2024, and this missed treatment was not documented in the resident's medical records. The attending physician was also not informed of the missed treatment. On 4/16/2024, the resident missed another scheduled dialysis treatment due to the absence of transportation. The facility staff, including the Admission Specialist, Admission Coordinator, and interim Director of Nurses, were aware of the transportation issue but did not take timely action to resolve it. The Social Service Worker was not informed of the missed treatment on 4/13/2024 and only became aware of the issue on 4/16/2024. The resident's family was also not informed of the missed treatments until the resident was transferred to the acute hospital on 4/17/2024 due to deteriorating health conditions.
Resident Restrained with Bed Sheet by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, resulting in a violation of the resident's rights. On April 11, 2024, a Certified Nursing Assistant (CNA) tied a resident to a wheelchair using a bed sheet to prevent the resident from getting up while the CNA attended to another resident. This action was taken without attempting other non-restrictive alternatives, obtaining a physician's order, or securing proper consent and evaluation, as required by the facility's policy. The resident involved had a history of severe cognitive impairment and was assessed as high risk for falls. Despite this, the resident was independent in walking with the use of a walker and required varying levels of assistance for other tasks. The incident occurred during the CNA's initial rounds, and the CNA did not seek help from other staff members, claiming no one was available in the hallway. The resident expressed feelings of helplessness, humiliation, and fear as a result of being restrained. Interviews with staff and other residents revealed that the CNA did not inform the Licensed Vocational Nurse (LVN) on duty about the restraint. A Speech Therapist (ST) discovered the resident tied to the wheelchair and reported it to the charge nurse and the Director of Rehabilitation (DOR). The facility's Director of Nursing (DON) confirmed that the use of the bed sheet as a restraint was inappropriate and classified it as a form of physical restraint, which could lead to emotional trauma and physical injuries for the resident.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner, as required by their policy. A speech therapist discovered a resident tied to a wheelchair with a bed sheet by a certified nursing assistant (CNA) and reported it to a charge nurse. However, the incident was not reported to the facility's abuse coordinator until the following day, resulting in an 18-hour delay in notifying the California Department of Public Health. This delay in reporting violated the facility's policy, which mandates that allegations of abuse be reported immediately, but no later than two hours after the incident. The resident involved in the incident had severe cognitive impairment and was unable to make decisions independently. The resident was found tied to a wheelchair by a CNA, who admitted to using the sheet to prevent the resident from falling while attending to other residents. The resident expressed feelings of fear, humiliation, and loss of freedom due to being restrained. The speech therapist, who witnessed the incident, acknowledged the failure to report it immediately, despite being a mandated reporter. Interviews with facility staff revealed a lack of communication and failure to follow proper reporting procedures. The Director of Rehabilitation received a text message about the incident but did not report it to the abuse coordinator until the next day. The Director of Nursing stated that the CNA should have been suspended immediately to protect the resident and others. The facility's policy on abuse investigation and reporting was not adhered to, resulting in a significant delay in addressing the abuse allegation.
Improper Delegation of Medication Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication administration, resulting in a deficiency. A Licensed Vocational Nurse (LVN) improperly delegated the task of administering medications to a Certified Nursing Assistant (CNA), who was not licensed or trained to perform this duty. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including pneumonia, anxiety, depression, and bipolar disorder. The resident was given a mixture of crushed medications in applesauce by the CNA, who was unaware of the contents and not trained to administer medications. Interviews with facility staff, including CNAs, LVNs, a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that CNAs are not trained or permitted to administer medications. The facility's policy and job descriptions also clearly state that only licensed personnel are authorized to administer medications. This breach in protocol placed the resident at risk for harm due to the lack of qualified supervision for potential adverse reactions following medication administration.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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