Temple Park Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2411 W. Temple Street, Los Angeles, California 90026
- CMS Provider Number
- 555019
- Inspections on file
- 46
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Temple Park Convalescent Hospital during CMS and state inspections, most recent first.
A nurse administered Benadryl to a resident but did not document the administration on the MAR as required by facility policy. The omission was confirmed through observation and staff interview, despite the resident having a history of muscle weakness, hypertension, and dementia.
A resident with multiple diagnoses and intact cognition was given Benadryl 25 mg by an LVN without a physician's order, and the medication was left unattended at the bedside rather than being directly administered and observed. The LVN did not verify the order in the MAR before giving the medication, and the RN Supervisor confirmed the absence of a physician order, in violation of facility policy.
A resident with diabetes and a sacral pressure ulcer, who was on enhanced barrier precautions and receiving metronidazole 500 mg via gastrostomy tube for infection, did not receive one of the ten prescribed doses of the antibiotic. This was confirmed through review of the MAR and medication bubble pack by two LVNs, indicating a failure to administer medication as ordered by the physician.
A nurse was observed leaving bubble packs of medications on top of an unattended medication cart while administering meds to a resident who required assistance with daily activities. This action was not in line with facility policy, which requires all medications to be secured and not left on top of the cart when out of the nurse's sight.
A resident with diabetes, dementia, and MASD to the buttocks did not receive the required weekly skin assessments and documentation as outlined in the care plan and facility policy. Although daily treatments were recorded, there was no evidence that licensed nurses completed or documented weekly evaluations of the MASD, making it unclear if the condition improved before discharge.
A resident with diabetes, muscle weakness, and mobility impairment experienced difficulty moving his wheelchair due to cluttered hallways filled with linen carts, hampers, and shower chairs on both sides. Multiple staff, including an LVN, infection preventionist, RN supervisor, and DON, confirmed the hallway was crowded and acknowledged the safety issue, which was not in line with facility policy.
A resident with severe cognitive impairment and limited capacity to consent was admitted without an advance directive in place, and facility staff did not verify, document, or communicate the resident’s advance directive status as required by policy. The resident was considered full code by default, and there was no evidence that the responsible party or physician was notified or involved in decision-making regarding end-of-life care.
A resident with cognitive impairment and multiple medical conditions was observed using a hand mitten restraint without an associated care plan. Despite staff obtaining physician orders and consent for the mitten, no care plan was developed or implemented, and required monitoring for skin integrity and circulation was not documented, contrary to facility policy.
A resident dependent on staff for ADLs and at risk for skin breakdown was left soiled for about 20 minutes before being cleaned, despite staff awareness and facility policies requiring prompt hygiene care. Staff delays and lack of immediate assistance contributed to the deficiency.
A resident with type 2 diabetes and moderate cognitive impairment received consecutive insulin injections in the same abdominal sites, contrary to facility policy requiring site rotation. Staff and the DON confirmed that injection sites were not rotated as documented in the MAR, despite having access to previous site information and clear policy guidelines.
A treatment nurse did not complete required weekly monitoring and documentation of a resident's unstageable pressure ulcers, despite the resident's complex medical conditions and care plan requirements. The last wound assessment was recorded weeks prior, and both the nurse and DON acknowledged the lapse, which was contrary to facility policy and could have allowed the wounds to worsen.
A lighter was found unattended on a resident's bedside table, despite the resident's care plan and facility policy requiring supervised smoking and secure storage of smoking materials. Staff interviews revealed inconsistent understanding of the policy, and the facility's procedures were not followed, resulting in a potential fire hazard.
A resident with respiratory conditions was observed using oxygen nasal cannula tubing that was wrapped around a trash can at the bedside, resulting in unsanitary conditions. Both a CNA and an LVN confirmed the tubing was dirty and needed replacement, in violation of facility policy requiring clean respiratory equipment. The DON also acknowledged that soiled tubing should be exchanged to prevent infection.
Two opened insulin pens were found stored in the medication refrigerator past their labeled discard dates, contrary to facility policy. Both an LVN and the DON acknowledged that such medications should have been discarded, and the facility's policy requires outdated drugs to be removed from storage. This failure created the potential for medication dispensing errors.
A facility failed to develop a care plan for a resident's right-hand swelling, noted during a record review and interview with the DON. The resident, with multiple diagnoses including dementia and diabetes, had a documented change in condition indicating edema, but no care plan was in place. The facility's policy requires care plans based on comprehensive assessments, which was not followed in this case.
A resident with severe cognitive impairment and multiple medical conditions was not offered substitute meals when consuming less than 50% of their meals, as required by facility policy. This oversight was confirmed by the DON and documented in the resident's CNA Daily Charting Form, highlighting a potential risk for malnutrition and health decline.
A resident with dementia and Alzheimer's disease, requiring substantial assistance with personal hygiene, was observed with inadequate mouth care, including a creamy substance at the mouth corner and a coated tongue. Despite the care plan's requirement for daily oral care, staff failed to provide comprehensive mouth care, leading to a deficiency in the facility's care standards.
A facility failed to document a resident's fluid and oral intake accurately on several occasions. The resident, with severe cognitive impairment and requiring assistance with daily activities, had missing entries in the CNA daily charting forms for specific afternoon shifts. The DON acknowledged the oversight, and the facility's policy on accurate documentation was not followed.
During a COVID-19 outbreak, a resident was observed not wearing a mask, and staff were not fit tested for N95 masks. Additionally, staff screening protocols were not followed, as observed with a dietary staff member who screened after attending a meeting. The facility lacked systems to ensure compliance with mask-wearing, fit testing, and screening protocols, increasing the risk of infection spread.
A facility failed to report alleged abuse between two residents and an injury of unknown origin to the State Agency. One incident involved a physical altercation between two residents over alleged theft, resulting in a skin tear. Another resident with severe cognitive impairments was found with a bruise of unknown origin, but no investigation or reporting was conducted. The facility did not adhere to its policies on abuse prevention and reporting, exposing residents to potential continued abuse.
A resident with severe cognitive impairments was found with a bruise under the left eye, which was not reported or investigated by the facility. Interviews with staff revealed that the injury was not consistent with a scratch, and the facility failed to follow its policies for reporting and investigating such incidents. The facility's policies required reporting to external agencies and implementing a 72-hour monitoring protocol, which were not adhered to.
The facility failed to ensure nurses had the competencies to assess pressure ulcers, leading to a stage 3 ulcer being unrecognized in a resident with diabetes and dementia. Additionally, the facility did not follow its abuse policy when a resident with severe cognitive impairments was found with a bruise of unknown origin, and no investigation or reporting was conducted.
The facility failed to manage and report abuse incidents involving three residents due to the absence of a full-time abuse coordinator. A resident reported being assaulted by a roommate, and another resident was found with unexplained bruising. The facility did not follow its policies on reporting and investigating these incidents, leading to deficiencies in resident protection and compliance with regulations.
A resident with severe cognitive impairments and a history of wandering ingested hand sanitizer due to inadequate supervision and a hazardous environment. The resident was left unsupervised at the nurses' station, leading to hospitalization for toxic encephalopathy. Observations revealed unattended areas with accessible toxic substances, including hand sanitizer and cleaning chemicals. Staff interviews confirmed the lack of supervision and failure to address the resident's behavior in the care plan.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairments and multiple diagnoses, leading to a deficiency. The resident's records contained incorrect information about their condition and treatment, which was confirmed by the DON. This failure was contrary to the facility's policy on charting and documentation, which requires complete and accurate records to ensure effective communication among the care team.
A resident with dementia did not have their care plan updated after the discontinuation of dementia medications Namenda and Aricept. The facility's MDS Coordinator and DON acknowledged the failure to revise the care plan, which was required to monitor the resident for increased confusion and behavioral changes. This oversight was contrary to the facility's policy for developing a resident-centered care plan.
A facility failed to prepare a resident for a safe discharge by not involving the primary caregiver in the process and not providing necessary medical equipment and supplies. The resident, with multiple medical conditions, was discharged without the caregiver receiving required training and resources, leading to significant challenges and stress for the caregiver.
The facility failed to label various food items with use-by dates and did not discard expired ground beef. Additionally, temperature logs for refrigerators and freezers were not maintained on two specific dates, which could potentially cause food-borne illnesses.
The facility failed to maintain the dignity of two residents. One resident's urinary collection bag was not covered with a privacy bag, and another resident was fed by a CNA standing over them instead of sitting at eye level. These actions were against the facility's policies and negatively impacted the residents' dignity.
The facility failed to ensure that a call light was within reach for a resident with Huntington disease and mildly impaired cognition. The call light was found on the floor, not within the resident's easy reach, which was confirmed by a CNA and acknowledged by the DON. The facility's policy requires call lights to be within easy reach when residents are in bed or confined to a chair.
The facility failed to ensure Advance Directive Acknowledgement forms were thoroughly completed for two residents. One resident's form was unsigned and incomplete, while another's form was signed but lacked necessary information. This could result in the residents' medical decisions not being honored.
The facility failed to provide a communication device or board for a resident who primarily spoke Chinese, despite the resident's severe cognitive impairment and language barrier. Staff acknowledged the absence of such a device, and the care plan did not include this necessary intervention, contrary to the facility's policy.
The facility failed to provide adequate assistance with ADLs for a visually impaired resident, leading to difficulties in locating and consuming food items. Staff did not consistently inform the resident about the placement of food, resulting in inadequate nutrition and self-care.
The facility failed to ensure that a CNA had an up-to-date BLS certificate, which had expired. Despite this, the CNA was found to be working in the facility. Both the DSD and DON confirmed the expiration and acknowledged the potential risk to residents receiving outdated medical care.
A facility failed to provide a visually impaired resident with activities that stimulate her senses, resulting in emotional distress and boredom. The resident did not receive a radio or TV, lacked a care plan for activities, and did not have a quarterly activity participation review. Staff were unaware of the resident's preferences and requests, leading to a decline in her quality of life.
A resident with severe cognitive impairment and multiple pressure ulcers did not receive appropriate care as the wound vac was found off and unplugged, and the care plan was not updated to reflect the current treatment. Both the IP and DON confirmed these deficiencies, which could worsen the resident's condition.
A resident's urinary catheter was not securely anchored, contrary to the care plan and facility policy, potentially causing pain and urethral trauma. Observations confirmed the catheter was not secured, and the Infection Preventionist and DON acknowledged the oversight.
The facility failed to provide appropriate respiratory care for a resident by administering oxygen via a non-rebreather mask without a physician's order and not monitoring oxygen saturation levels as required. The resident's oxygen use was also not included in the care plan, despite experiencing shortness of breath.
A resident dependent on hemodialysis was found without an emergency kit at their bedside, despite facility policy requiring such kits for dialysis patients. The resident, who had multiple diagnoses including ESRD, was unaware of the need for the kit, and staff confirmed its absence, highlighting a failure to ensure proper emergency preparedness.
The facility failed to post staffing information per its policy, as the staff posting did not include the facility's name. This was confirmed by the DSD and DON, who acknowledged the potential for confusion among residents, visitors, and staff.
The facility failed to meet the nutritional needs of two residents by not providing double portion meals as ordered by their physicians. Both residents did not receive the prescribed double portions, which were crucial for their nutritional support and weight maintenance. The issue was confirmed by the Registered Dietitian and the Director of Nursing.
A resident's food preferences were not evaluated quarterly as required, leading to dissatisfaction and emotional distress due to unappetizing food options. The Dietary Supervisor and Director of Nursing confirmed the lapse in conducting timely Nutrition Evaluations.
The licensed nursing staff failed to maintain accurate POLST records for a resident, leading to confusion during an emergency. The resident's POLST form had conflicting instructions, which were not identified or corrected by multiple staff members, resulting in the initiation of CPR despite the form also indicating 'Do Not Resuscitate'.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one of three sampled residents. Specifically, a registered nurse supervisor administered Benadryl 25 mg orally to a resident but did not document the administration on the Medication Administration Record (MAR) at the time the medication was given. The omission was confirmed during an interview with the nurse, who acknowledged that documentation should have occurred immediately after the medication was administered. Observation confirmed that the resident received the medication, but the corresponding entry on the MAR for that date was left unsigned. The resident involved had a history of generalized muscle weakness, hypertension, and dementia, and was assessed as having intact cognition. Facility policy required that the individual administering medication must initial the MAR after giving each medication and before administering the next, including recording the date, time, dosage, route, symptoms, and the signature and title of the person administering the drug. The failure to document the administration of Benadryl was contrary to this policy and was identified through both record review and staff interview.
Medication Administered Without Physician Order and Improper Supervision
Penalty
Summary
A deficiency occurred when a resident was administered Benadryl 25 mg orally without a physician's order. The resident, who had diagnoses including generalized muscle weakness, hypertension, and dementia but was assessed as having intact cognition, requested Benadryl for itching. The medication was provided by an LVN, who did not verify the presence of a physician's order prior to administration. The LVN admitted to not checking the Medication Administration Record (MAR) or confirming the order before giving the medication, stating it was a mistake and acknowledging the importance of verifying orders to prevent medication errors. Additionally, the Benadryl tablet was left unattended on the resident's bedside table, rather than being administered directly and observed by the nurse. The Registered Nurse Supervisor confirmed that there was no physician order for the Benadryl and that facility policy requires medications to be administered only as prescribed and in accordance with orders. The facility's failure to obtain a physician order and to ensure proper administration and observation of the medication constituted a significant medication error.
Missed Dose of Physician-Ordered Antibiotic
Penalty
Summary
A resident with diagnoses including diabetes mellitus and a sacral pressure ulcer was admitted to the facility and placed on enhanced barrier precautions due to a gastrostomy tube and pressure injury. The resident's care plan included the administration of antibiotic medications as ordered by the physician. A physician's telephone order was received to administer metronidazole 500 mg via gastrostomy tube every eight hours for the pressure sore. According to the Medication Administration Record (MAR) and the resident's metronidazole bubble pack, the resident was supposed to receive a total of 10 doses of metronidazole over a specified period. Upon review, it was found that only nine doses of metronidazole were administered, as confirmed by both the MAR and the medication bubble pack. This discrepancy was acknowledged by two LVNs during a concurrent interview and record review. The facility's policy and procedures required medications to be administered in a safe and timely manner as prescribed, but the resident missed one dose of the ordered antibiotic.
Medications Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) prepared medications for a resident and left the bubble packs containing the medications on top of the medication cart while stepping inside the resident's room. The medication cart was left unattended with the medications on top, making them accessible to others. This action was observed during a medication pass and was not in accordance with the facility's policy, which requires that no medications be left on top of the cart and that the cart be locked and secured when not in direct view of the nurse. The resident involved had a history of pneumonia and generalized muscle weakness and was assessed as cognitively intact but required varying levels of assistance with daily activities. Both the LVN and the assistant director of nursing (ADON) confirmed during interviews that medications should not be left unattended on top of the cart for safety reasons. Facility policies reviewed also specified that all drugs and biologicals must be stored securely and not left accessible on the cart.
Failure to Document Weekly Skin Assessments for MASD
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with multiple diagnoses, including diabetes mellitus, difficulty in walking, and dementia, and who had moisture associated skin damage (MASD) on the buttocks. The care plan required weekly assessment and documentation of the MASD, including measurements and observations of the affected area. However, there was no documentation that these weekly assessments were completed as required by the care plan and facility policy. Record reviews and staff interviews confirmed that while daily treatments for the MASD were documented, there was no evidence of weekly skin assessments or documentation of the MASD's status or progress. The lack of documentation made it impossible to determine whether the MASD had healed prior to the resident's discharge. The facility's policy required licensed nurses to document the status of all skin conditions at least weekly, but this was not done for this resident.
Cluttered Hallway Creates Accident Hazard for Resident with Mobility Impairment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one of three sampled residents. During observations, the hallway was found to be cluttered with linen carts, dirty linen hampers, trash hampers, and shower chairs placed on both sides, creating obstacles. A resident with diabetes mellitus, muscle weakness, and mobility issues, who was cognitively intact and independent in activities of daily living, reported difficulty self-propelling his wheelchair due to the clutter. Multiple staff members, including an LVN, infection preventionist, registered nurse supervisor, and director of nursing, acknowledged that the hallway was crowded and that items should be placed on one side to allow safe passage. The facility's policy emphasized the importance of keeping the environment as free from hazards as possible, but observations and staff interviews confirmed that this was not being followed at the time of the survey.
Failure to Ensure Advance Directive Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident had an advance directive in place or that the resident’s wishes regarding advance directives were properly documented and communicated. The resident, who was admitted and later readmitted with diagnoses including metabolic encephalopathy, cerebral infarction, and moderate intellectual disabilities, was found to have limited capacity to consent and was severely cognitively impaired. Documentation from the care conference indicated the resident did not have an advance directive and did not wish to formulate one, but there was no evidence that the responsible party or legal representative was involved in this decision-making process, despite the resident’s impaired capacity. Interviews with facility staff revealed that the Discharge Planner did not verify the existence of an advance directive upon admission or readmission, nor did she document follow-up with the Regional Center or notify the physician of the resident’s advance directive status. The Director of Nursing confirmed that the facility’s policy required inquiry about advance directives prior to or upon admission, but this was not followed. As a result, the resident was considered full code by default, and the facility did not have documentation to support the resident’s or representative’s wishes regarding end-of-life care.
Failure to Implement Care Plan for Resident Using Hand Mitten Restraint
Penalty
Summary
The facility failed to implement a care plan for a resident who was using a hand mitten, which is considered a restraint. The resident, admitted with diagnoses including cerebral infarction, legal blindness, and requiring assistance with personal care, was observed with a hand mitten on the right hand. Staff interviews and record reviews revealed that there was no care plan in place for the use of the hand mitten, despite the resident's cognitive impairment and the presence of a physician's order and consent for the mitten after admission. The Minimum Data Set (MDS) did not trigger a care plan for the mitten because the need was identified after the initial assessment, and the nurse who obtained consent did not initiate the care plan as required. Further interviews with nursing staff and the Director of Nursing confirmed that no interdisciplinary team meeting was held and no care plan was developed for the hand mitten. Facility policy requires that care plans for restraints address both immediate medical symptoms and underlying causes, but this was not followed. The lack of a care plan resulted in the absence of documented monitoring for skin integrity, circulation, and other risks associated with restraint use, as required by facility policy.
Delay in Providing Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including personal hygiene and incontinence care, was left soiled for approximately 20 minutes before being cleaned. The resident had a history of muscle weakness, hemiplegia, hemiparesis, and was at risk for skin breakdown, as documented in the care plan and medical records. Orders were in place for frequent skin assessments and specialized equipment, such as a low air loss mattress, due to an existing stage 3 pressure injury. On the day of the incident, staff were aware that the resident had soiled himself. The treatment nurse acknowledged the need for assistance but was waiting for help. A CNA entered the resident's room but left without providing care, stating he was looking for someone to assist him. The CNA was later observed assisting another resident before returning with a second CNA to clean the original resident. This resulted in a delay of about 20 minutes from the time staff were notified of the need for care to when the resident was actually cleaned. Interviews with staff, including the DON, confirmed that the delay was not in accordance with facility policy, which requires prompt cleaning to maintain hygiene and prevent infection or skin breakdown. Facility policies reviewed emphasized the importance of timely perineal care and assistance with ADLs for residents unable to perform these tasks independently.
Failure to Rotate Insulin Injection Sites per Facility Policy
Penalty
Summary
The facility failed to administer insulin according to its policy by not rotating injection sites for a resident with type 2 diabetes. Review of the resident's Medication Administration Records (MAR) over two months showed that consecutive doses of insulin were given in the same abdominal quadrants on multiple occasions. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that staff had access to previous injection site information and acknowledged that insulin should not be administered in the same location for consecutive doses. The facility's policy also required rotation of injection sites to ensure safe administration. The resident involved had moderate cognitive impairment and was receiving hypoglycemic medication for diabetes management. Physician orders specified subcutaneous administration of Humulin R Insulin per sliding scale before meals and at bedtime. Despite these orders and the facility's policy, staff failed to rotate injection sites, as confirmed during interviews and record reviews. This failure was identified through review of documentation and staff interviews, which indicated that the practice was not followed as required.
Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
Treatment Nurse 1 (TN1) failed to monitor and document the progression of pressure ulcers for a resident who was readmitted with multiple complex diagnoses, including metabolic encephalopathy, dementia, HIV, chronic respiratory failure, congestive heart failure, and dysphagia. The resident was identified as having two unstageable pressure ulcers—one on the medial back and one on the coccyx—both related to immobility. The care plan required weekly documentation of wound measurements, descriptions, and monitoring for changes, but this was not completed as required. The last documented Pressure Sore Skin Problem Report for the resident was completed on 2/28/2025, with no subsequent reports found in the record. TN1 acknowledged during an interview that he was responsible for monitoring and documenting the resident's pressure ulcers weekly but admitted to falling behind due to feeling overwhelmed by the volume of required documentation. Both TN1 and the Director of Nursing (DON) confirmed that weekly documentation was necessary to track the progression of the wounds and ensure appropriate treatment. A review of the facility's policy and procedure confirmed the expectation for nursing staff to assess and document pressure ulcers, including location, stage, measurements, and other relevant factors. The lack of ongoing weekly documentation and monitoring for this resident's pressure ulcers constituted a failure to follow the care plan and facility policy, with the potential for the resident's pressure ulcers to worsen.
Unattended Lighter Left at Bedside in Violation of Smoking Policy
Penalty
Summary
A deficiency occurred when a lighter was found unattended and unsecured on a resident's bedside table, despite facility policy prohibiting residents from keeping lighters or cigarettes in their rooms. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and nicotine dependence, and was assessed as requiring supervised smoking. The resident's care plan and risk assessments indicated that smoking should only occur in designated areas under supervision, and that the facility should monitor for unsafe smoking materials. During observations, the resident was seen smoking in the designated area while a green fluorescent lighter was left on the bedside table in his room, unattended. Staff interviews revealed inconsistent understanding and enforcement of the facility's smoking policy. While some staff members stated that lighters should not be kept at the bedside and recognized the fire hazard, others, including the DON, indicated that residents were allowed to keep lighters and cigarettes at the bedside. The Activities Director confirmed that the facility had procedures for storing smoking materials in locked boxes and that staff were expected to check for contraband items. A review of the facility's smoking policy confirmed that residents assessed as safety risks were not permitted to keep lighters or cigarettes in their possession, and smoking was only allowed in designated outdoor areas under supervision. Despite these policies and the resident's care plan, the lighter was left unattended in the resident's room, creating a potential fire hazard and risk of injury.
Failure to Maintain Sanitary Oxygen Tubing for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with multiple respiratory diagnoses, including pneumonia, acute and chronic respiratory failure with hypoxia, and COPD. The resident was receiving oxygen via nasal cannula tubing, which was observed wrapped around a trash can at the bedside. Both a CNA and an LVN confirmed that the tubing was left in this unsanitary position and acknowledged it was dirty and needed to be replaced. The facility's own policy required replacement of nasal cannula tubing every seven days or when soiled, and staff recognized that the current tubing was a potential source of infection. Record review showed that the resident's care plan included monitoring for signs and symptoms of respiratory infection, and the facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent the spread of communicable diseases. Despite these policies, the unsanitary handling of the oxygen tubing was observed and confirmed by staff, and the DON stated that soiled tubing should be exchanged to prevent infection. The deficiency was identified through direct observation, staff interviews, and review of facility policies and resident records.
Failure to Discard Expired Insulin Pens per Facility Policy
Penalty
Summary
Surveyors observed that two opened insulin pens, a Novolog Flexpen and a Lantus Solostart pen, were stored in the facility's medication refrigerator past their labeled discard dates. The Novolog Flexpen was labeled with an open date of 3/8/2025 and a discard date of 4/5/2025, while the Lantus Solostart pen had an open date of 2/5/2025 and was labeled for discard. Both pens remained in the refrigerator despite being past their use dates. During interviews, both an LVN and the DON confirmed that opened insulin pens should not be kept in the refrigerator and that medications labeled for discard should be removed and not left in storage. A review of the facility's policy and procedure for medication storage indicated that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. The failure to remove and discard the expired insulin pens was not in accordance with the facility's policy and created the potential for medication dispensing errors, as staff could inadvertently administer medication that should have been discarded.
Failure to Implement Care Plan for Resident's Hand Swelling
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's right-hand swelling, which was noted on January 5, 2025. This deficiency was identified during a review of the resident's records and an interview with the Director of Nursing (DON). The resident, who was admitted with multiple diagnoses including diabetes mellitus, dementia, muscle weakness, hypertension, dysphagia, abnormal posture, and Alzheimer's disease, had a documented change in condition indicating right-hand edema. Despite this change, there was no care plan addressing the edema in the resident's records, as confirmed by the DON. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and varying levels of assistance required for daily activities. The facility's policy and procedures for care planning, reviewed in June 2024, state that care plans should be based on comprehensive assessments and developed by an interdisciplinary team. However, the absence of a care plan for the resident's right-hand edema suggests a failure to adhere to these procedures, potentially impacting the delivery of care and services to the resident.
Failure to Offer Meal Substitutes for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that a resident was offered a substitute meal when they consumed less than 50% of their meal, as required by the facility's policy. This deficiency was identified during a review of the resident's CNA Daily Charting Form, which documented multiple instances where the resident's intake was less than 50% for various meals, yet no substitute was offered. The Director of Nursing verified these entries and acknowledged that a substitute should have been offered and documented. The resident involved had a complex medical history, including diagnoses of diabetes mellitus, dementia, muscle weakness, hypertension, dysphagia, abnormal posture, and Alzheimer's disease. The resident was assessed to have severely impaired cognition and required varying levels of assistance for daily activities, including eating. The facility's failure to offer meal substitutions as per their policy had the potential to result in malnutrition, dehydration, and an overall decline in the resident's health and medical condition.
Failure to Provide Regular Mouth Care for a Resident
Penalty
Summary
The facility failed to provide regular mouth care for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, required substantial assistance with personal hygiene, including oral care. Observations on December 30th revealed that the resident had a creamy substance at the corner of the mouth, a tongue coated with white crust, and dry, crusted lower lips. Despite these observations, the certified nursing assistant (CNA) only wiped the creamy substance from the resident's mouth without providing comprehensive oral care. The resident's care plan, initiated in October and November, indicated the need for daily mouth care and highlighted the risk of oral pain, weight loss, and infection due to dental health problems. The facility's policy on Activities of Daily Living (ADLs) required that residents unable to perform ADLs independently receive necessary services, including oral hygiene. However, the observations and interviews with staff, including a registered nurse supervisor, indicated that the resident's mouth care needs were not adequately met, resulting in the deficiency noted in the report.
Incomplete Documentation of Resident's Fluid and Oral Intake
Penalty
Summary
The facility failed to ensure complete and accurate documentation of fluid and oral intake for a resident, identified as Resident 1, on specific dates. Resident 1, who was admitted with diagnoses including dementia and Alzheimer's disease, required substantial assistance with various activities of daily living and moderate assistance with eating. The Minimum Data Set indicated severe cognitive impairment, necessitating careful monitoring of oral and fluid intake. However, the Certified Nursing Assistant (CNA) daily charting forms for the afternoon shifts on four specific dates were found to be incomplete, with no recorded data on Resident 1's intake. During interviews, the registered dietitian emphasized the importance of monitoring oral and fluid intake to detect any changes in the resident's condition. The Director of Nursing (DON) confirmed the omission in documentation and acknowledged that the nurse responsible had forgotten to document the intake. The facility's policy on charting and documentation, which requires all services and changes in a resident's condition to be documented objectively and accurately, was not adhered to in this instance.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during an active COVID-19 outbreak. One of the sampled residents, who had moderate cognitive impairments and required assistance with activities of daily living, was observed not wearing a mask in the facility's front lobby. The Director of Nursing (DON) acknowledged that the resident had refused to wear a mask but could not provide documentation that a mask was offered. This oversight occurred while the facility was experiencing an active outbreak, increasing the risk of COVID-19 transmission. Additionally, the facility did not ensure that staff were fit tested for N95 respirators. Two Licensed Vocational Nurses (LVNs) admitted they had not been fit tested for the N95 masks they were wearing. The Infection Prevention Nurse (IPN) confirmed that there was no system in place to ensure new staff were fit tested upon hire, and the last audit for fit testing was conducted five months prior. The facility's policy required annual fit testing or whenever there was a change in the employee's facial structure or mask model, but this was not adhered to, potentially compromising mask effectiveness. Furthermore, the facility failed to ensure proper staff screening before shifts. Dietary Staff (DS) was observed self-screening after attending a meeting, contrary to the protocol requiring screening before entering the facility. The receptionist indicated uncertainty about who was responsible for ensuring compliance with screening requirements, and the facility did not require visitor temperature checks. The Infection Prevention Nurse admitted there was no system to ensure staff entering through the back door were properly screened and tested, which could increase the risk of infection spread.
Failure to Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting alleged abuse between two residents and an injury of unknown origin to the State Agency. The first incident involved two residents, where one resident accused the other of stealing money, leading to a physical altercation. The accused resident reportedly used racial slurs and threw ice, prompting the other resident to retaliate by hitting him with a stick, resulting in a skin tear. Despite the severity of the incident, there was no documented evidence that the physical abuse was reported to the Ombudsman or the Department of Public Health (DPH). In the second incident, a resident with severe cognitive impairments was found with a bruise of unknown origin. The resident was unable to recall the cause of the injury due to confusion and dementia. The Assistant Director of Nursing (ADON) speculated that the resident might have scratched himself or hit his head against the siderail, but admitted that the bruise was inconsistent with a scratch. No investigation was conducted, and the event was not reported to the police, DPH, or the Ombudsman, as required by the facility's policy. The facility's policy on unusual occurrence reporting and abuse prevention requires reporting allegations of abuse, neglect, and misappropriation of resident property. It also mandates the protection of residents from abuse by anyone, including other residents, and requires staff training on abuse prevention and reporting. The facility failed to adhere to these policies by not investigating or reporting the incidents within the required timeframes, thereby exposing residents to potential continued abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting an injury of unknown origin for one of the residents to the State Agency. The resident, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was found with a bruise under the left eye. The bruise was not consistent with a scratch, and no one witnessed the events leading to the injury. Despite this, the facility did not conduct an investigation or report the incident to the appropriate authorities, including the police, Department of Public Health, and the Ombudsman. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) acknowledged the bruise was not consistent with a scratch and admitted that no investigation was completed. The Assistant Administrator (AADM) confirmed that the bruise should have been considered an injury of unknown origin, requiring investigation and reporting to external agencies. The AADM also noted that a 72-hour monitoring protocol should have been implemented. The facility's policies and procedures, which were reviewed, clearly outlined the requirement to report unusual occurrences, including injuries of unknown origin, to relevant agencies. The policies also emphasized the need for staff training in abuse prevention and the investigation and reporting of any allegations of abuse. However, these procedures were not followed in this instance, leading to a deficiency in the facility's compliance with its own policies and federal regulations.
Deficiencies in Pressure Ulcer Assessment and Abuse Reporting
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to adequately assess pressure ulcers, specifically in the case of a resident with a stage 3 pressure ulcer. The resident, who was admitted with conditions including diabetes mellitus, dysphagia, and dementia, was identified as high risk for skin breakdown. Despite multiple assessments by the treatment nurse, Director of Nursing (DON), Desk Nurse, and Infection Preventionist Nurse/Quality Assurance Nurse, the resident's skin was initially reported as intact. However, the DON later admitted that the facility failed to appropriately assess and identify the pressure ulcer, which could lead to the resident not receiving the necessary treatments. Additionally, the facility did not implement its abuse policy and procedure effectively, as evidenced by the case of another resident who was found with a bruise of unknown origin. This resident, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was observed with a significant bruise under the left eye. The Assistant Director of Nursing (ADON) suggested possible causes for the bruise but admitted that no investigation was conducted, and the event was not reported to the appropriate authorities, such as the police, Department of Public Health, and the Ombudsman. The facility's policies and procedures, including those for pressure ulcer assessment and unusual occurrence reporting, were not followed. The DON's job description emphasizes the responsibility for ensuring nursing services meet residents' needs, including proper assessment and reporting of incidents. However, the failure to assess the pressure ulcer and investigate the bruise indicates a lapse in adhering to these protocols, potentially compromising resident care and safety.
Failure to Manage and Report Abuse Incidents
Penalty
Summary
The facility failed to have a full-time abuse coordinator, which resulted in the mismanagement of abuse and neglect incidents involving three residents. Resident 3, who was cognitively intact, reported being physically assaulted by his roommate, Resident 4, after a dispute over alleged theft. Despite the incident being reported, there was no documented evidence that it was reported to the appropriate authorities, such as the Department of Public Health or the Ombudsman, as required by the facility's policy. Resident 5, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was found with unexplained bruising. The Assistant Director of Nursing admitted that the bruise was not consistent with a scratch and that no investigation was conducted to determine the cause of the injury. The facility's policy requires that injuries of unknown origin be investigated and reported, but this was not done in Resident 5's case. The facility's policies on unusual occurrence reporting and abuse prevention were not followed, as evidenced by the lack of reporting and investigation of the incidents involving Residents 3, 4, and 5. The absence of a full-time abuse coordinator contributed to these deficiencies, as the facility did not ensure the protection of residents from abuse or conduct necessary investigations and reporting as required by federal and state regulations.
Resident Safety Compromised by Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for a resident identified with wandering episodes, as outlined in the resident's care plan. The resident, who had severe cognitive impairments and a history of wandering and placing items in their mouth, was left unsupervised at the nurses' station. During this time, the resident ingested approximately 160 cc of hand sanitizer, which led to their admission to a General Acute Care Hospital with a diagnosis of toxic encephalopathy and dehydration. Further observations revealed additional safety hazards within the facility. The reception area was found unattended with a half-full bottle of hand sanitizer accessible to residents. In the dining room, the resident was observed unsupervised with an open bottle of sanitizing wipes within reach. Additionally, the maintenance room, which stored cleaning solutions and chemicals, was found unlocked and unattended, providing residents with potential access to hazardous substances. Interviews with facility staff confirmed the lack of supervision and the presence of accessible toxic substances. The Licensed Vocational Nurse admitted that the resident was known to place items in their mouth, yet this behavior was not addressed in the care plan. The Director of Nursing acknowledged the potential toxicity of hand sanitizer if ingested by residents, especially those on medication. The facility's policies and procedures regarding the installation and use of alcohol-based hand rub dispensers were not adequately followed, contributing to the unsafe environment.
Inaccurate Medical Records for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one of the nine sampled residents, leading to a deficiency in accordance with accepted professional standards and practices. Specifically, the medical records for a resident, who was initially admitted and later readmitted with diagnoses including toxic encephalopathy, dementia, COPD, and aphasia, contained inaccurate information. The Minimum Data Set (MDS) for this resident indicated severe cognitive impairments and a need for substantial assistance with Activities of Daily Living (ADLs). The deficiency was identified during a review of the resident's admission nursing risks evaluation and assessments, which contained incorrect information about the resident's condition and treatment. The Director of Nursing confirmed the facility's failure to identify the wrong information, acknowledging that this could compromise the resident's care. The facility's policy and procedures on charting and documentation emphasized the need for complete and accurate documentation to facilitate communication among the interdisciplinary team, which was not adhered to in this case.
Failure to Update Dementia Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia, which had the potential to negatively affect the delivery of care and services. The resident, who was admitted with diagnoses including dementia and a history of falling, had a care plan initiated for impaired cognitive function related to dementia. However, after the discontinuation of the dementia medication Namenda, the care plan was not updated to reflect the change in medication and the potential for increased confusion. The resident's Minimum Data Set (MDS) indicated moderately impaired cognitive skills, and the care plan included interventions such as asking yes/no questions, administering medications as ordered, and engaging the resident in structured activities. Despite these interventions, the care plan was not revised after the discontinuation of Aricept, another dementia medication, which was ordered after Namenda was discontinued. The facility's MDS Coordinator acknowledged the requirement to update the care plan following the discontinuation of dementia medications but failed to do so. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the facility did not develop a person-centered care plan with interventions after the discontinuation of Aricept. The facility's policy required the Interdisciplinary Team to identify a resident-centered care plan to maximize function and quality of life, but this was not adhered to, resulting in a lack of appropriate care and monitoring for the resident.
Failure to Prepare Resident for Safe Discharge
Penalty
Summary
The facility failed to sufficiently prepare a resident for a safe and orderly discharge to their home. The resident, who was cognitively intact and required assistance with various activities of daily living, was discharged without involving their primary caregiver in the discharge process. This lack of involvement meant that the caregiver did not receive necessary training, education, or resources to adequately care for the resident at home. Additionally, essential medical equipment and supplies, such as a hospital bed and caregiving services, were not provided as promised by the facility. The resident had multiple medical conditions, including functional quadriplegia, neuromuscular dysfunction of the bladder, and essential hypertension, which required significant care and support. The resident's care plan included interventions to manage these conditions, but these were not communicated to the caregiver. The social worker admitted to not meeting with the caregiver to discuss and provide the required education for a safe discharge, which was against the facility's policy. The caregiver expressed feeling stressed and unprepared due to the sudden change in discharge plans and the lack of support from the facility. The caregiver had to make costly arrangements, such as installing a ramp, and faced difficulties in navigating the apartment and managing the resident's care. The facility's failure to involve the caregiver and ensure the provision of necessary medical equipment and supplies resulted in significant challenges for the caregiver and compromised the resident's safety and well-being.
Failure to Label Food and Maintain Temperature Logs
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling various food items with their use-by dates. Specifically, sliced ham, ground chicken, chicken meat, sliced bacon, creamy Italian dressing, and sausage were found in the refrigerator without use-by date labels. Additionally, ground beef was found in the refrigerator past its use-by date and had not been discarded. The Dietary Supervisor Assistant confirmed that all food items should be labeled with an open date and a use-by date, and that the ground beef should have been discarded immediately after its expiration date. Furthermore, the temperature logs for the refrigerators and freezers were not maintained on two specific dates, which is a requirement to ensure food safety. During interviews, the Dietary Supervisor and the Director of Nursing both acknowledged that the staff should label all food products with open and use-by dates and monitor refrigerator and freezer temperatures three times a day. The facility's policy on labeling and dating food was reviewed, which indicated that newly opened food items should be labeled with an open date and a use-by date, and that correct temperatures for storing and handling food should be maintained. The failure to follow these procedures had the potential to cause food-borne illnesses among the residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents, Resident 85 and Resident 92. For Resident 85, the facility did not cover the urinary collection bag with a privacy bag, despite the resident having an indwelling catheter and being cognitively intact. This was observed during a room inspection, and the MDS Coordinator Assistant confirmed that the urinary collection bag should have been covered to promote dignity. However, the Director of Nursing stated that covering the urinary collection bag was not required inside residents' rooms, indicating a discrepancy in the facility's practices and policies regarding resident dignity. For Resident 92, the facility failed to provide dignified care during meal assistance. The resident, who had diagnoses including muscle weakness, dysphagia, and dementia, was observed being fed by a CNA who was standing over the resident instead of sitting at eye level. The CNA admitted to not using a chair because it took too long, despite a folding chair being available at the bedside. The Director of Nursing confirmed that staff should be seated at the same level as the resident to ensure proper control and dignity during feeding. The facility's policy on meal assistance also emphasized the importance of feeding residents with attention to safety, comfort, and dignity, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident 90, who was admitted with diagnoses including Huntington disease, hypertension, and abnormalities in gait and mobility. The resident had mildly impaired cognition and required moderate assistance with various activities of daily living. The care plan for Resident 90 indicated that the call light should be within reach to allow the resident to communicate their needs. However, during an observation, it was found that the call light was on the floor and not within the resident's easy reach. Certified Nurse Assistant 3 confirmed this observation and acknowledged that the call light should always be within reach. The Director of Nursing also stated that call lights should always be within a resident's easy reach to ensure staff can respond to their needs. The facility's policy, reviewed in May 2023, indicated that call lights should be placed within easy reach when residents are in bed or confined to a chair. This deficiency had the potential to result in residents not being able to call for assistance when needed.
Incomplete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure the Advance Directive Acknowledgement forms were completed thoroughly for two residents. For Resident 36, who was admitted with diagnoses including polyneuropathy, dementia, and hypertension, the form was not signed by the resident or her legal representative and did not indicate if the resident had executed an Advance Directive. This was confirmed during a review of the resident's medical chart with the Social Services Director, who acknowledged the incomplete form dated 8/15/2023. For Resident 85, admitted with diagnoses including muscle weakness and paraplegia, the form was signed by the resident but was not completed to indicate whether the resident had executed an Advance Directive. This was confirmed during a review with the Social Service Assistant, who stated that staff were required to complete the form thoroughly. The Director of Nursing confirmed that the forms for both residents were not completed as required, which could result in the residents' medical decisions not being honored.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident was provided a communication device or board in a language the resident could understand. Resident 25, who was admitted with diagnoses including chronic obstructive pulmonary disease, dementia, hypertension, and depression, had a fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS) indicated that the resident was severely cognitively impaired and had a psychosocial wellbeing problem related to a language barrier. Despite this, the care plan did not include an intervention like a communication board to assist the resident in communicating with staff. During observations and interviews, it was noted that Resident 25 primarily spoke Chinese and had difficulty communicating in English. Certified Nurse Assistant 3 and Licensed Vocational Nurse 2 both acknowledged the resident's language barrier and the absence of a communication device or board in the resident's room. The Minimum Data Set Coordinator admitted that she did not include a communication board in the care plan, despite recognizing its importance. The Director of Nursing confirmed that the lack of a communication device could hinder accurate communication between the resident and staff. The facility's policy indicated that residents should be provided with communication boards if they use a language other than the dominant language of the facility, but this was not followed in Resident 25's case.
Failure to Assist Visually Impaired Resident with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for a resident with severely impaired vision, identified as Resident 29. Despite the resident's need for supervision and assistance with meal setup due to his blindness, staff did not consistently provide the necessary support. During an observation, Resident 29 struggled to locate food items on his tray and required help from a Certified Nursing Assistant (CNA) to find his utensils and add sugar to his coffee. The CNA acknowledged that the resident needed assistance with meal setup and directions about the location of food items, which was not properly provided by the staff initially. In another instance, Resident 29 was unaware of a sandwich placed on his side table because staff did not inform him about it or its location. This lack of communication prevented the resident from consuming the snack. A CNA confirmed that staff were required to inform Resident 29 about the placement of food items due to his visual impairment. The Director of Nursing (DON) also acknowledged that the resident needed meal setup assistance and that the nutrition evaluation was not completed correctly, leading to insufficient care. The facility's policy on supporting ADLs indicated that residents unable to carry out ADLs independently should receive necessary services to maintain good nutrition and hygiene. However, the observations and interviews revealed that the staff did not consistently follow this policy, resulting in inadequate care for Resident 29. The failure to provide proper meal setup and communication about food placement directly impacted the resident's ability to maintain adequate nutrition and self-care.
Expired BLS Certificate for CNA
Penalty
Summary
The facility failed to ensure that one of the six sampled staff, a Certified Nursing Assistant (CNA 2), had an up-to-date Basic Life Support (BLS) certificate. A review of CNA 2's employee file indicated that the BLS certificate had expired. Despite this, CNA 2 was found to be working in the facility on a date after the certificate had expired. During interviews and record reviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNA 2's BLS certificate had expired and had not been renewed. The DON acknowledged that staff CPR certificates were to be renewed every two years and that not having a valid BLS certificate could potentially result in residents receiving outdated medical care. The facility's policy on emergency procedures for cardiopulmonary resuscitation (CPR) indicated that personnel should have completed training on CPR and BLS, and that clinical staff, including non-licensed personnel, should maintain certification in BLS/CPR. The failure to ensure that CNA 2's BLS certification was current had the potential to result in residents receiving emergency care that was not up to date, which could lead to resident harm or death.
Failure to Provide Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with visual impairment and functional limitations was provided with activities that stimulate the resident's senses. Specifically, the facility did not provide the resident with a radio or television, did not formulate a care plan for activities, and did not perform an activity participation review quarterly. This resulted in the resident experiencing emotional distress, feeling that her days were empty, and expressing frustration and discomfort due to boredom. The resident, who was admitted with diagnoses including adult failure to thrive, cachexia, muscle weakness, dysphagia, difficulty in walking, dementia, and schizophrenia, was dependent on assistance for various activities of daily living. Despite the resident's severe cognitive impairment and visual impairment, the facility did not conduct an activity participation review after the initial review on 12/26/2023. The resident's care plan did not address activities, and the activity attendance records indicated inconsistent room visits and lack of engagement in activities. Interviews with staff revealed that the resident enjoyed sensory stimulation, nail care, listening to music, and watching TV, but these preferences were not adequately addressed. The Activities Director and other staff members were unaware of the resident's request for a radio and the absence of a TV in her room. The facility's policy required quarterly activity evaluations and care plans to reflect the resident's preferences, but these were not followed, leading to a decline in the resident's quality of life.
Failure to Ensure Proper Pressure Ulcer Care and Update Care Plan
Penalty
Summary
The facility failed to ensure that Resident 98 received appropriate pressure ulcer care as per their policy and procedure. Specifically, the facility did not ensure that the resident's wound vac was on and functioning. During an observation, the wound vac was found off and unplugged, which was verified by the Infection Preventionist (IP). The IP acknowledged that the wound vac should be on continuously to drain the resident's wound and prevent it from getting bigger. The Director of Nursing (DON) also confirmed that the wound vac should be on continuously as per the physician's orders. Additionally, the facility failed to revise Resident 98's care plan to include the wound vac treatment that was initiated. The care plan, which was last revised before the wound vac treatment started, did not reflect the current treatment plan. Both the IP and the DON confirmed that the care plan should have been updated to reflect the resident's current treatment needs. The care plan is essential for staff to know the resident's needs and ensure they receive the appropriate care. Resident 98 was admitted with multiple diagnoses, including a Stage 4 pressure ulcer of the sacral region and a Stage 3 pressure ulcer of the right buttock. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for various activities of daily living. The failure to ensure the wound vac was functioning and the care plan was updated had the potential to worsen the resident's pressure ulcer, leading to severe complications.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident's urinary indwelling catheter was securely anchored, which had the potential to cause pain and urethral trauma. Resident 84, who was admitted with diagnoses including urinary tract infection, diabetes, and chronic kidney disease, had severe cognitive impairment and required total assistance with toileting hygiene. The resident's care plan included specific instructions to secure the catheter to prevent dislodgement and complications. However, during observations on two separate occasions, the catheter was found not to be anchored, and the Infection Preventionist confirmed that the catheter should have been secured to prevent dislodgement. The Director of Nursing stated that staff were expected to secure the catheter with a stabilization device or a bedside Foley clamp, as per the facility's policy. The facility's policy on Foley Catheter Care, revised in April 2023, also indicated that the catheter should remain secured to reduce friction and movement at the insertion site. Despite these guidelines, the catheter was not anchored during the observations, indicating a failure to adhere to the prescribed care plan and facility policy, potentially compromising the resident's safety and comfort.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services according to professional standards of practice for Resident 39. The resident was administered oxygen via a non-rebreather mask without a physician's order and without the required 10-15 liters per minute (LPM) oxygen flow for the correct functioning of the mask. Additionally, the facility did not monitor the resident's oxygen saturation levels as per the physician's order, and the resident's oxygen use was not included in the care plan despite the resident experiencing shortness of breath. Resident 39 was admitted with diagnoses including myocardial infarction, type 2 diabetes, and high blood pressure. The resident's care plan for shortness of breath, developed on 12/2/2023, did not specify the required pulse oximetry level and did not include the resident's oxygen use. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for various activities. The physician's order dated 4/19/2023 specified oxygen administration parameters, but the facility failed to document oxygen saturation levels in the Medication Administration Records (MAR) for March and April 2024. Observations revealed that Resident 39 was using a non-rebreather mask with an insufficient oxygen flow rate, and the reservoir bag was not fully inflated. Interviews with Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed the lack of a physician's order for the non-rebreather mask, the absence of oxygen saturation documentation, and the failure to include oxygen use in the care plan. The facility's policies and procedures for care planning and oxygen administration were not followed, leading to the identified deficiencies.
Failure to Provide Emergency Dialysis Kit for Resident
Penalty
Summary
The facility failed to ensure that a resident dependent on hemodialysis had an emergency kit at their bedside. Resident 32, who had diagnoses including end-stage renal disease (ESRD) requiring hemodialysis, type 2 diabetes mellitus, legal blindness, and a right foot amputation, was observed without an emergency kit at their bedside. The resident's care plan indicated a risk for bleeding due to heparin administration during dialysis, and the goal was to have no complications related to hemodialysis. However, during multiple observations and interviews, it was confirmed that no emergency kit was present at the resident's bedside, and the resident was unaware of what a dialysis emergency kit was. The Infection Preventionist and the Director of Nursing both confirmed that dialysis residents should have an emergency kit at their bedside to stop bleeding and for emergencies. The facility's policy on the care of residents with ESRD indicated that staff should be trained to recognize and intervene in medical emergencies such as hemorrhages. Despite this policy, the necessary emergency kit was not provided, potentially delaying intervention during accidental bleeding for Resident 32.
Failure to Post Complete Staffing Information
Penalty
Summary
The facility failed to post staffing information per its policy and procedure titled 'Posting Direct Care Daily Staffing Numbers.' During an observation, the staff posting was displayed at the nursing station but did not indicate the facility's name. This omission was confirmed during interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON). Both acknowledged that the absence of the facility's name on the staff posting could lead to residents, visitors, and staff not knowing the staffing information pertains to their facility. The facility's undated policy and procedure require that the staff posting include the facility's name, the current date, the resident census at the beginning of the shift, the 24-hour shift schedule, the type and category of nursing staff, the actual time worked, and the total number of licensed and non-licensed nursing staff for the posted shift. The failure to include the facility's name on the staff posting was identified as a deficiency, as it did not comply with the facility's policy and had the potential to cause confusion among residents, visitors, and staff regarding the staffing information.
Failure to Provide Double Portion Meals as Ordered
Penalty
Summary
The facility failed to meet the nutritional needs of two residents by not providing double portion meals as ordered by their physicians. Resident 14, who had a history of unplanned weight loss and was underweight, did not receive the prescribed double entree during lunch. The Registered Dietitian (RD) confirmed that the resident's meal did not meet the double portion requirement, which was crucial for maintaining the resident's weight. The Dietary Supervisor also acknowledged the discrepancy and took immediate steps to correct the meal, but the initial failure to provide the correct portion was noted during the surveyor's observation. Similarly, Resident 29, who required a No Added Salt (NAS) and Controlled Carbohydrate (CCHO) diet with double portions, did not receive the prescribed double portion for lunch. The RD observed that the meal ticket did not reflect the double portion order, which was a recurring issue due to some orders not appearing correctly on meal tickets. The RD admitted that this issue had been manually corrected for some residents but was missed for Resident 29. The Director of Nursing (DON) confirmed that the facility was required to serve meals based on physician's orders and acknowledged the potential negative outcomes of not doing so. The facility's policies on food preferences and nutrition services were reviewed, indicating that diets should be provided as ordered by the physician and that portion modifications should be made as part of care plan interventions. However, the failure to adhere to these policies resulted in the residents not receiving the necessary nutritional support, as evidenced by the observations and interviews conducted during the survey.
Failure to Conduct Quarterly Nutrition Evaluations
Penalty
Summary
The facility failed to evaluate the food preferences for one resident, as evidenced by not performing a Nutrition Evaluation quarterly. The resident, who had been admitted with multiple diagnoses including COPD, hypertension, depressive episodes, type 2 diabetes, and hyperlipidemia, had their last Nutrition Evaluation on 11/8/2023. Despite being cognitively intact and capable of making decisions, the resident's food preferences were not reassessed quarterly as required. This led to the resident feeling that their needs were not being met and experiencing emotional distress due to unappetizing food options. During an observation, the resident was seen with an untouched breakfast tray and expressed dissatisfaction with the food, stating that staff never asked about their preferences. The Dietary Supervisor confirmed that Nutrition Evaluations were overdue and acknowledged the importance of these evaluations in ensuring residents receive food they like. The Director of Nursing also verified the lapse in conducting the required quarterly Nutrition Evaluations, which are essential for meeting residents' dietary needs and preferences.
Failure to Maintain Accurate POLST Records
Penalty
Summary
The licensed nursing staff failed to maintain accurate medical records for Resident 16, specifically regarding the Physician's Order for Life-Sustained Treatment (POLST). Resident 16, who was severely cognitively impaired and dependent on assistance for daily activities, had conflicting instructions on their POLST form. Both 'Attempt Resuscitation' and 'Do Not Resuscitate' options were marked, leading to confusion among the staff. This discrepancy was not identified or corrected by multiple staff members, including the Assistant Director of Nursing, the Director of Staff Development, and the Director of Nursing, who all reviewed the POLST at different times but failed to notice the conflicting instructions. During an emergency situation, the Assistant Director of Nursing initiated CPR based on the 'Attempt Resuscitation' option marked on the POLST, despite the form also indicating 'Do Not Resuscitate'. The confusion was further confirmed during interviews with the Minimum Data Set Coordinator and a Licensed Vocational Nurse, both of whom acknowledged the POLST was unclear and did not provide accurate guidance. The facility's policy on advanced directives was not followed, as the plan of care did not align with the resident's documented treatment preferences due to the conflicting POLST entries.
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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