Temple City Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple City, California.
- Location
- 5101 Tyler Avenue, Temple City, California 91780
- CMS Provider Number
- 056413
- Inspections on file
- 26
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Temple City Healthcare during CMS and state inspections, most recent first.
A resident with dementia, impaired cognition, and multiple ADL dependencies was maintained on several psychotropic medications, including scheduled antidepressant, benzodiazepine, mood stabilizer, antipsychotic, and PRN benzodiazepine for behaviors such as crying, yelling, and aggressive anger. Psychiatric evaluations documented ongoing delusions, yet IDT meetings did not include required psychoactive medication reviews, and the MDS coordinator confirmed that quarterly reviews and reassessments after multiple falls were not done. An LVN reported that specific target behaviors and adverse effects (e.g., TD, cognitive impairment, akathisia, parkinsonism) were not being monitored, and an RN acknowledged there was no documentation of non‑pharmacological alternatives before frequent PRN Lorazepam use. This resulted in the resident receiving psychotropic medications without adequate monitoring, behavioral documentation, or IDT review, constituting unnecessary chemical restraint.
A resident with dementia, difficulty walking, and a documented history of multiple recent falls was identified as high risk for falls using the Morse Fall Scale and placed on a high-risk fall care plan. Despite this, after the resident fell while getting out of bed to use the bathroom and later sustained another fall with a facial laceration while again attempting to use the bathroom, the facility did not revise or add individualized interventions to the care plan. Assessments showed severe cognitive impairment and dependence for most ADLs, while staff reported the resident frequently got up, especially at night, to toilet without using the call light. The DON acknowledged that an intervention for frequent visual checks, discussed for this resident, was never entered into the care plan, and the resident went on to experience additional falls, including one resulting in a left hip fracture and loss of prior ambulation ability.
A resident with DM and ESRD on hemodialysis, who was cognitively intact and required staff assistance with several ADLs, experienced a change in attending physician after the original physician stopped responding to facility and pharmacy calls. The DON reported that the Medical Director assumed care and that the resident was only informed of the change, not involved in selecting the new physician. This process conflicted with facility policies on informed consent and physician services, and failed to honor the resident’s right to choose an attending physician.
A resident with diabetes, ESRD on hemodialysis, and neuropathy had an order for Lyrica 150 mg TID that was not administered because the medication was unavailable from the pharmacy. MAR review showed repeated non-administration, while the DON and pharmacist reported that required Schedule II–V medication therapy authorization forms were faxed multiple times but not returned by the attending physician, and the pharmacy was not informed when the medical director assumed care. Facility policies required timely medication regimen review and physician coverage when the attending is unavailable, but these processes did not prevent the interruption in the resident’s ordered Lyrica therapy.
Two residents with severe cognitive impairment were involved in an incident where one threatened the other with a slipper. Although the event was reported internally to the DON and Administrator, it was not reported to CDPH, the ombudsman, or police within the required timeframe, as mandated by the facility's abuse reporting policy.
A resident with multiple medical conditions developed a skin tear to the left shin during a transfer, and although immediate treatment and physician orders were provided, the care plan was not updated to reflect this change in condition. The treatment nurse and DON both confirmed the omission, which was not in accordance with facility policy requiring care plan updates after changes in resident status.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency for not following the established care plan.
The facility failed to ensure that an LVN and two CNAs completed their annual competency evaluations, leaving sections of their assessment worksheets blank. Interviews with the DSD and DON revealed that these evaluations are required annually, but they were not completed as per the facility's policy.
The facility failed to maintain sanitary conditions in food service, affecting all residents. Logs for sanitization and dishwashing were incomplete, with missing entries for solution concentration and water temperature. Additionally, a trashcan in the food prep area was left open, contrary to policy, posing contamination risks.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a resident while feeding her, contrary to the facility's policy requiring staff to sit at eye level. The resident, with severe cognitive impairment and requiring moderate assistance with eating, was observed in this situation, which was confirmed by the DON as not adhering to the expected standards of care.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairments, as required by their care plans and facility policy. The call lights were found stored in drawers, making them inaccessible, which could prevent timely assistance and increase the risk of falls.
A facility failed to complete the Notification of Bed-Hold and Return form for a resident transferred to a GACH, violating the resident's rights to be informed about their return policy. The resident, with diabetes and hypertension, had the mental capacity to make decisions and required limited assistance. The DON confirmed the form should have been signed, but it was not provided, breaching facility policy.
A facility failed to create a care plan for monitoring the side effects of Apixaban, an anticoagulant prescribed to a resident for DVT prophylaxis. The resident, who lacked decision-making capacity, was readmitted with multiple diagnoses, including palliative care. Despite a physician's order for Apixaban, the necessary care plan was not documented, as confirmed by the DON, potentially affecting the resident's care and safety.
A facility failed to monitor a resident for bruising and bleeding while on Apixaban, a blood-thinning medication. Despite a physician's order to monitor for bleeding every shift, the MAR showed no documentation of such monitoring on specific dates. The DON confirmed the lack of evidence that nurses monitored the resident for bleeding, contrary to the facility's anticoagulation therapy policy.
A facility failed to ensure proper labeling and storage of medications. A resident's Depakote was mislabeled as delayed release instead of extended release, contrary to the physician's order. Additionally, expired medications were found in the storage area, which should have been removed according to facility policy. These deficiencies were identified during observations and interviews with staff.
The facility failed to follow infection control protocols, as staff did not perform hand hygiene while distributing meal trays to two residents, and a nebulizer mask for a resident was improperly stored. The facility's policy requires hand hygiene before and after resident contact and proper storage of nebulizer masks in labeled plastic bags to prevent contamination.
A facility failed to obtain consent and provide information about the side effects of Invega Sustenna to a resident with fluctuating decision-making capacity. The resident received sample medication from the former DON without documented consent or instructions, violating the resident's rights.
The facility failed to provide the required minimum of 80 square feet per resident care area in eight rooms, including seven two-bed rooms and one four-bed room. Despite the deficiency, the facility had requested a waiver, claiming no compromise to resident safety. Observations showed residents had enough space for movement and equipment, with no adverse effects noted.
Failure to Monitor and Review Psychotropic Medications Leading to Unnecessary Chemical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving multiple psychotropic medications was free from unnecessary chemical restraints. The resident had diagnoses including unspecified dementia, difficulty walking, and Non-Hodgkin lymphoma, and was admitted from a general acute care hospital with recurrent falls and later documented as lacking capacity to make medical decisions. The resident’s MAR over a two‑month period showed scheduled Duloxetine for depression, Clonazepam for anxiety, Depakote for irritation and mood stabilization, Seroquel for schizophrenia with aggressive anger, and PRN Lorazepam for anxiety manifested by yelling and screaming, with the Lorazepam dose increased after a physician call related to inability to sleep and roaming. Psychiatric evaluations documented that the resident remained delusional, believing people were in her room, yet the quarterly IDT meeting and a later IDT admission review documented no medication review, contrary to the facility’s psychoactive medication management policy requiring at least quarterly review of response to psychoactive medications and consideration of continued use, dose reduction, or discontinuation. The MDS showed the resident had a severely impaired BIMS score and required substantial to maximal assistance with most ADLs, but there was no evidence that this functional and cognitive status was incorporated into a systematic review of the psychotropic regimen. The MDS coordinator confirmed that the required IDT psychoactive medication reviews were not conducted, including after multiple falls. Nursing staff interviews further demonstrated a lack of appropriate monitoring and use of alternatives related to the psychotropic medications. An LVN stated the resident was being monitored for crying, yelling, anger, and resisting care, and that monitoring was intended to support medication reduction, but also acknowledged that behaviors tied to each medication and side effects such as tardive dyskinesia, cognitive impairment, akathisia, and parkinsonism were not being monitored. An RN reported that Lorazepam was used when the resident was getting out of bed and crying, and that she could not stay with the resident due to other duties. The RN also stated there was no documentation of non‑pharmacological alternatives attempted before administering PRN Lorazepam, despite it being given repeatedly over two consecutive months, indicating the resident was subjected to psychotropic use without documented behavioral monitoring, side‑effect monitoring, or attempts at alternatives as required by facility policy.
Failure to Revise Fall Prevention Care Plan After Repeated Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident as free from accident hazards as possible and to provide adequate supervision to prevent accidents, particularly related to falls. The resident had a history of multiple falls prior to admission from an assisted living facility, with 3–4 emergency room visits in a two‑week period, and was admitted with diagnoses including unspecified dementia, difficulty in walking, and Non‑Hodgkin lymphoma. A History and Physical dated 11/15/2025 documented that the resident did not have the mental capacity to understand and make medical decisions. A Morse Fall Scale completed on 12/3/2025 showed a score of 105, indicating high fall risk. The resident’s care plan, initiated on 10/17/2025, identified high risk for falls due to confusion, gait/balance problems, psychoactive drug use, and unawareness of safety needs, with goals for the resident to remain free of falls and injury and interventions including anticipating and meeting needs and following the facility fall protocol. Despite these identified risks, the facility did not adequately update or individualize the care plan after repeated falls. On 12/28/2025, a post‑fall assessment documented that the resident fell while attempting to get out of bed to go to the bathroom and was found with no apparent injury and assisted to the bathroom. However, no new interventions were added to the high‑risk falls care plan after this fall. On 1/7/2026, another post‑fall assessment indicated the resident slipped when attempting to get up to use the bathroom, and progress notes documented an open cut to the bridge of the nose with bruising, requiring transfer to a general acute care hospital and repair of the laceration with Dermabond. The resident was also treated for a UTI and then readmitted to the facility the same day. Further assessments and staff interviews showed that the resident remained severely cognitively impaired and dependent for most ADLs, including toileting and walking short distances, yet continued to attempt to get up and use the bathroom without calling for assistance. The MDS dated 1/20/2026 documented severe cognitive impairment and substantial/maximal assistance needs for toileting and mobility. Nursing staff, including an LVN and RN supervisor, reported that the resident never called for help, frequently tried to get up without telling anyone, believed she could still move normally despite weakness, and often got up at night to use the bathroom without assistance. The DON acknowledged that although the resident could use the call light, she chose not to, and that an intervention for frequent visual checks was not entered on the resident’s care plan, despite the facility’s policy requiring care plans to be re‑evaluated and modified with significant changes in status. The resident subsequently experienced additional falls, including a fourth fall from standing on 1/21/2026 resulting in a left hip fracture and the need for surgical hemi‑arthroplasty, followed by a decline in ADL function from walking 10 feet to no longer walking after readmission.
Failure to Involve Resident in Choice of Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose an attending physician when changing medical providers. A cognitively intact resident with diagnoses including Diabetes Mellitus and ESRD on hemodialysis was admitted with functional limitations requiring varying levels of staff assistance for ADLs such as bathing, dressing, toileting hygiene, and footwear. The resident’s admission record and MDS confirmed intact decision-making abilities. When the initially assigned attending physician stopped responding to calls from facility and pharmacy staff regarding the resident’s care, the facility did not engage the resident in selecting a new physician. Instead, the DON reported that the issue with the non-responsive attending physician was communicated to the Medical Director, who then assumed care of the resident, as reflected in an order summary documenting transfer of care from the first physician to the Medical Director. The DON stated that the resident was informed of the change in physician but was not involved in choosing the replacement provider. This process did not align with the facility’s own policies on Informed Consents and Physician Services, which state that residents have the right to make informed decisions about their care and that physicians are responsible for supervising medical care, including responding when contacted by the facility.
Failure to Administer Ordered Lyrica Due to Lack of Timely Physician Authorization
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and administer Lyrica as ordered for a resident with neuropathy. The resident was admitted with diagnoses including diabetes mellitus and end stage renal disease on hemodialysis, and had intact cognition but required varying levels of assistance with ADLs. The physician’s order, dated at admission, specified Lyrica 150 mg by mouth three times daily for neuropathy. Review of the MARs for December and January showed that Lyrica was not administered, with documentation indicating the medication was unavailable from the pharmacy. The DON reported that the pharmacy had faxed a Request for New/Continuance of Schedule II–V Medication Therapy authorization to the facility and the attending physician, but the physician did not respond. The DON stated the attending physician was not responding to the facility or pharmacy regarding the resident’s care, and that the medical director subsequently took over the resident’s care. The registered pharmacist stated that the pharmacy faxed the authorization request on two occasions, but the authorization was not received from the physician until several weeks later, and the pharmacy was not informed of the change in attending physician. Facility policies on Medication Therapy and Physician Services required review of the medication regimen shortly after admission and ensuring another physician supervises care when the attending is unavailable, but Lyrica remained unavailable and was not administered as ordered during the period reviewed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required two-hour timeframe to the ombudsman, local police department, and California Department of Public Health (CDPH), as mandated by the facility's Abuse and Neglect Prohibition Policy. The incident occurred when a certified nurse assistant (CNA) heard a commotion and found one resident holding a slipper and another resident reporting that she had been threatened with it. Both residents had severely impaired cognition and memory, with one diagnosed with paranoid schizophrenia and bipolar disorder, and the other with major depressive disorder and hypertension. The incident was documented in the residents' records and reported internally to the Director of Nursing (DON) and the Administrator (ADM), but not to the required external authorities. Interviews with staff and residents confirmed that the resident with cognitive impairment became agitated, believed her bed was occupied by another, and threatened the other resident with a slipper. The threatened resident expressed fear during the incident. Staff responded by separating the residents and moving one to a different room. Despite these actions, the facility did not classify the event as abuse and therefore did not escalate or report it to CDPH, the ombudsman, or the police as required by policy. A review of the facility's policies confirmed that all alleged violations involving abuse must be reported immediately, but not later than two hours, to the appropriate authorities. The facility's failure to report the incident as required resulted in underreporting of abuse allegations and a failure to follow established abuse protocols.
Failure to Update Care Plan After Resident Skin Tear
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan following a change in condition involving a skin tear to the left shin. The resident, who had a history of cellulitis of the right lower limb, chronic respiratory failure, and lack of coordination, sustained a skin tear during a transfer from a shower chair to a wheelchair. Immediate treatment was provided, including cleansing, application of steri strips, and a dry dressing, and a physician's order was obtained for ongoing wound care and skin maintenance. Despite these interventions, there was no documented evidence that the care plan was updated to reflect the new skin tear. The treatment nurse confirmed that the care plan was not revised to include the new condition, and acknowledged the importance of updating care plans after such changes. The Director of Nursing also stated that care plans should be updated after any change in condition to ensure all staff are aware of the necessary interventions. The facility's policy requires care plans to be modified as needed to reflect changes in status, but this was not followed in this instance.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Complete Annual Competency Evaluations for Staff
Penalty
Summary
The facility failed to ensure that one Licensed Vocational Nurse (LVN) and two Certified Nursing Assistants (CNAs) had the necessary competencies and skills to provide quality care to residents. The deficiency was identified through interviews and record reviews, which revealed that the annual competency assessments and evaluations for these staff members were incomplete. Specifically, the competency evaluation worksheets for the LVN and CNAs were found to have sections left blank, indicating that their skills and competencies were not properly assessed. This lack of evaluation could potentially impact the quality of care provided to residents. The Director of Staff Development (DSD) and the Director of Nursing (DON) were interviewed and confirmed that competency evaluations are supposed to be conducted upon hiring and annually for all staff. However, they were unable to explain why the annual competency assessments for the LVN and CNAs were not completed in the previous year. The facility's policy, revised in July 2019, mandates annual competency evaluations for all employees, but this policy was not adhered to in these cases.
Sanitation and Documentation Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, affecting all 47 residents. The Sanitization Bucket Log, which tracks the concentration of Quaternary Ammonia solution used to sanitize food preparation areas, had missing entries for several time slots on 3/14/2025. Staff were supposed to fill out the log after each meal and use, but many columns were left blank, with the last entry recorded at 7:30 AM. The Dietary Supervisor acknowledged the oversight and stated that all kitchen staff are responsible for completing the log, but it was not consistently done. Additionally, the Dish Machine Cleaning Log, which records the temperature of water during dishwashing and the sanitation concentration, also had missing entries for 3/14/2025, with the last entry made at breakfast. The facility's policy requires these logs to be completed, but this was not adhered to. Furthermore, during a kitchen tour, a trashcan in the food preparation area was found open, contrary to the facility's policy that requires trash to be contained in covered, leak-proof containers. This oversight posed a risk of contamination and pest attraction.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect during meal assistance. Specifically, a Certified Nursing Assistant (CNA) was observed standing over Resident 27 while assisting her with a meal, rather than sitting at eye level as required by the facility's policy. This action was noted during a meal observation in the dining room, where the CNA was feeding lunch to the resident who was seated in a wheelchair. Resident 27, who was admitted to the facility with diagnoses including diabetes mellitus and hypertension, had a history of fluctuating capacity to understand and make decisions. According to the Minimum Data Set, her cognitive skills for daily decision-making were severely impaired, and she required moderate assistance with eating. The Director of Nursing confirmed that staff should sit while feeding residents, aligning with the facility's policy to ensure safety, comfort, and dignity during meal assistance.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's policy. Resident 1, who has Parkinson's Disease and severe cognitive impairment, and Resident 12, who has Type 2 Diabetes Mellitus and unspecified dementia, both had care plans indicating they were at risk for falls and required their call lights to be within reach. However, during an observation, it was found that the call lights for both residents were stored inside their personal belongings drawer, making them inaccessible. The Director of Nursing (DON) confirmed that call lights should be within the residents' reach and acknowledged that the residents had a behavior of placing their call lights in drawers. The facility's policy, dated August 2017, mandates that call lights be plugged in and within reach when residents are in bed or confined to a chair. This oversight had the potential to prevent the residents from receiving timely assistance, which could lead to accidents and falls.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to complete the Notification of Bed-Hold and Return form for a resident who was transferred to a General Acute Care Hospital (GACH). This form is crucial as it informs the resident or their representative about their rights to return to the facility after hospitalization. The deficiency was identified during a review of the resident's clinical records, which revealed that the necessary notification was not provided when the resident was transferred to the hospital. The Director of Nursing confirmed that the bed hold notification form should have been acknowledged and signed by the resident or their responsible party, and that the bed hold is valid for seven days. The resident involved was admitted to the facility with diagnoses of diabetes mellitus and hypertension. The resident had the mental capacity to make medical decisions and required limited assistance for activities of daily living. On the day of transfer, the resident exhibited symptoms of red-colored urine and a pain level of 5-6 out of 10. Despite these conditions, the facility did not adhere to its policy and procedure, which mandates providing written notification of the bed-hold policy upon admission and at the time of transfer, in accordance with federal and state guidelines.
Failure to Develop Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a resident-specific care plan for monitoring the side effects of Apixaban, an anticoagulant medication prescribed for DVT prophylaxis. This deficiency was identified during a review of Resident 35's records, which showed a lack of documented evidence of a care plan addressing the monitoring of Apixaban's side effects, such as bruising and bleeding. The Director of Nursing (DON) confirmed the absence of this care plan during an interview and record review, acknowledging that it should have been initiated when the medication was first ordered. Resident 35 was readmitted to the facility with diagnoses including palliative care, peripheral vascular disease, and hypertension. The resident lacked decision-making capacity, and a physician had ordered Apixaban to be administered twice daily. Despite the facility's policy requiring comprehensive care plans to be developed within seven days of a comprehensive assessment, the necessary care plan for Apixaban was not in place, potentially compromising the resident's care and safety.
Failure to Monitor Resident on Apixaban for Bleeding
Penalty
Summary
The facility failed to prevent the unnecessary use of medication by not monitoring a resident for bruising and bleeding while receiving Apixaban, a blood-thinning medication. The resident, who was readmitted to the facility with conditions including peripheral vascular disease and hypertension, was prescribed Apixaban for DVT prophylaxis. Despite a physician's order to monitor for bleeding every shift, the Medication Administration Record (MAR) showed no documentation of monitoring for bleeding or bruising on specific dates. During an interview and record review, the Director of Nursing (DON) confirmed the absence of documented evidence that licensed nurses monitored the resident for bleeding or side effects of Apixaban during the specified periods. The facility's policy on Anticoagulation Therapy Management requires monitoring for signs and symptoms of bleeding and notifying the physician if bleeding is noted. However, this protocol was not followed, leading to the deficiency.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to accepted professional principles. Specifically, a resident's medication, Depakote, was incorrectly labeled as Divalproex Sodium DR (delayed release) instead of ER (extended release) as per the physician's order. This discrepancy was identified during a review of the resident's Medication Administration Record (MAR) by an LVN, who noted that the bubble pack label did not match the physician's order. The LVN acknowledged the importance of matching the physician's order with the medication label to ensure the correct medication form is administered, as the different release forms could affect the resident's behavior. The Director of Nursing also emphasized the importance of following the physician's order and verifying it with the pharmacy. Additionally, the facility failed to properly manage the storage of medications and supplies, as observed in the house supply medication storage room. Expired medications, including Curad triple antibiotic ointment and Stomahesive protective powder, were found in the storage area. A treatment nurse confirmed that expired medications should not be included in the house supply to prevent their use, as they may not be effective. The facility's policy and procedure on medication storage indicated that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to implement its infection control policy and procedure, resulting in deficiencies involving three residents. Activity Assistant 1 and CNA 4 did not perform hand hygiene while distributing meal trays to two residents. This lapse in protocol was observed when CNA 4 did not wash hands between setting up meal trays for the two residents, despite the facility's policy requiring hand hygiene before and after physical contact or care procedures. Interviews with the staff confirmed the failure to adhere to hand hygiene practices, which are crucial to preventing cross-contamination between residents. Additionally, the facility did not properly store a nebulizer mask for a third resident, which was found in the resident's personal belongings drawer instead of a clear plastic bag as required by the facility's guidelines. The Director of Nursing confirmed that nebulizer masks should be stored in labeled plastic bags to prevent contamination. The failure to store the nebulizer mask properly could lead to contamination, posing a risk of infection to the resident.
Failure to Obtain Consent for Medication Administration
Penalty
Summary
The facility failed to inform and provide written information to a resident regarding their right to be informed and sign a written consent about the use and side effects of the medication Invega Sustenna before administration. The resident, who was admitted with diagnoses including Parkinson's disease, encephalopathy, and muscle weakness, had fluctuating capacity to understand and make decisions. Despite this, there was no documented evidence of consent or instructions provided to the resident about the medication's side effects. The deficiency occurred when the facility's former Director of Nursing provided sample medication of Invega Sustenna to be administered to the resident because the pharmacy did not deliver the medication. Licensed Vocational Nurses were instructed to administer the sample medication without ensuring the resident's consent or providing necessary information about the medication. Interviews with staff and a review of the resident's clinical record confirmed the lack of documented consent and information provided to the resident, resulting in a violation of the resident's rights.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident care area in eight out of twenty-eight resident rooms. These rooms included seven two-bed capacity rooms and one four-bed capacity room. The deficiency was identified during a survey, which included observations, interviews, and record reviews. The rooms in question did not meet the space requirements, with some rooms providing as little as 68.5 square feet per resident. Despite this, the facility had previously requested a room waiver, asserting that the variance would not compromise the health, welfare, and safety of the residents. During the survey, the Administrator confirmed that there had been no changes in the number of bed occupancies in the affected rooms and that no complaints had been received from residents, families, or staff regarding room sizes. Observations during the survey indicated that residents had enough space to move freely, and there was adequate room for wheelchairs, walkers, or canes. The survey did not observe any adverse effects on the adequacy of space, nursing care, comfort, or privacy for the residents in the affected rooms.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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