Sea Cliff Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington Beach, California.
- Location
- 18811 Florida St, Huntington Beach, California 92648
- CMS Provider Number
- 555249
- Inspections on file
- 58
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Sea Cliff Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its own care planning policy by not implementing required monitoring for bedrail entrapment for two residents whose care plans called for safety checks every shift, with no documentation in the medical record that such monitoring occurred and an LVN confirming it was not done. The facility also did not develop a care plan for a resident with intergluteal/perianal MASD despite an active treatment order, as confirmed by an RN. In addition, another resident’s care plan inaccurately documented the location of a midline catheter as being in the right upper arm when it was actually in the left upper arm, a discrepancy verified by nursing staff and acknowledged by the DON.
A resident who had difficulty swallowing medication was not properly assessed or monitored after the incident, and the care plan was not updated to reflect the change in condition. Additionally, warfarin sodium was not administered as ordered due to missing laboratory results and lack of follow-up, and meal intake documentation was incomplete.
A resident with severe cognitive impairment was given crushed iron and tamsulosin medications by an LVN after experiencing difficulty swallowing whole pills. Facility policy and national guidelines indicate these medications should not be crushed, but the LVN proceeded to do so without consulting appropriate references. The DON was made aware of the incident.
A resident with severe cognitive impairment developed new swallowing difficulties, including coughing when taking medication and sips of water. Although the medication was subsequently crushed, the care plan was not reviewed or updated to reflect these changes, contrary to facility policy. The DON confirmed the care plan should have been revised.
A resident was found self-administering multiple medications at bedside without a required assessment, physician's order, or care plan documentation. Staff confirmed that the resident was not authorized to have medications unattended and that facility policy requiring IDT assessment and documentation was not followed.
A facility failed to maintain an effective infection control program, with issues in laundry room cleanliness, inaccurate infection reporting, and improper use of PPE. Staff did not consistently sanitize equipment or perform hand hygiene, and a feeding tube was not disinfected after falling on the floor. These deficiencies were confirmed by staff and the DON.
The facility failed to follow its protocols for enteral feeding and medication administration for three residents. Nurses administered medications via GT by pushing instead of using gravity, and did not check tube placement and residuals as required. These actions were confirmed by the DON and had the potential to cause complications.
A resident requiring continuous oxygen therapy did not receive it as ordered, as the nasal cannula was found hanging on a feeding tube stand instead of being in place. A nurse confirmed the oversight, and the DON acknowledged the findings. The resident was dependent on staff for daily activities and had a physician's order for continuous oxygen to maintain saturation levels above 90%.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses for 157 residents. Observations included improperly thawed chicken without a pull date, a dirty frying pan, improper storage of dry bulk food, wet meal preparation equipment, lack of backflow prevention in floor drains, and unsanitary storage of cleaning equipment.
A facility failed to ensure accurate completion and review of nutritional assessments for a resident, leading to an oversight of significant weight gain. The RD did not participate in or verify the MDS Nutritional Status assessment, which was incorrectly coded by the DSS, resulting in inaccurate documentation of the resident's nutritional status.
The facility failed to ensure two residents under hospice care received scheduled hospice aide visits as required. Despite physician orders for biweekly visits, documentation showed missed visits for both residents. Interviews confirmed the absence of required signatures from hospice staff, indicating visits were not completed. The DON acknowledged the need for hospice staff to sign visit logs, but facility nurses were not documenting visits unless orders were received from the hospice doctor.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident was treated for pneumonia without meeting McGeer's criteria, and the physician was not notified for reevaluation. Another resident was treated for an infection related to elevated WBCs, but symptoms did not meet the criteria, and the physician was not informed.
The facility failed to properly clean and sanitize its ice machine according to the manufacturer's instructions, posing a risk of contamination. The Maintenance Assistant was confused about the cleaning process, using incorrect amounts of cleaner and sanitizer, and the instructions were difficult for him to understand. This failure could potentially lead to food contamination and health issues for residents.
The facility failed to meet pharmaceutical service needs by leaving medications unattended, not replacing an opened CII E-kit within 72 hours, improperly disposing of a refused Percocet tablet, and discarding medication wastes inappropriately. These actions were against the facility's policies, potentially leading to medication misuse and unavailability of emergency medications.
A facility was found to have a 20% medication error rate during an observation, involving two residents. Errors included not measuring heart rate before administering blood pressure medications, incorrect aspirin dosage, and improper form of multivitamins. Additionally, the facility failed to follow enteral tube medication administration procedures, not flushing the GT with the required water amount. Interviews confirmed these practices did not align with physician orders and facility policies.
The facility failed to properly label and store medications, including megestrol acetate without a shake well label, Katerzia stored at room temperature instead of refrigerated, and an opened Levemir insulin vial without an open date. Additionally, expired Tempa-DOT thermometers were found in Medication Room A. These deficiencies were acknowledged by the staff and the DON.
The facility failed to maintain accurate medical records for several residents, including errors in POLST forms, incomplete documentation of treatments and medications, and inaccuracies in meal consumption records. Staff interviews confirmed these lapses, which were acknowledged by the DON.
The facility failed to accurately code the MDS for two residents regarding significant weight changes. One resident experienced a weight loss of over 5% in a month, while another had a 14% weight gain, yet these changes were not reflected in their MDS assessments. The errors were confirmed by the MDS Coordinator, with the dietary department responsible for the assessments.
A resident experienced an unwitnessed fall, and the facility failed to conduct timely neurological assessments as per their policy. The assessments were supposed to occur every hour after the initial evaluations, but one scheduled assessment was missed, leading to a delay in care. The DON confirmed the oversight during a review.
Two residents in an LTC facility were involved in a physical altercation, where one resident scratched the other's face, prompting a defensive bite. Both residents sustained injuries, and the facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse. Medical records indicated cognitive impairments in both residents, and staff observations confirmed the altercation.
A facility failed to create a care plan for a resident who repeatedly refused medications, despite having a policy that mandates comprehensive, person-centered care plans. The resident's medical records documented instances of medication refusal, but no care plan was developed to address this issue, as confirmed by the DON.
The facility did not comply with State law as two CNAs were observed without their name badges, wearing visitor stickers instead. Both CNAs acknowledged the importance of wearing badges for resident identification. The DON confirmed the facility had run out of temporary badges and stressed the importance of staff identification for residents and visitors.
The facility failed to provide necessary care for two residents, leading to deficiencies in medication administration and timely medical response. A resident did not receive Marinol as ordered, and the physician was not notified of the lapse. Another resident experienced stroke symptoms, but the physician was not notified until over six hours later. Interviews with staff confirmed the lack of timely communication and assessment, potentially impacting the residents' health.
A facility failed to order and administer a resident's aspirin and atorvastatin according to hospital discharge orders. The resident, admitted with CVA, pneumonia, and potential stroke, did not receive the prescribed medications. Interviews with staff confirmed the oversight, and the DON acknowledged the failure in the medication reconciliation process.
Failure to Develop and Implement Accurate, Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans consistent with its own policy and residents’ assessed needs. The facility policy required the IDT to develop comprehensive care plans with measurable objectives and timeframes, and to implement baseline care plans within 48 hours of admission. For one resident with moderately impaired cognition who used bilateral half side rails, the care plan identified a risk for entrapment and required monitoring of the resident’s safety for entrapment every shift. However, review of the medical record showed no documented evidence that this monitoring occurred, and an LVN confirmed that the intervention to monitor for entrapment every shift had not been implemented or documented in the MAR or progress notes. A second resident, cognitively intact and using a bariatric bed with built-in bilateral half side rails, also had a care plan identifying risk for entrapment/bodily injury and requiring monitoring of safety for entrapment every shift. Medical record review similarly failed to show documentation that this monitoring was performed. During interview and concurrent record review, the same LVN verified that the resident’s care plan intervention to monitor for entrapment every shift was not implemented as ordered. In both cases, the care plan interventions related to bedrail entrapment risk were not carried out or documented as required. The facility also failed to develop appropriate care plans for two additional residents’ identified conditions. One resident had a physician’s order to cleanse intergluteal cleft extending to perianal MASD with soap and water, pat dry, and apply barrier cream each day shift, but the medical record contained no care plan addressing this MASD; an RN confirmed the absence of such a care plan. Another resident had a documented midline IV access in the left upper arm, but the care plan referenced IV medication and a midline catheter in the right upper arm instead. An RN verified that the midline was actually in the left upper arm and that the care plan inaccurately identified the right upper arm. The DON was informed of and acknowledged these findings for the involved residents.
Failure to Monitor Change in Condition and Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced difficulty swallowing medications. After the resident coughed and choked when given a whole medication tablet with water, the nurse crushed the remaining medications and informed speech therapy (ST) of the change in condition. However, there was no documented evidence that the resident was assessed or monitored following this event, nor were care and safety measures provided as required by facility policy. The resident's care plan was not reviewed or revised to address the new swallowing problem, and meal intake documentation was incomplete for the day of the incident. Additionally, the facility did not administer warfarin sodium, an anticoagulant, as ordered by the physician. The medication was unavailable because the pharmacy required recent laboratory results, which had not been obtained or ordered. The nurse responsible acknowledged that the medication was not given and that follow-up with the pharmacy and physician was not completed due to being occupied with another emergency. The resident's medical record did not contain a physician's order for the necessary blood tests (prothrombin time and INR) required for warfarin dosing. Interviews with staff confirmed these lapses in care and documentation. The Director of Nursing (DON) verified that the resident was not monitored after the change in condition and that the warfarin sodium was not administered as ordered. The DON also confirmed the absence of a care plan update and the lack of orders for required laboratory tests, as well as incomplete documentation of the resident's meal intake.
Improper Crushing and Administration of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and administered an iron tablet to a resident, despite facility policy stating that only medications which may be crushed should be altered in this way. The facility's policy requires nursing staff to use available references to determine which medications are safe to crush. According to the National Library of Medicine, iron tablets are enteric coated and should not be crushed, as the coating is intended to protect the stomach. The resident in question had a physician's order for iron 25 mg and tamsulosin hydrochloride 0.4 mg, both of which were administered on the day of the incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of three, began coughing and choking after the LVN attempted to administer the whole pill with water. In response, the LVN crushed all of the resident's medications, including those that should not be crushed according to reference materials. The Director of Nursing (DON) was informed and acknowledged these findings during the investigation.
Failure to Revise Care Plan for Swallowing Difficulties
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised to reflect the resident's current care needs and interventions following a change in condition. Specifically, after the resident experienced difficulty swallowing medication and coughed when taking sips of water, the care plan was not updated to address these new swallowing problems. The facility's policy required documentation of changes in condition and updates to the care plan as indicated, but this was not followed in this case. Medical record review showed that the resident had severe cognitive impairment, as indicated by a BIMS score of three, and was observed to cough after attempting to swallow a whole medication tablet with water. The medication was subsequently crushed, but the care plan was not revised to reflect this intervention or the resident's new swallowing difficulties. The Director of Nursing confirmed that the care plan should have been updated to address the resident's change in condition.
Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed with a medication cup containing multiple medications at their bedside and proceeded to self-administer these medications without the presence of a licensed nurse. The resident's medical record did not contain an assessment, physician's order, or care plan addressing the ability to self-administer medications. The facility's policy requires that the interdisciplinary team (IDT) assess the safety of self-administration, clarify physician orders to include "may keep at bedside," and document these determinations in the care plan, none of which were completed for this resident. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not supposed to have medications unattended at the bedside and that the required assessment and documentation were missing. The medications involved included blood pressure medications, blood thinners, and supplements. The DON verified that the resident's records lacked the necessary assessment, physician's order, and care plan problem for self-administration of medications, in direct violation of facility policy and federal requirements.
Plan Of Correction
Corrective Action for those residents identified as being affected by this deficiency: Resident 3 was assessed by the DON if he wishes to self-administer medications on 7/24/2025 and resident declined. Identification of other residents having the potential to be affected by this same deficiency: All residents have the potential to be affected by the same deficiency. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. How the facility will monitor its performance to make sure that solutions are sustained: Documented findings of the audit will be forwarded to the QAPI committee monthly for at least 4 weeks beginning September 2025 for review and action planning as indicated or as the QAPI committee determines compliance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the laundry and clean linen rooms, conditions were not maintained to ensure a clean area free from potential contamination. Puddles of water were observed on the floor, adhesive residue on the clean linen folding table, and signs of damage and discoloration on the walls and cabinets, which could lead to mold formation. These conditions were verified by the Maintenance Director, who acknowledged the potential for mold and contamination. The facility's infection surveillance and reporting were also found to be inadequate. Resident 144's infection was not reported on the facility's monthly infection control log, and infections for Residents 127 and 159 were incorrectly listed as meeting McGeer's Criteria. The Infection Preventionist (IP) confirmed these discrepancies, indicating a failure in accurately identifying and reporting infections, which is crucial for preventing potential outbreaks. Additionally, there were multiple instances of staff failing to adhere to proper infection control practices. Two licensed nurses did not wear appropriate personal protective equipment (PPE) during medication administration for residents on enhanced barrier precautions (EBP). Furthermore, the same nurses did not sanitize blood pressure cuffs and stethoscopes before and after use, and hand hygiene was not consistently performed during medication administration. In one instance, a nurse did not disinfect a feeding tube after it fell on the floor before reattaching it to a resident's gastrostomy tube (GT). These lapses in infection control practices were confirmed through interviews with the involved staff and the Director of Nursing (DON).
Failure to Follow Enteral Feeding and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding enteral feeding and medication administration for three residents. Two licensed nurses administered medications to residents via gastrostomy tubes (GT) by pushing the medications through the tube instead of allowing them to flow by gravity, as per the facility's policy. This was observed during medication pass observations for two residents, where one nurse admitted to using the incorrect method initially and then switched to the gravity method. The Director of Nursing (DON) confirmed that medications should be administered by gravity, with gentle pushing only if there is resistance. Additionally, one licensed nurse did not check the tube placement and residual volume before administering medications to a resident, which is required by the facility's policy. This oversight was acknowledged by the nurse during an interview and confirmed by the DON, who stated that checking tube placement and residual volume is necessary to ensure safe medication administration. Furthermore, another resident's enteral feeding was initiated without verifying the GT placement and checking gastric residuals, as required by the facility's policy. The nurse involved admitted to not performing these checks, and the DON confirmed the importance of these procedures to prevent complications. These failures in following established protocols had the potential to lead to complications related to GT care and management.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident who required continuous oxygen therapy. The facility's policy on oxygen administration, revised in February 2023, mandates that oxygen therapy be administered by a licensed nurse as ordered by the physician. However, during an observation on February 11, 2025, it was noted that the resident's nasal cannula tubing was not in place on the resident but was instead hanging on the feeding tube stand, despite the oxygen being set at two liters per minute. A registered nurse (RN) confirmed the observation and acknowledged that the nasal cannula should have been on the resident's nose to ensure continuous oxygen administration. The Director of Nursing (DON) also verified and acknowledged these findings during an interview and medical record review. The resident, who was dependent on staff for activities of daily living, had a physician's order for continuous oxygen to maintain oxygen saturation levels above 90%.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk for foodborne illnesses among the 157 residents who consumed food prepared in the kitchen. During an inspection, it was observed that frozen meat was not thawed safely, as seven bags of thawed raw chicken in the walk-in refrigerator lacked a pull date, making it impossible to determine when they were placed there. Additionally, a frying pan with heavy black residue was found, indicating it was not clean or in good working condition, and should have been discarded. Further observations revealed that dry bulk food was not stored properly, with a plastic scoop left in a powdered thickener container. Meal preparation equipment was not air-dried, as evidenced by a wet blender stored with its lid on. Two floor drains lacked backflow prevention, as the drainage pipes of the juice machine and walk-in refrigerator did not have an air gap. Lastly, cleaning equipment was not stored in a sanitary manner, with a broom found on the floor in the utility closet, contrary to guidelines requiring maintenance tools to be stored off the floor to prevent pest harborage.
Failure to Accurately Complete Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Registered Dietitian (RD) completed or reviewed the Minimum Data Set (MDS) Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of the residents, identified as Resident 87. The California Business and Professions Code 2586 requires Registered Dietitians to conduct nutritional and dietary assessments. However, the RD did not participate in completing or verifying the accuracy of the MDS Section K assessment, which was incorrectly coded by the Dietary Services Supervisor (DSS). The MDS Coordinator confirmed that the assessment was incorrectly coded, and the RD acknowledged that she was not involved in the process. Resident 87 experienced a significant weight gain of 17 pounds, or 13%, over six months, which was not accurately reflected in the assessments. The quarterly nutritional assessment completed by the DSS inaccurately indicated that the resident's weight was stable, despite the significant weight gain. The RD verified that the assessments were not accurate and that she was not involved in reviewing them, which posed a risk to the resident's nutritional needs being unmet.
Failure to Provide Scheduled Hospice Visits
Penalty
Summary
The facility failed to provide necessary hospice care services for two residents, identified as Residents 16 and 93, who were under hospice care. Resident 16, diagnosed with heart failure, was admitted under Hospice A with a physician's order for hospice aide (HA) visits twice a week. However, from January to February 2025, there were no documented HA visits conducted twice a week as required. Specifically, during the week of February 9 to February 15, 2025, there was no evidence of a scheduled HA visit on February 11, 2025. The hospice visit sign-in sheets lacked entries or signatures from hospice staff for the scheduled visits, and the facility's licensed nurse was expected to contact the hospice provider if visits were not completed. Similarly, Resident 93, diagnosed with cerebral atherosclerosis, was admitted under Hospice B with a similar requirement for HA visits. From December 2024 to February 2025, there were multiple weeks where no HA visits were documented, despite being scheduled. Interviews with the Licensed Vocational Nurse (LVN) and the Hospice Case Manager confirmed the absence of documented visits, as hospice staff were required to sign the calendar and visit description log to confirm their visits. The Director of Nursing (DON) acknowledged that hospice staff must sign the hospice calendar or visit log to confirm completed visits, but facility nurses were not required to document visits unless orders were received from the hospice doctor.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for two nonsampled residents. Resident 127 was prescribed antibiotics for pneumonia, but a review of the medical records indicated that the symptoms did not meet the McGeer's criteria for a true infection. Despite this discrepancy, the resident's physician was not notified to reassess the necessity of the antibiotic treatment. Similarly, Resident 159 was prescribed antibiotics for an infection related to elevated white blood cells, which was initially thought to meet the McGeer's criteria. However, upon further review, it was found that the symptoms did not align with the criteria for a true infection. The facility's Infection Preventionist (IP) confirmed the absence of a McGeer's criteria tool for such infections and acknowledged that the physician was not informed about the need to reevaluate the antibiotic use.
Improper Cleaning of Ice Machine
Penalty
Summary
The facility failed to maintain its essential equipment, specifically the ice machine, in safe operating conditions. The ice machine was not cleaned and sanitized according to the manufacturer's instructions, which could potentially lead to contamination of food and illnesses among residents. The facility's policy required monthly cleaning of the ice machine's internal components, but the Maintenance Assistant (MA) did not follow the correct procedure. The MA mixed five ounces of cleaner with an unspecified amount of water and ran it through the machine, then soaked the parts in bleach, which was not in accordance with the manufacturer's guidelines. During an observation and interview, the MA admitted to not knowing the exact amount of water used in the cleaning process and was confused about the instructions, which were in English and difficult for him to understand. The Maintenance Director confirmed the MA's confusion and acknowledged the discrepancy between the cleaning process used and the manufacturer's instructions. This failure to adhere to proper cleaning procedures posed a risk of the ice machine not functioning as intended, potentially leading to contamination and health issues for the residents who consumed food prepared in the kitchen.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's policies and procedures. During a medication administration observation, a licensed nurse left medications unattended on a resident's bedside table multiple times while retrieving supplies, which was against the facility's policy that requires medications to be secured or taken with the nurse if the line of vision cannot be maintained. This oversight had the potential for misuse of medications by residents, staff, or visitors. Additionally, the facility did not replace an opened CII E-kit within the required 72-hour timeframe, as per the facility's policy. The CII E-kit, which contained controlled medications, was opened and not replaced in a timely manner, potentially leading to the unavailability of emergency medications when needed. Furthermore, a tablet of Percocet was removed from the CII E-kit and not disposed of properly after a resident refused it, contrary to the facility's policy that requires refused or held doses to be destroyed. Moreover, a staff member improperly disposed of non-scheduled medication wastes by discarding them into a regular trash bin instead of using the designated drug disposal system. This action was observed during the preparation for medication administration, where the nurse failed to identify which medications were prepared and subsequently discarded the remaining medications into the trash. This practice was not in line with the facility's policy, which mandates the use of a drug disposal system to prevent misuse and environmental harm.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a cumulative error rate of 20% during a medication administration observation. Six medication errors were identified out of 30 opportunities involving two residents. For one resident, the errors included not measuring the heart rate before administering blood pressure medications, administering the incorrect dosage of aspirin, and providing a tablet form of multivitamins instead of the prescribed liquid form. The Licensed Vocational Nurse (LVN) involved did not adhere to the physician's orders, which required checking both systolic blood pressure and heart rate before administering certain medications. Additionally, the facility's policies and procedures for enteral tube medication administration were not followed. The LVN did not flush the resident's gastrostomy tube (GT) with the required amount of water before and after medication administration, nor between each medication, as per the physician's orders. This was observed during the administration of medications to two residents, where the LVN used less water than prescribed and did not flush the GT between medications, potentially leading to tube clogging. Interviews with the LVN and the Director of Nursing (DON) confirmed the discrepancies between the observed practices and the facility's policies. The DON acknowledged that the licensed nurses should have adhered to the physician's orders and the facility's procedures, including the specific instructions for medication administration and GT flushing. These failures in following established protocols contributed to the high medication error rate observed during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications according to the manufacturer's instructions and the facility's policies and procedures. An amber bottle of megestrol acetate oral suspension was found without the necessary label instructing nurses to shake the container well before use. This omission was acknowledged by LVN 10, who confirmed that the information was crucial for the proper preparation of the medication. The Director of Nursing (DON) also confirmed that suspension medications require adequate shaking to ensure uniform preparation. Additionally, a bottle of Katerzia oral suspension, which requires refrigerated storage, was found stored at room temperature in Medication Cart 2. LVN 10 acknowledged that the medication was improperly stored and suggested that it might have been left in the cart after use. The DON confirmed that medications should be stored according to the manufacturer's instructions and returned to the refrigerator after use. Furthermore, an opened vial of Levemir insulin was found without an open date in Medication Cart 1, making it impossible to determine its expiration. LVN 9 confirmed that insulin vials should be discarded 28 days after opening. The DON reiterated the importance of dating insulin vials upon opening. Lastly, three boxes of expired Tempa-DOT thermometers were found in Medication Room A, which the Central Supply Staff confirmed should have been removed. The DON stated that staff should check expiration dates and dispose of expired supplies.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 12 out of 33 sampled residents. This included errors in the Physician Orders for Life-Sustaining Treatment (POLST) forms, such as missing physician signatures for two residents and incorrect documentation of advanced directives and health care agents for another resident. Additionally, there was a lack of documentation of staff review and confirmation of POLST information with a resident's responsible party. Further deficiencies were noted in the documentation of treatment administration records (TARs) and medication administration records (MARs). For instance, one resident's treatment for xerosis and pruritus was not documented as completed, and another resident's low air loss mattress monitoring was not recorded for a specific shift. There were also inaccuracies in documenting meal consumption, with one resident's intake being overestimated in the records compared to actual observations. The facility's failure to maintain accurate records extended to the documentation of vital signs, pain levels, and medication administration for several residents. This included missing entries for monitoring COVID-19 symptoms, administering medications, and providing nonpharmacological interventions for pain. Interviews with staff confirmed these documentation lapses, which were acknowledged by the Director of Nursing.
Inaccurate MDS Coding for Weight Changes
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which could impact their individualized care plans. Resident 25 experienced a significant weight loss of more than 5% in a month, as evidenced by a decrease from 153 lbs to 139.6 lbs over a period of one month. Despite this, the MDS was inaccurately coded to indicate no significant weight loss. The MDS Coordinator confirmed the error, noting that the dietary department was responsible for completing the nutrition assessment. Similarly, Resident 87's MDS was inaccurately coded regarding weight gain. The resident's weight increased from 114 lbs to 130.8 lbs, a 14% increase, yet the MDS did not reflect this change. The MDS Coordinator verified the incorrect coding, which was completed by the Dietary Services Supervisor (DSS). These inaccuracies in the MDS coding could lead to residents not receiving appropriate care plans tailored to their nutritional needs.
Failure to Conduct Timely Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable well-being for a resident who experienced an unwitnessed fall. The facility's policy and procedure for neurological evaluations, revised on 3/28/23, required assessments every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, and then every shift for 72 hours. However, after the resident's fall on 1/18/25, the required hourly neurological assessments were not completed as scheduled. Specifically, the first hourly assessment was conducted at 0155 hours on 1/19/25, but the subsequent assessment due at 0255 hours was missed, with the next assessment occurring two hours later at 0355 hours. During an interview on 2/13/25, the Director of Nursing (DON) confirmed that the neurological assessments should have been conducted according to the specified frequency on the flowsheet. The DON reviewed the resident's Neurological Assessment Flowsheet and acknowledged that the scheduled assessment for 0255 hours on 1/19/25 was not completed. This oversight in following the established protocol for post-fall neurological evaluations had the potential to delay necessary care for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from physical abuse, resulting in an altercation between them. Resident 2 allegedly called Resident 1 a derogatory name and scratched her face, prompting Resident 1 to bite Resident 2's hand in self-defense. This incident was observed by staff, who found Resident 1 with Resident 2's hand in her mouth. Both residents sustained injuries, with Resident 1 having a scratch on her face and Resident 2 having a bite mark on her hand. The facility's policies and procedures on abuse prevention and resident rights were reviewed, revealing that the facility is responsible for ensuring residents are free from abuse and neglect. Despite these policies, the altercation between the residents occurred, indicating a failure in oversight and monitoring. The facility's investigation confirmed the abuse incident, with both residents admitting to their involvement in the altercation. Medical records showed that Resident 1 had moderate cognitive impairment, while Resident 2 had severe cognitive impairment. Both residents were assessed following the incident, with Resident 1 having dried scratches on her face and neck, and Resident 2 having a deep laceration on her hand. Staff interviews corroborated the residents' accounts of the incident, confirming that Resident 1 acted in self-defense after being scratched by Resident 2.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to take medications. The facility's policy requires the interdisciplinary team to create a person-centered care plan with measurable objectives and timeframes to address the medical, nursing, and psychosocial needs identified in the comprehensive assessment. Despite this policy, the medical records for the resident showed multiple instances of medication refusal, with notes indicating the resident was shouting and calling out. However, there was no care plan problem developed to address the resident's refusal to take medications, as confirmed by the Director of Nursing during an interview.
Failure to Ensure Staff Wore Identification Badges
Penalty
Summary
The facility failed to comply with State law by not ensuring that two Certified Nursing Assistants (CNAs) were wearing their name badges while on duty. This was observed during a survey when CNA 2 and CNA 6 were both found wearing visitor sticker badges instead of their employee name badges. CNA 2 acknowledged the importance of wearing the badge for resident identification, and CNA 6 similarly confirmed the necessity for residents to recognize staff. The Director of Nursing (DON) admitted that the facility had run out of temporary sticker name badges and emphasized the importance of staff wearing identification badges for resident and visitor recognition.
Deficiencies in Medication Administration and Timely Medical Response
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in medication administration and timely medical response. Resident 2 did not receive Marinol, a medication to stimulate appetite, as ordered from February 2 to February 7, 2024. The physician was not notified of this lapse, and there was no follow-up with the pharmacy regarding the medication's delayed delivery. The facility's policy on medication administration requires medications to be administered within one hour before or after the prescribed time, which was not adhered to in this case. Resident 5 experienced symptoms indicative of a stroke, including numbness and a feeling of having a stroke, but the physician was not notified until over six hours later. The facility's policy on change of condition reporting mandates that all changes in a resident's condition be communicated to the physician promptly. Despite the resident's complaints and the serious nature of stroke symptoms, there was a significant delay in notifying the physician and transferring the resident to an acute care hospital. Interviews with facility staff, including the ADON and LVN, confirmed the lack of timely communication and assessment in both cases. The ADON acknowledged the delay in following up with the pharmacy for Resident 2's medication, and the DON confirmed that the RN or physician should have been notified immediately when Resident 5 reported stroke-like symptoms. These failures in communication and adherence to facility policies had the potential to negatively impact the residents' health and well-being.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide the necessary care and services to a resident as ordered by the physician. Specifically, the facility did not order and administer the resident's aspirin and atorvastatin according to the discharge medication orders from the hospital. The resident was admitted with diagnoses of CVA, pneumonia, and potential stroke, and the discharge instructions included new orders for aspirin and atorvastatin. However, these medications were not included in the resident's Order Summary Report or MARs for April and May 2024, indicating that the medications were not administered as prescribed. Interviews with LVN 3 and the DON confirmed that the new medication orders were not followed. LVN 3 verified that the aspirin and atorvastatin were necessary for the resident's condition and should have been administered. The DON stated that the admitting nurse was responsible for reconciling the medication orders from the hospital discharge list but failed to do so. There was no documentation to show that the facility's physician was notified of the new medications, and the DON acknowledged the oversight in the medication reconciliation process.
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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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