Sherman Oaks Hospital Snf Dp
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman Oaks, California.
- Location
- 4929 Van Nuys Blvd, Sherman Oaks, California 91403
- CMS Provider Number
- 555885
- Inspections on file
- 18
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sherman Oaks Hospital Snf Dp during CMS and state inspections, most recent first.
Nursing staff failed to follow physician orders and facility policy for flushing g-tubes with water before, after, and between medication administrations for three residents with severe cognitive impairment and feeding tubes. In each case, staff either did not flush with the required amount of water or omitted flushing between medications, as observed and confirmed by interviews and record reviews.
The facility failed to ensure its medication error rate remained below 5%, with four errors out of 26 observed opportunities. Two residents with g-tubes did not have their tubes flushed with water between medication administrations, as required by physician orders and facility policy. Nurses acknowledged missing the required flushes, and the Director of Subacute confirmed these were medication errors.
Surveyors found that kitchen staff failed to label opened boxes of bacon, sausage, and a tray of eggs with open or use by dates, as required by facility policy. This lapse in food storage practices had the potential to affect a medically compromised resident who received food from the kitchen.
Two residents who were dependent on staff for all activities of daily living and had significant medical conditions were found with their call lights out of reach, despite care plans and facility policy requiring call lights to be accessible at all times. Staff confirmed during observations and interviews that the call lights should have been placed within reach, but this was not done after providing care.
A resident with chronic respiratory failure, seizure disorder, and a tracheostomy experienced a significant change in condition, including fever and increased secretions. Nursing staff observed these symptoms late at night but did not notify the attending physician until approximately six hours later, resulting in a delay in obtaining new medical orders. Staff interviews and record review confirmed that this delay was not in accordance with facility policy for timely physician notification.
A resident with a history of deep tissue injury and significant cognitive and physical impairments was observed with heels resting on the mattress, despite physician orders and a care plan requiring heels to be floated on two pillows. A nurse confirmed the intervention was not followed, in violation of facility policy for pressure ulcer management.
A resident with chronic respiratory failure, encephalopathy, and dementia, who was fully dependent on staff, was observed lying in bed with the bed brakes unlocked and no staff present. A nurse confirmed this was unsafe, and the bed's manual requires brakes to be applied whenever a resident is in bed.
A resident with significant medical needs and an indwelling urinary catheter was observed with catheter tubing that was looped and not draining properly, despite care plan and facility policy requirements to keep tubing free of kinks and obstructions. A nurse confirmed the improper positioning, which could impede urine flow and increase infection risk.
A resident receiving TPN via a PICC line did not have the TPN bag and tubing labeled with the date and time they were started, as required by facility policy. This lapse was confirmed by an RN during observation, despite the resident's care plan specifying adherence to protocol for tubing changes. The resident had significant medical needs and was fully dependent on staff.
A resident who was ventilator-dependent and required frequent suctioning had a Yankauer suction catheter in use that was not labeled with the date it was to be changed next, as required by facility policy. Staff interviews confirmed that all respiratory equipment should be labeled after being changed, but the catheter in the resident's room lacked this information, making it unclear when it was last replaced and placing the resident at risk for infection.
Two residents experienced inaccurate medical record documentation: one received a different form of docusate sodium than what was ordered, and another was administered Eliquis despite documentation of bleeding. Staff failed to clarify orders and document care accurately, resulting in discrepancies between physician orders and actual care provided.
The facility did not follow its antibiotic stewardship policy for two residents by failing to monitor and document antibiotic use, side effects, and adverse reactions, and by not completing the infection control surveillance log for antibiotic therapy. Staff interviews confirmed that required monitoring and documentation were not performed, and key information was missing from surveillance records.
The facility failed to ensure its Infection Preventionist was qualified and competent in managing the infection control program, as evidenced by a lack of monitoring for antibiotic use and adverse reactions in a resident, and incomplete documentation in the Infection Control Surveillance Log for another resident receiving antibiotics. The IP had not established required surveillance processes and had not fulfilled job description requirements.
The facility failed to establish and implement a policy on enhanced barrier precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs) in four residents. Staff did not follow EBP protocols, such as wearing gowns during high-contact care activities, despite the residents' high risk of infection. The Nurse Manager, Infection Preventionist, and Chief Nursing Officer acknowledged the lack of EBP implementation and staff training.
The facility failed to rotate subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin, leading to potential risks of bruising and bleeding. This was confirmed by the MDSC-RN, PHARM 1, and the NM, and was against the facility's policy and prescribing information for these medications.
The facility failed to act on pharmacist recommendations for three residents, including not tapering methadone dosage, not documenting conditions for lorazepam administration, and not discontinuing Robitussin when not in use.
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin. This failure was confirmed by the MDSC-RN, pharmacist, and NM, and was identified as a significant medication error by the surveyors.
The facility failed to adhere to food safety standards by not storing the ice scooper in a covered container, not ensuring a food service worker wore a hairnet, and not labeling an opened container of canola/extra virgin olive oil with an open date. These practices could lead to foodborne illnesses among residents.
The facility failed to maintain an infection prevention and control program, including not sanitizing a barcode scanner between uses, not implementing Enhanced Barrier Precautions during medication administration for residents with indwelling devices, and not discarding single-use normal saline vials after use.
The facility failed to develop and implement comprehensive care plans on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Both residents lacked appropriate signage and isolation carts, and the LVN did not wear a gown during medication administration. The facility did not adhere to its care planning policies, risking the spread of infection.
The facility failed to ensure adequate supervision by leaving a medication cup with ointments unattended in a shared room, involving two residents who were totally dependent on staff. This breach of policy posed a risk of accidental ingestion.
The facility failed to properly administer and document IV fluids for two residents. One resident's midline catheter dressing was not labeled with the date of the last change, and another resident's midline catheter care and dressing changes were not documented as required. These deficiencies were against the facility's policies and placed the residents at risk for complications.
The facility failed to ensure proper medication storage and labeling when an opened and unlabeled single-use vitamin A&D ointment packet was found in Medication Cart 2. The LVN and Nurse Manager confirmed that the ointment should have been discarded or labeled, indicating a lapse in following the facility's policies.
A facility failed to inspect a handheld nebulizer compressor by its due date, compromising a resident's respiratory care. The resident, in a persistent vegetative state, required routine and as-needed nebulizer treatments. Staff interviews revealed confusion over inspection responsibilities, and the Biomed Engineering Site Lead confirmed the nebulizer was out of service due to missed inspections.
Failure to Adhere to G-Tube Medication Flushing Protocols
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for three residents who required medication administration via gastrostomy tube (g-tube). For one resident with chronic respiratory failure, ventilator dependence, and dysphagia, the physician's order and care plan required flushing the g-tube with 20-50 ml of water before and after medication administration. However, a registered nurse administered only 10 ml of water after the last medication, contrary to the order. The nurse acknowledged that this amount might not be sufficient and could result in clogging the g-tube. The Director of Subacute confirmed that the facility's policy was to flush with 30-50 ml of water after medication administration to ensure hydration and complete delivery of medication. Another resident with chronic hypoxemic respiratory failure, tracheostomy, and pneumonia also had orders to flush the g-tube with 20-50 ml of water before and after medication administration. During observation, a licensed vocational nurse administered two medications sequentially without flushing the tube in between, as required by facility policy. The pharmacist noted that the medications given had a moderate risk of interaction, and the lack of flushing could contribute to this risk, although no immediate action was required for most residents. A third resident with chronic respiratory failure, ventilator dependence, and dysphagia was also observed to have medications administered via g-tube without flushing with water between medications. The nurse involved admitted to missing the flush, and the Director of Subacute reiterated that the facility's policy is to flush with water between medications to prevent drug interactions. Review of the facility's medication administration policy confirmed the requirement to flush the tube with a minimum of 50 ml of water and to rinse the medication cup to ensure complete dosing.
Failure to Flush G-Tubes Between Medications Results in High Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 15.38% based on four medication errors out of 26 observed opportunities. The errors involved two residents who were dependent on staff for activities of daily living and had gastrostomy tubes (g-tubes) for medication and nutrition administration. Both residents had physician orders and care plans specifying that their g-tubes should be flushed with water before and after medication administration, as well as between medications, to maintain tube patency and ensure proper medication delivery. In the case of one resident, a nurse administered crushed Keppra mixed with water via the g-tube, followed by additional water to flush the remaining medication, and then administered crushed fluconazole. The nurse did not flush the g-tube with water between the two medications, contrary to facility policy and the resident's care plan. A pharmacist interview confirmed that administering Keppra and fluconazole in this manner could have moderate drug interactions, and the facility's policy required flushing between medications to prevent such issues. For another resident, a nurse administered liquid Colace followed by crushed Urecholine mixed with water through the g-tube without flushing the tube in between the two medications. The nurse acknowledged the omission during an interview, and the Director of Subacute confirmed that this was a medication error and not in accordance with facility policy. Review of the facility's medication administration policy further supported the requirement to flush g-tubes with water between medications to ensure complete dosing and prevent complications.
Failure to Label Opened Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Specifically, during a kitchen tour, a large box of sausage, a large box of bacon, and a large open carton of eggs were found unsealed and without an open or use by date written on them inside a refrigerator. The Dietary Clerk confirmed that the cook is responsible for labeling these items and acknowledged that the boxes and carton were not labeled with an open or best by date. The Dietary Clerk also stated that without an open date, the facility would not know if the food is safe to serve. The Food and Nutrition Director stated that every food item received must have a received and best by date, and every food item opened must have an open date to prevent foodborne illnesses. A review of the facility's policy and procedure on food storage indicated that food should be stored in a safe and sanitary manner to prevent contamination and that items should be rotated so the oldest dates are used first. The failure to label these food items had the potential to result in harmful bacteria growth and cross contamination, affecting at least one medically compromised resident who receives food from the kitchen.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for two residents who were dependent on staff for all activities of daily living. For one resident with chronic respiratory failure, ventilator dependence, seizure disorder, and severely impaired cognition, the care plan specifically required the call light to be within reach at all times to prevent falls or injury. However, during an observation, the call light was found hanging on the wall at the head of the bed, out of the resident's reach, after staff had finished turning and repositioning the resident. Both a CNA and an LVN confirmed that the call light should have been placed within reach before leaving the room, and acknowledged that this was not done. A second resident, also dependent on staff for activities of daily living and with diagnoses including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed lying in bed with the call light behind the head of the bed and out of reach. The care plan for this resident also required the call light to be kept within reach at all times. A CNA confirmed during the observation that the call light was not accessible and should have been placed next to the resident. Interviews with nursing staff further confirmed that facility policy and procedure required call lights to be placed within reach of residents at all times, and that failure to do so could result in a delay in care. Review of the facility's policy reiterated the requirement to always place call cords within the resident's reach, which was not followed in these instances.
Delay in Physician Notification Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the attending physician following a significant change in condition for one resident. The resident, who had a history of chronic respiratory failure, seizure disorder, traumatic brain injury, and was in a vegetative state, developed a fever and increased thick, dark yellow secretions late in the evening. Nursing documentation indicated that these symptoms were observed at 11 p.m., but there was no record of the attending physician being notified at that time. The attending physician was eventually notified approximately six hours later, in the early morning, after the resident continued to exhibit symptoms including fever, increased secretions, excessive coughing, and vomiting. At that point, the physician provided new orders for diagnostic tests and treatments, including blood cultures, laboratory tests, intravenous fluids, and antibiotics. Both the registered nurse and the director of subacute care acknowledged during interviews that the delay in physician notification was not in accordance with facility policy and could result in delayed care. Facility policy required prompt notification of the physician in the event of an acute medical change, with documentation of all attempts to notify and follow-up actions. The nurse in charge was responsible for ensuring the physician and family or legal representative were notified prior to the end of the shift when a change in condition was noted. In this case, the delay in notification was confirmed through record review and staff interviews, constituting a failure to follow established procedures for timely communication regarding changes in a resident's condition.
Failure to Float Heels as Ordered for Pressure Injury Prevention
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for a resident with a history of a deep tissue injury on the left heel. The resident, who was dependent on staff for all activities of daily living and had significant cognitive and physical impairments, had an order and care plan in place to float her heels on two pillows to prevent pressure injuries. During an observation, it was noted that the resident's heels were resting directly on the mattress, contrary to the prescribed intervention. A registered nurse confirmed during the observation that the resident's heels were not floated as required and acknowledged that the order to float the heels on two pillows was not followed by facility staff. The facility's policy on pressure ulcer management also indicated the use of appropriate pressure relief devices, which was not implemented in this instance.
Failure to Secure Bed Brakes for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that the brakes were set on the hospital bed for one of four sampled residents during a random observation. The resident involved was admitted with multiple significant diagnoses, including chronic respiratory failure requiring a ventilator, chronic encephalopathy, and dementia. The resident was documented as being dependent on staff for activities of daily living and was rarely or never able to make decisions or provide meaningful information. During an observation, the resident was found lying in bed with the bed brakes unlocked and no staff present in the room. A registered nurse, upon noticing the unlocked brakes, acknowledged that this was dangerous and could cause a fall or injury. Review of the hospital bed's operations manual confirmed that brakes should always be applied when a resident is on the bed, and staff should ensure the brakes are locked by pushing on the bed after application.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident who was dependent on staff for all activities of daily living and had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed with a deficiency in urinary catheter care. The resident's care plan specifically required staff to ensure that the urinary catheter tubing was not kinked and that urine could flow freely at all times to prevent infection. During an observation, the resident was found in bed with the urinary catheter tubing hanging below the bed and forming a large loop, which contained yellow liquid with sediment. A registered nurse confirmed that the tubing was looped and that urine was not draining properly, acknowledging that the tubing should be straight to allow for proper drainage. Review of the facility's catheter care policy also indicated the need to keep tubing free of kinks and obstructions. This failure to maintain proper catheter tubing positioning constituted a deficiency in providing appropriate care to prevent urinary tract infections.
Failure to Label TPN Bag and Tubing per Protocol
Penalty
Summary
Facility staff failed to administer total parenteral nutrition (TPN) in accordance with professional standards of practice for one resident. Specifically, the TPN bag and the peripherally inserted central catheter (PICC) line tubing were not labeled with the date and time they were started. This was observed during a random screening, and the omission was confirmed by a registered nurse, who acknowledged that facility policy requires all TPN bags, medications, and tubing to be labeled with the date and time to ensure proper tracking and reduce confusion among nursing staff. The resident involved had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder. The resident was dependent on staff for all activities of daily living and was rarely or never able to communicate or make decisions. The care plan for this resident included an intervention to change tubing according to protocol, but this protocol was not followed as evidenced by the lack of labeling on the TPN bag and tubing.
Failure to Label Yankauer Suction Catheter with Change Date
Penalty
Summary
A deficiency was identified when a resident who was ventilator-dependent and required frequent suctioning did not have their Yankauer suction catheter properly labeled with the date it was to be changed next. The resident had a history of respiratory failure, severe cognitive impairment, and required total assistance with all activities of daily living. Physician's orders and the care plan specified suctioning every two hours and as needed, with interventions to minimize infection risk, including regular equipment changes and labeling. During observation, the resident's Yankauer suction catheter was found inside an opened storage bag without a label indicating the date it was to be changed. Interviews with nursing staff and the Director of Sub Acute confirmed that facility policy required daily changes of respiratory equipment, with labeling to indicate the next change date and staff initials. The absence of this label meant staff could not verify when the catheter was last changed, which was inconsistent with professional standards and facility policy, and placed the resident at risk for infection from potentially contaminated equipment.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with chronic respiratory failure, ventilator dependence, and dysphagia with a gastrostomy tube, there was a discrepancy between the written physician's order and the electronic order for docusate sodium. The written order specified docusate sodium soft gel capsules to be administered via g-tube, while the electronic order listed the medication in liquid form. Observation confirmed that the liquid form was administered, and staff interviews revealed that the order should have been clarified with the physician to ensure consistency and accuracy in the resident's medical record. For another resident with acute hypoxic respiratory failure, tracheostomy, and sepsis, the medical record was inaccurate when a nurse documented the presence of bleeding and still administered Eliquis, an anticoagulant. The care plan for this resident included monitoring for signs of bleeding and holding anticoagulant therapy if bleeding was observed. Review of the Medication Administration Record showed that Eliquis was given despite documentation of bleeding, and staff interviews confirmed that the medication should have been held under these circumstances. These failures resulted in medical records containing inaccurate documentation, with discrepancies between physician orders and actual care provided. The facility's policy required accurate, factual, and specific documentation of resident conditions and interventions, which was not followed in these instances.
Failure to Monitor and Document Antibiotic Use and Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two residents by not adequately monitoring antibiotic use, side effects, or adverse reactions, and by failing to maintain complete infection control surveillance records. For one resident, who was admitted with multiple complex diagnoses including seizure disorder, traumatic brain injury, respiratory failure with tracheostomy, and was in a vegetative state, there was a documented fever and increased secretions, leading to the initiation of intravenous antibiotics (Zosyn and Vancomycin). Despite care plan interventions requiring observation for adverse reactions, there was no documentation in the nurses' notes of monitoring for antibiotic use or adverse reactions during the course of treatment. Interviews with facility staff, including the MDS nurse, Infection Preventionist, and pharmacist, confirmed that the expectation was for nurses to monitor and document antibiotic use and any side effects or adverse reactions every shift. However, this monitoring and documentation did not occur as required. The pharmacist also relied on these notes for their own monitoring, further highlighting the gap in the process. For another resident, who was also in a vegetative state and dependent on staff for all activities of daily living, the facility failed to complete the Infection Control Log related to antibiotic use for a wound infection. Key information such as date of admission, signs and symptoms, organism, and date infection resolved were missing from the log. Staff interviews confirmed that the log was incomplete and that the responsibility for documentation was not consistently followed. The facility's policy required antibiotic surveillance as part of its stewardship program, but this was not carried out as documented.
Inadequate Infection Preventionist Oversight and Incomplete Antibiotic Surveillance
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was qualified and competent in implementing the infection prevention and control program. Specifically, the IP did not monitor antibiotic use, side effects, or adverse reactions for a resident who was prescribed Zosyn and Vancomycin for a fever. Despite care plan interventions requiring observation for adverse reactions, there was no documented monitoring in the nurse's notes for the duration of the antibiotic therapy. Additionally, the facility's Infection Control Surveillance Log for another resident receiving antibiotics for a wound infection was incomplete. Key information such as date of admission, signs and symptoms, organism location, and date infection resolved were missing from the log. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that the log was incomplete for this resident. Interviews with the IP revealed that she had not started her own antibiotic surveillance log as required by her job description, and she acknowledged that the antibiotic surveillance process was not being completed. The IP also stated that she was responsible for multiple facilities and had not attended required training or conventions. The Director of Subacute and Chief Nursing Officer confirmed that the IP had not met the qualifications outlined in her job description and that the infection control tracking and monitoring duties were not being fulfilled.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement a policy and procedure on enhanced barrier precautions (EBP) designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. This deficiency was observed in four sampled residents during medication administration. The facility did not have EBP signs or isolation carts at the entrance of the residents' rooms, and staff did not don appropriate personal protective equipment (PPE) such as gowns during high-contact resident care activities. This failure was confirmed through observations, interviews, and record reviews involving Residents 10, 13, 12, and 14, all of whom had conditions that made them prone to infections, such as tracheostomies, g-tubes, and open wounds. Resident 10 was admitted with diagnoses including chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status. The resident was on isolation for an active infectious disease and required various medical interventions. During medication administration, the nurse did not follow EBP protocols, such as wearing a gown, despite the resident's high risk of infection. The Nurse Manager and Infection Preventionist acknowledged the lack of EBP implementation and the absence of staff training on the procedure. Similarly, Resident 13, who had chronic respiratory failure, tracheostomy status, and g-tube status, did not have EBP signs or isolation carts in their room. The nurse administering medications did not wear a gown, and the Nurse Manager confirmed that EBP should have been implemented. Resident 12 and Resident 14, both with tracheostomies and g-tubes, also did not have EBP protocols followed during medication administration. Interviews with the Nurse Manager, Infection Preventionist, and Chief Nursing Officer revealed that the facility was aware of the need for EBP but had not yet developed or implemented the necessary policies and procedures.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to provide care in accordance with professional standards to three residents by not rotating subcutaneous injection sites for medications. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential risks of bruising and bleeding. The Medication Administration Record showed that injections were not rotated on multiple dates, and this was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). The facility's policy and prescribing information for heparin also indicated the need for site rotation to prevent such issues. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated on several dates, which was corroborated by the Pharmacist (PHARM 1) and the NM. The facility's policy and the prescribing information for enoxaparin sodium highlighted the importance of alternating injection sites to prevent complications. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated on numerous dates, and this was supported by PHARM 1 and the NM. The facility's policy and the prescribing information for Lantus emphasized the need for site rotation to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon the recommendations of the consultant pharmacist for two of five sampled residents. For Resident 2, the facility did not taper down the dosage of methadone as recommended by the pharmacist. Despite the pharmacist's recommendation to reduce the dosage to 10 mg every 24 hours, the physician continued the existing pain management regimen without documenting the rationale for not following the recommendation. The pharmacist also failed to document her conversation with the physician regarding the recommendation, leaving the healthcare team unaware of the rationale for not tapering the medication. For Resident 17, the facility did not document episodes of respiratory distress or heart rate greater than 120 in the electronic medication administration record (eMAR) when administering lorazepam. The medication was administered on multiple occasions without documented evidence of the required conditions being met. This lack of documentation prevented the care team from assessing the necessity of the medication and ensuring it was used appropriately. For Resident 7, the facility did not act upon the pharmacist's recommendation to consider discontinuing Robitussin if it was not being used. The medication order remained active without a stop date, and there was no documentation indicating that the recommendation was communicated to the physician or acted upon. This oversight could lead to the resident receiving unnecessary medication and potential side effects from prolonged use of Robitussin.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential bruising and bleeding. The Medication Administration Record showed multiple instances where the injection sites were not rotated as required, which was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). Both acknowledged that not rotating the injection sites is considered a medication error. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated, and this was confirmed by both the pharmacist and the NM. The facility's policy and the prescribing information for enoxaparin sodium both indicated the necessity of rotating injection sites to prevent adverse effects. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated, and this was corroborated by the pharmacist and the NM. The facility's policy and the prescribing information for Lantus emphasized the importance of rotating injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. The failure to rotate injection sites for these residents was identified as a significant medication error by the surveyors.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation and interview with the Director of Food and Nutrition (DFN), it was noted that the ice scooper was stored in an uncovered holder mounted on the side of the machine. The DFN acknowledged that the ice scooper should be stored in a closed container to prevent outside contaminants from settling in the scooper, which could cause foodborne illnesses. Additionally, Food Service Worker 1 (FSW 1) was observed not wearing a hairnet while inside the kitchen. The DFN confirmed that FSW 1 should wear a hairnet at all times when working in the kitchen to prevent hair from contaminating food and equipment, which could result in serving contaminated food to residents. Furthermore, an opened container of canola/extra virgin olive oil was found without an open date label. The DFN stated that the container should have an open date label to inform kitchen staff when to discard the oil. The absence of this label could potentially result in staff using expired oil, leading to foodborne illnesses among residents. The facility's policies and procedures, including those for dispensing ice, dress code, and food labeling and dating, were reviewed and found to support the need for these practices to prevent contamination and ensure food safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Firstly, the barcode scanner used during medication administration was not sanitized before and after use, potentially causing cross-contamination between residents. This was observed during medication administration for two residents, where the Licensed Vocational Nurse (LVN) did not clean the scanner after placing it on a resident's tablet and before using it on another resident. The Nurse Manager confirmed that the barcode scanners should be disinfected between uses to prevent the spread of infections, but this practice was not followed by the LVN. Secondly, the facility did not implement Enhanced Barrier Precautions (EBP) during gastrostomy tube medication administration for residents with indwelling devices. The LVN administered medications to residents without donning an isolation gown, despite the residents having conditions that made them prone to infections. Both the Nurse Manager and the Infection Preventionist acknowledged that EBPs should be used for residents with wounds or indwelling devices, but the facility had not implemented this practice. The Chief Nursing Officer also confirmed that the EBP policy was not finalized or implemented, despite being aware of its importance. Lastly, the facility failed to discard opened and partially used normal saline solution unit dose vials after use. During an observation, two opened vials were found inside a box, which were supposed to be single-use only. Both a Registered Nurse and a Respiratory Therapist confirmed that these vials should have been discarded after use to prevent infection. The facility's policy also indicated that single-use items should be discarded after use, but this was not adhered to, posing a risk of infection to the residents.
Failure to Implement Enhanced Barrier Precaution Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Resident 10, admitted with chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status, did not have an enhanced barrier precaution sign or isolation cart outside their room. During medication administration, the Licensed Vocational Nurse (LVN) did not wear a gown, and it was confirmed that Resident 10's care plan did not include enhanced barrier precautions, which was acknowledged as important by both the LVN and the Nurse Manager (NM). Similarly, Resident 13, admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, also lacked an enhanced barrier precaution sign and isolation cart outside their room. The same LVN did not wear a gown during medication administration for Resident 13, and it was confirmed that Resident 13's care plan did not address enhanced barrier precautions. The facility's policy required a comprehensive care plan to be developed within seven days of admission and updated regularly, but this was not followed for these residents. The observations and interviews revealed that the facility did not adhere to its own care planning policies, which required the development of a coordinated and comprehensive written plan based on the resident assessment and individual needs. This failure to implement appropriate infection control measures had the potential to spread infection among residents and staff, as evidenced by the lack of enhanced barrier precaution care plans for Residents 10 and 13.
Failure to Prevent Accidents Due to Unattended Medication
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents by leaving a medication cup containing clear and white ointment unattended and readily accessible in a shared room. This incident involved two residents, one of whom was in a persistent vegetative state and totally dependent on staff for all activities of daily living, while the other resident was sometimes able to make himself understood and also totally dependent on staff for mobility and hygiene. Both residents had physician orders for the application of ointments for skin management and maintenance, which were not properly administered and monitored by the staff. During an observation, a Certified Nursing Assistant (CNA) found a medication cup with ointments on a wall-mounted workstation in the shared room of the two residents. The CNA did not know who placed the cup there and stated that ointments should be discarded after each use and not left in residents' rooms. Further interviews with a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) confirmed that the medication cup was not labeled, and it was against facility policy to leave medications in residents' rooms due to the risk of accidental ingestion. The Nurse Manager reviewed the facility's policy and procedure regarding medication administration, which indicated that medications should not be left with residents to self-administer unobserved. The policy was not followed in this instance, leading to a potential risk for the residents. The facility's failure to adhere to its medication administration policy resulted in a deficiency that could have caused harm to the residents involved.
Failure to Administer and Document IV Fluids Properly
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice for two residents. For Resident 1, the facility did not label the midline catheter dressing with the date of the last dressing change. This was observed during a bedside check, and the registered nurse confirmed the omission. The facility's policy requires midline catheter dressings to be changed every seven days and as needed, and the absence of a date on the dressing could lead to untimely changes and potential infection. The resident had severe cognitive impairment and required total assistance with all activities of daily living, making proper catheter care crucial. For Resident 2, the facility failed to document midline catheter care and dressing changes as per the facility's policy. The resident's midline catheter dressing was observed to be dated, but there was no documented evidence of the dressing change in the nursing records. Additionally, there was no documentation of midline catheter care for specific shifts. The registered nurse verified these documentation gaps, which are against the facility's policy that mandates documenting all assessments and interventions. Resident 2 had intact cognition but required total assistance with all activities of daily living, and proper documentation is essential to ensure timely and appropriate care. Both residents had physician's orders for midline catheter care, including dressing changes every seven days and flushing with normal saline every shift. The facility's failure to adhere to these orders and document the care provided placed the residents at risk for complications such as infection. The facility's policies on midline catheter management and charting guidelines were not followed, leading to these deficiencies.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe provision of pharmaceutical services during an inspection of Medication Cart 2. An opened and unlabeled single-use vitamin A&D ointment packet was found in the top drawer of the cart. The Licensed Vocational Nurse (LVN) present during the inspection stated that the ointment packet should have been discarded after use in the resident's room. The LVN did not know which resident the packet was opened for or if it had been used, indicating a lapse in proper medication handling procedures. The Nurse Manager confirmed that such ointment packets are not meant for multiple residents and should be labeled with the resident's name if unused and opened in the medication cart. A review of the facility's policies indicated that drugs and devices should be stored to ensure stability and integrity, and that all medications must be appropriately labeled to promote safety. The facility's policy on medication storage and labeling was not followed, as evidenced by the presence of the opened and unlabeled ointment packet. This failure had the potential to result in cross contamination and decreased efficacy of the medication, posing a risk to resident safety.
Failure to Maintain Nebulizer Compressor
Penalty
Summary
The facility failed to maintain a handheld nebulizer compressor in safe operational condition for a resident in a persistent vegetative state. The nebulizer compressor, which was essential for administering respiratory treatments, was labeled with a next inspection due date of July 2023 but had not been inspected by the time of the survey in April 2024. This oversight was identified during an observation of the resident's environment and confirmed through interviews with nursing and respiratory therapy staff, who acknowledged the lapse in inspection and maintenance protocols. The resident, who was totally dependent on staff for all activities of daily living, had multiple physician orders for routine and as-needed nebulizer treatments to manage respiratory conditions. Despite these orders, the nebulizer compressor had not been inspected as required, potentially compromising the effectiveness of the resident's respiratory care. Staff interviews revealed a lack of clarity regarding the responsibility for ensuring the equipment was inspected, with both nursing and respiratory therapy staff assuming the other party would handle it. Further investigation with the Biomed Engineering Site Lead revealed that the nebulizer had been placed in out-of-service status because it had not been located for inspection. The facility's Environment of Care Manual indicated that medical equipment should be inspected, tested, and maintained regularly, but this protocol was not followed in this case. The failure to inspect the nebulizer compressor as scheduled was attributed to an oversight and a breakdown in communication among staff responsible for the equipment's maintenance.
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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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