The Bellefontaine Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 150 Bellefontaine St, Pasadena, California 91105
- CMS Provider Number
- 056080
- Inspections on file
- 31
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Bellefontaine Healthcare Center during CMS and state inspections, most recent first.
A resident with a UTI due to MRSA, gout, and a femur fracture did not receive Vancomycin at the prescribed infusion rate because a nurse administered the IV medication by gravity without the required dial-a-flow set, resulting in the infusion continuing beyond the ordered timeframe. Facility policy and protocol for IV medication administration were not followed.
A resident with an indwelling catheter and severe cognitive impairment did not have urine output consistently or accurately documented in accordance with physician orders and facility policy. Multiple shifts lacked documentation or contained inconsistent entries between CNA logs and the MAR, with some records showing only frequency instead of the required volume in milliliters. Staff interviews confirmed lapses in communication and documentation, contrary to facility procedures requiring complete and objective recordkeeping.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident who had recently undergone spinal surgery was given Plavix earlier than ordered due to the facility's failure to verify hospital discharge instructions with the attending physician. The medication was started based on an incomplete faxed list, and staff did not monitor or document for signs of bleeding, despite the resident's high risk. The resident suffered a fatal intracranial hemorrhage after these failures.
The facility did not ensure that advance directives were present in the medical charts for two residents, despite documentation indicating that both had executed such directives. One resident with end stage renal disease and another with diabetes and asthma both required significant assistance with daily activities. In both cases, staff confirmed that the advance directives were missing from the charts, contrary to facility policy requiring this information to be prominently displayed.
Surveyors found that food items, including opened sesame dressing and juice cups, were not properly labeled or discarded according to policy, and an outside maintenance worker was observed in the kitchen without a required hair net. Staff confirmed these practices did not meet facility standards for food safety and hygiene.
Multiple infection control lapses were observed, including a nurse failing to change gloves and perform hand hygiene during wound care for a resident with dementia and sepsis, an LVN not doffing PPE or performing hand hygiene before handling the medication cart after medication administration to a resident with sepsis and pneumonia, a catheter drainage bag touching the floor while a resident was transported, and soiled linens being washed at insufficient water temperatures, all contrary to facility policy.
A resident with severe cognitive impairment and multiple care needs was found with food particles on their bed linen, and staff acknowledged that the bed was not cleaned after meals as required. This failure to maintain cleanliness did not align with facility policy on resident dignity and respect.
Two residents were not provided with necessary accommodations according to facility policy: one resident with mobility issues had a call light out of reach while in bed, and another resident with severe cognitive impairment was found in a bed missing a footboard, with staff elevating the bed's foot instead of reporting the missing equipment. Staff interviews and policy reviews confirmed these lapses in ensuring resident safety and comfort.
Staff failed to protect a resident's confidential medical information by leaving a computer unattended with the resident's records visible on the screen. Interviews confirmed that staff are required to log out or turn off computers when not in use to prevent unauthorized access to PHI, in accordance with HIPAA and facility policy.
A resident receiving Ozempic injections for weight loss was incorrectly documented on the MDS as receiving insulin daily for 7 days, rather than the correct weekly administration and drug classification. Interviews with the resident, MDS nurse, and DON confirmed the errors, and facility policy requiring accurate and complete documentation was not followed.
A resident with schizoaffective disorder and dementia was not provided a required PASARR Level II evaluation after a Level I screening indicated serious mental illness. The evaluation was not completed due to unresponsiveness from facility staff to state agency communication, and responsible staff were unaware of the missed evaluation and did not follow up as required.
A resident with CHF and chronic kidney disease received fluids in excess of the physician-ordered 1200 cc/24 hours restriction on multiple days, with staff failing to remove the water pitcher from the bedside and not consistently posting or specifying the fluid restriction in the room, contrary to facility policy and physician orders.
A resident with severe cognitive impairment and upper limb contractures did not receive proper application of a resting hand splint and elbow splint as ordered by the physician. Instead, a CNA, who was not trained or authorized to apply splints, attempted to reapply and adjust the devices, contrary to facility policy and staff training requirements.
A resident with asthma was observed receiving oxygen therapy without a required No Smoking sign posted outside their room. Nursing staff confirmed that facility policy mandates visible No Smoking signage when oxygen is in use, but this was not followed, resulting in a deficiency related to fire safety procedures.
A nurse failed to administer cholecalciferol and Miralax as ordered to a resident with a G-tube and multiple medical conditions, despite these medications being scheduled on the resident's MAR. The omission was identified during a medication pass observation, and the nurse acknowledged the error after review. Facility policy required medications to be given as prescribed, which was not followed in this case.
A medication error rate above 5% was identified when an LVN failed to administer cholecalciferol and Miralax as ordered to a resident with a G-tube and multiple medical conditions. The LVN omitted these medications during a scheduled med pass, resulting in two errors out of 33 opportunities, and later acknowledged the oversight. The DON confirmed that all medications should have been administered as ordered, in accordance with facility policy.
A resident with multiple medical conditions experienced ongoing pain and poor food intake due to ill-fitting dentures. Despite reporting the issue to staff, appropriate dental referrals were not made in a timely manner, as communication between nursing, therapy, and social services staff was lacking. Facility policy required prompt referral for dental issues, but this was not followed, resulting in a delay in care.
A resident with end stage renal disease and multiple dietary restrictions was allowed to receive home-cooked food from family without documented education or monitoring to ensure the food met prescribed renal diet and fluid restriction requirements. The care plan did not address food brought in by family, and staff failed to provide or document education on diet adherence or food safety, despite facility policy requiring these actions.
A resident with severe cognitive impairment and high fall risk experienced a fall after staff failed to keep the bed locked as required by the care plan. Observation and staff interviews confirmed the bed was left unlocked, contrary to facility policy and individualized interventions for fall prevention.
The facility failed to ensure call lights were within reach for two residents, both at risk for falls. One resident with dementia had a call light on the floor, while another with quadriplegia had a call light wrapped around side rails. Both situations contradicted care plans and facility policies requiring accessible call lights.
Two residents were found in an unsanitary and potentially hazardous environment due to overflowing trash and cluttered floors. One resident, with quadriplegia and cognitive impairment, and another with asthma and sepsis, were both at risk for falls. An LVN and the ADON acknowledged the issues, highlighting the need for regular trash disposal and clutter-free spaces to ensure safety.
A resident with dementia and a stage 2 pressure ulcer was found to be on a Low Air Loss (LAL) mattress that was turned off, contrary to their care plan. The LAL mattress, essential for pressure distribution and wound healing, was unplugged, as confirmed by nursing staff. The facility lacked a specific policy to ensure the mattress was continuously operational.
The facility failed to follow Physician's Orders and implement care plan interventions for two residents, leading to potential safety risks. One resident was observed kicking the footboard of his bed without padding, and another resident's bed was found in a high position despite orders to keep it low.
The facility failed to provide necessary respiratory care for two residents on oxygen therapy. One resident's nasal cannula tubing was found touching the wheelchair wheels and the floor, while another resident's CPAP mask was not stored properly and lacked an active physician's order. These deficiencies were confirmed by staff and violated the facility's infection prevention policies.
The facility failed to ensure control and accountability of controlled substances awaiting final disposition, as the Narcotic and Hypnotic Record accountability logs for March and May 2024 did not include the required verifying signatures of the DON or an RN along with the LVN. This inconsistency increased the risk of CS diversion and accidental exposure of residents to harmful medications.
The facility failed to monitor a resident for signs and symptoms of bleeding while on Eliquis for 15 days. The resident's clinical record lacked documentation for monitoring side effects and did not include a care plan for managing atrial fibrillation and Eliquis use. Interviews with staff and the Pharmacy Consultant confirmed these deficiencies.
The facility failed to follow proper food handling practices, including labeling and sealing food containers, discarding expired items, and maintaining cleaning logs. These deficiencies were confirmed through observations and interviews with the Dietary Supervisor and kitchen staff.
The facility failed to follow its policy on Advance Directives for two residents, resulting in the absence of these critical documents in their medical charts. This oversight could lead to conflicts with the residents' healthcare wishes during emergencies.
The facility failed to provide a clean, comfortable, and sanitary environment for a resident by not ensuring the bathroom toilet was free of fecal matter. The resident required substantial assistance with toileting and personal hygiene. Observations by an LVN and housekeeping staff confirmed the presence of dry stool on the toilet seat, which should have been cleaned according to the facility's policies and procedures.
The facility failed to accurately complete the MDS for a resident by including a diagnosis of schizophrenia without supporting evidence in the clinical record. The diagnosis was likely inferred from a quetiapine prescription, despite the absence of documentation in the resident's medical records. The DON and MDS Nurse confirmed the inaccuracy, emphasizing the importance of accurate assessments for appropriate care.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in monitoring and treatment for conditions such as dementia, CVA, DVT, atrial fibrillation, and schizoaffective disorder. Interviews with staff confirmed the absence of necessary care plans and the importance of having them to ensure proper monitoring and treatment adjustments.
The facility failed to inform physicians and follow care plans for two residents. One resident's rashes were not reported or referred to dermatology, and another resident's refusal to elevate his leg was not communicated, nor was the need for TED hose verified. These deficiencies led to potential delays in treatment and physical discomfort.
The facility failed to follow physician orders and care plan interventions for a resident receiving g-tube feedings by not consistently elevating the head of the bed to at least 30 degrees. Multiple observations showed the resident lying flat or inadequately elevated, increasing the risk of aspiration pneumonia. The resident had severe cognitive impairment and physical limitations, making proper positioning crucial.
The facility failed to address the use of Trazadone for a resident in accordance with their medication regimen review policy. The resident, with diagnoses of major depressive disorder, anxiety disorder, and delusional disorder, was prescribed Trazadone for depression manifested by an inability to sleep. However, the order should have been for insomnia, and there was no separate order to monitor sleep hours. The Pharmacist Consultant and Assistant Director of Nursing acknowledged the oversight.
The facility failed to ensure proper use and monitoring of psychotropic medications for two residents. One resident's Quetiapine order lacked specific target behaviors, and another resident's Trazadone use was not monitored for hours of sleep, contrary to facility policies.
The facility failed to ensure that cereal portions were accurately measured using a measuring cup for five residents. A kitchen staff member was observed scooping cereal with her hand instead of using the designated measuring cup, contrary to the facility's portion control policy. This practice could lead to improper caloric intake for residents needing to gain or lose weight.
The facility failed to ensure that a resident with severe cognitive impairment and under conservatorship had the arbitration agreement signed by his legal representative. The agreement was signed by the resident and a facility representative, contrary to the facility's policy, leading to the resident and his conservator not being informed of their rights.
The facility failed to keep one of three washing machines in good repair. During an observation and interview with the IP and MS in the dirty laundry room, a washing machine was found to have a large gash-like hole on the top of the left panel due to a leak of sanitizing chemicals. The facility's policy indicated that equipment should be maintained in a safe and operable manner, which was not followed.
The facility failed to ensure that the call light was within reach for a resident with severe cognitive impairment and a high risk for falls. Despite the care plan and facility policy requiring the call light to be accessible, it was observed out of reach, necessitating intervention by staff to move it within the resident's reach.
The facility failed to ensure the accuracy of the Daily Posted Nurse Staffing information, with discrepancies found on multiple dates between the posted and actual number of CNAs, RNs, and LVNs working each shift. The DSD acknowledged these inaccuracies, and the DON emphasized the importance of accurate staffing information for informing residents, families, and visitors about nursing coverage.
Failure to Administer IV Medication at Prescribed Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer intravenous Vancomycin to a resident at the prescribed infusion rate. The resident, who had diagnoses including urinary tract infection (UTI) due to MRSA, gout, and a right femur neck fracture, was ordered to receive Vancomycin 750 mg in 250 ml normal saline over 90 minutes every 24 hours. During observation, the nurse was found to be administering the medication by gravity without a dial-a-flow infusion set, which is required by facility protocol to control the infusion rate. The nurse was unable to confirm the infusion rate and acknowledged that the medication might not be completed within the prescribed 90 minutes. Further review showed that the Vancomycin infusion was still ongoing well past the intended completion time. The facility's policies require that IV medications be administered as prescribed, including the use of appropriate equipment to ensure correct infusion rates. Both the DON and the pharmacist confirmed the importance of adhering to the ordered infusion rate and the facility's protocol, which was not followed in this instance.
Failure to Accurately Document Urine Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain accurate documentation of urine output for a resident with an indwelling catheter, as required by both physician orders and facility policy. The resident, who was admitted with urinary retention and had severe cognitive impairment, was dependent on staff for all activities of daily living and required close monitoring of urinary output. The physician's order specified that urine output should be recorded in milliliters every shift for 30 days. Upon review of the urine output task log and Medication Administration Record (MAR) for the specified period, multiple discrepancies and omissions were identified. There were several shifts where no urine output was documented, and in some instances, the output was recorded as zero without explanation. Additionally, inconsistencies were found between the amounts recorded by CNAs in the task log and those entered by licensed staff in the MAR, with some entries reflecting only the frequency of urination rather than the required volume in milliliters. Interviews with CNAs, LVNs, and the Director of Nursing confirmed that the documentation practices did not align with facility policy or physician orders. Staff acknowledged that accurate and complete documentation of urine output is necessary for monitoring the resident's condition, but failed to consistently communicate and record the required information. The facility's policy emphasized that all services provided to residents must be objectively, completely, and accurately documented to facilitate communication among the interdisciplinary team.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Verify Discharge Orders and Monitor Anticoagulant Use Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and services in accordance with professional standards of practice for a resident who had recently undergone lumbar decompression and fusion surgery. The facility did not ensure that the admitting RN reviewed and verified the hospital discharge records with the attending physician, specifically regarding the start date for Plavix, an antiplatelet medication. The hospital discharge orders clearly indicated that Plavix was to be started nine days after admission, but the facility's licensed nurses began administering the medication immediately upon admission, based on an incomplete faxed medication list that lacked start dates. The facility also failed to provide continuity of care by not following the neurosurgeon's specific order to delay the initiation of Plavix. The medication was administered for four days prior to the intended start date, and there was no evidence that the nurses clarified the discrepancy with the attending physician. Additionally, the facility did not assess, monitor, or document the resident for signs and symptoms of bleeding, hematoma, or hemorrhage, despite the resident's recent spinal surgery and use of an antiplatelet medication, both of which increased the risk for such complications. As a result of these failures, the resident experienced a change of condition, becoming unresponsive and requiring emergency transfer to a hospital, where imaging revealed multiple intracranial hemorrhages. The resident subsequently died, with the immediate cause of death listed as nontraumatic intracranial hemorrhage. Interviews with facility staff and physicians confirmed that the medication was given earlier than ordered and that appropriate monitoring and verification of orders did not occur.
Removal Plan
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates.
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy for potential side effects such as signs/symptoms of bleeding.
- The DON and designee provided in-service to the licensed nurses regarding: Review and verify GACH discharge orders with facility's attending physician. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work.
- Residents on anticoagulants were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning monitoring.
- The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding.
- DON, ADON or RN Supervisor/designee will conduct medication reconciliation with the residents GACH discharge orders and admitting orders carried out by licensed nurse.
- Newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three residents weekly for four weeks, then two residents weekly for two weeks, then two residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA meeting.
- DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: Review and verify GACH discharge orders with attending physician. Use of anticoagulant and its side effects. Following GACH discharge orders. PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect of the medication.
- The Quality and Safety (QS) RN/Consultant will complete audits on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents.
- ADM, DON or Designee will submit audit findings to QAA committee monthly until compliance is met.
- The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting.
- ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC).
Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that advance directives were present in the medical charts for two of four sampled residents, as required by its own policy. For one resident with end stage renal disease and atherosclerotic heart disease, the admission record and MDS indicated moderate cognitive impairment and significant assistance needs. Although the POLST form referenced an advance directive, no such document was found in the resident's medical chart during review. Social Services staff confirmed that the advance directive was not available in the chart until after the review, acknowledging that it should have been accessible to licensed staff. For another resident with diabetes mellitus and asthma, the admission record and MDS showed intact cognitive skills but substantial assistance required for daily activities. The resident's records included an Advance Directives Acknowledgement form indicating an executed advance directive, but the actual document was not present in the medical chart. The DON confirmed the absence of the advance directive in the chart and stated that it should have been included to ensure the facility could honor the resident's wishes and identify decision-makers in emergencies. Facility policy required that information about advance directives be displayed prominently in the medical record, which was not followed in these cases.
Deficient Food Storage, Labeling, and Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store and label food items in accordance with professional standards and facility policy. Specifically, an opened bottle of sesame dressing was found in the walk-in refrigerator that had been stored for two months after opening, despite staff confirming it should be discarded after one month. Additionally, multiple small cups of cranberry and orange juice were found on a tray without any prepared date, and staff acknowledged that these should be dated to prevent serving spoiled juice. Review of facility policies confirmed that all foods stored in the refrigerator must be covered, labeled, and dated with a use-by date, and that prepared foods require labeling and dating. Further, the facility did not ensure that all personnel in the kitchen, including outside maintenance workers, wore hair nets as required by policy. An outside maintenance worker was observed repairing kitchen equipment without a hair net, and both the worker and the Dietary Service Supervisor confirmed that hair nets are required for anyone entering the kitchen to prevent contamination. These lapses in food storage, labeling, and hygiene practices were confirmed through staff interviews and review of facility policies.
Infection Control Lapses in PPE Use, Catheter Care, and Laundry Practices
Penalty
Summary
The facility failed to observe infection control measures for three residents, as evidenced by direct observations and staff interviews. In one instance, a treatment nurse did not change gloves or perform hand hygiene after repositioning a resident with dementia and sepsis before continuing wound care. The nurse continued the wound care treatment using the same gloves, contrary to facility policy and infection control standards. Both the Director of Nursing and the Infection Preventionist Nurse confirmed that gloves should have been changed and hand hygiene performed to prevent the spread of infection. In another case, a licensed vocational nurse administered medications to a resident with sepsis and pneumonia and then, without doffing PPE or performing hand hygiene, exited the resident's room and touched the medication cart. The nurse acknowledged this lapse, and both the DON and IPN confirmed that PPE should have been removed and hand hygiene performed before leaving the room and handling the medication cart, as per facility policy. The facility's infection prevention and hand hygiene policies specifically require hand hygiene after glove removal and after contact with objects in the resident's vicinity. Additionally, a resident with an indwelling catheter was observed being transported by a certified occupational therapy assistant while the catheter drainage bag was touching the floor. The assistant stated the bag must have become unhooked, and both the Director of Rehabilitation and DON confirmed that the bag should be kept off the floor to prevent infection. Furthermore, a load of soiled linens was washed in a machine with water that did not reach the required temperature according to facility policy. The maintenance director and infection preventionist nurse confirmed that the water temperature was below the required 160°F, which is necessary to disinfect linens and prevent the spread of infection.
Failure to Maintain Resident Dignity by Not Ensuring Clean Bed Linen
Penalty
Summary
A deficiency was identified when a resident with major depressive disorder and dementia, who was severely cognitively impaired and required substantial to maximal assistance with daily activities, was found with food particles, specifically eggs, on their bed linen. During an observation, a CNA acknowledged the presence of the food crumbs and stated that it was not acceptable, as residents should be treated with dignity. The CNA also admitted that after the resident finished eating, they did not clean up the resident or the bed, although it was their responsibility to do so to maintain cleanliness and dignity. Further interviews with nursing staff confirmed that bed linens should be free of food particles and that linens should be changed if such particles are observed. The facility's policy on dignity and quality of life requires that each resident be cared for in a manner that promotes their well-being, self-worth, and self-esteem, and that residents are treated with dignity and respect at all times. The failure to keep the resident's bed linen clean and free of food particles was not in accordance with this policy.
Failure to Ensure Call Light Accessibility and Bed Footboard for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' needs and preferences were reasonably accommodated in accordance with facility policy. For one resident with a history of post laminectomy syndrome and mobility impairments, the call light was observed to be out of reach, lying on the floor beside the bed while the resident was sleeping. The resident's care plan specifically indicated the need to encourage use of the call light for assistance, and the facility's policy required that call lights be within reach to assure prompt assistance. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been accessible to the resident at all times. For another resident with diagnoses including cerebral infarction, malnutrition, and pneumonia, the bed was found to be missing a footboard. The resident was assessed as having severely impaired cognitive skills and required substantial assistance with daily activities. Observations showed the foot of the bed was elevated to prevent the resident from sliding, but no footboard was present. A CNA confirmed the bed had been without a footboard for an extended period and had not reported it to maintenance. The DON acknowledged that the bed should have been checked and the missing footboard reported, as it was important for the resident's comfort and positioning. Facility policies reviewed indicated that maintenance services are responsible for ensuring equipment is safe and operable, and that the environment should support residents' safe functioning and well-being. The deficiencies were identified through observation, interviews, and record review, demonstrating lapses in following established procedures for resident safety and comfort.
Failure to Safeguard Resident Medical Records
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of a resident's medical records when a computer displaying the resident's information was left unattended and the screen was not turned off. This incident was observed at a nurse's station, where the computer showed the resident's medical record without any staff present. Interviews with the Registered Nurse Supervisor, MDS Nurse, and Director of Nursing confirmed that staff are expected to log out or turn off the computer screen when leaving it unattended to prevent unauthorized access to protected health information (PHI). The resident involved had a history of post laminectomy syndrome, arthrodesis status, and postural kyphosis, and required significant assistance with daily activities. Facility policy and procedures reviewed indicated that all personnel are responsible for safeguarding resident information to prevent unauthorized disclosure, in accordance with HIPAA and state law. The failure to log out or secure the computer resulted in a violation of the resident's right to privacy and confidentiality.
Inaccurate MDS Assessment of Medication Administration
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's medication on the Minimum Data Set (MDS) as required by facility policy. A resident was admitted with diagnoses including unspecified dislocation of the left hip, abnormalities of gait and mobility, and hyperlipidemia. The resident was prescribed Ozempic, a weekly injection for weight loss, and not insulin. However, the MDS assessment incorrectly documented that the resident received insulin for 7 days during the look-back period and also inaccurately recorded the frequency of Ozempic administration as daily injections for 7 days, rather than the correct weekly administration. Interviews with the resident, the MDS nurse, and the DON confirmed that the resident was not receiving insulin and that Ozempic was not classified as insulin. The MDS nurse acknowledged the errors in both the classification and frequency of the medication on the MDS. Facility policy required all persons completing any portion of the MDS to attest to the accuracy of the information, and documentation was to be objective, complete, and accurate. These requirements were not met in this instance.
Failure to Complete Required PASARR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to follow through with the Preadmission Screening and Resident Review (PASARR) process by not obtaining a required Level II evaluation for a resident with a diagnosis of schizoaffective disorder and dementia. The resident's records indicated a need for a Level II mental health evaluation after a Level I PASARR screening identified a serious mental illness. The California Department of Health Care Services was unable to complete the Level II evaluation because facility staff were unresponsive to multiple communication attempts within the required timeframe. The MDS nurse, who was responsible for PASARR screenings, was not aware that the evaluation was not completed and could not provide documentation of any follow-up actions. Interviews with facility staff revealed a lack of awareness and follow-up regarding the incomplete PASARR Level II evaluation. The MDS nurse acknowledged the importance of completing the evaluation, especially for residents with serious mental illness, but could not recall or document any follow-up. The Social Services Director stated she did not have access to the PASARR portal and was unable to verify the status of the evaluation. The Director of Nursing was also unaware that the evaluation had not been completed. The facility's policy indicated that residents identified as potentially having mental disorders should be referred for Level II screening, but this process was not followed in this case.
Failure to Adhere to Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to follow a physician-ordered fluid restriction for one resident with diagnoses of congestive heart failure and chronic kidney disease. The resident's care plan and physician's order specified a 1200 cc per 24 hours fluid restriction, with specific allocations for dietary and nursing staff. However, documentation showed that on multiple days, the resident received fluids significantly exceeding the prescribed limit, with totals ranging from 1320 cc to 2800 cc in a 24-hour period. Observations also revealed that the resident had access to a water pitcher and additional fluids at the bedside, contrary to the fluid restriction order. Interviews with staff confirmed that the resident should not have had a water pitcher at the bedside and that a fluid restriction sign specifying the allowed amount should have been posted in the room. On one occasion, the fluid restriction sign was missing, and when present, it did not indicate the specific restriction amount. The facility's policy required adherence to physician orders, removal of water pitchers for residents on fluid restrictions, and clear communication of restrictions to staff and visitors, but these procedures were not consistently followed.
Improper Application of Splints by Untrained Staff
Penalty
Summary
The facility failed to ensure the proper application of a resting hand splint and elbow splint for a resident with limited range of motion as indicated by the physician's order. The resident, who had diagnoses of contracture of the upper arm muscle and right hand, was dependent on staff for most activities of daily living and had severe cognitive impairment. The physician's order and care plan specified that a Restorative Nursing Aide (RNA) should apply the splints to the resident's right arm for four hours daily, five times a week, with skin checks before and after application. However, during observation, a Certified Nursing Assistant (CNA) was seen attempting to reapply and adjust the splints, despite not being trained or authorized to do so. The CNA struggled with the application and later confirmed that it was not within her responsibilities or training to apply splints, which was corroborated by interviews with other staff, including an LVN and an RNA. The facility's policy required that only trained staff, such as RNAs, apply splints and that in-service training be provided for any device ordered other than a simple hand roll. Interviews with staff confirmed that CNAs were not trained to apply splints and could potentially cause harm if they attempted to do so. The failure to ensure that only properly trained personnel applied the splints, as well as the lack of adherence to the physician's order and facility policy, constituted the deficiency identified during the survey.
Failure to Post No Smoking Sign During Oxygen Use
Penalty
Summary
The facility failed to follow its policy regarding fire safety and prevention by not posting a No Smoking sign outside the room of a resident who was receiving oxygen therapy. The resident, who had a diagnosis of asthma and required varying levels of assistance with daily activities, was observed using oxygen at 2 liters per minute via nasal cannula. Despite the use of oxygen, which is a known fire hazard, there was no No Smoking sign posted outside the resident's room as required by the facility's policy. Interviews with nursing staff confirmed that a No Smoking sign should have been visibly placed at the resident's door whenever oxygen was in use, in accordance with the facility's Fire Safety and Prevention policy. The policy, last revised in May 2011, specifically states that visible No Smoking signs must be used where oxygen is stored and administered. The absence of the required signage was directly observed and acknowledged by staff, constituting a failure to implement established safety protocols.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer two prescribed medications, cholecalciferol and Miralax, to a resident as ordered by the physician. The resident, who had a history of gastrostomy, respiratory failure, and peritoneal abscess, was dependent on staff for all activities of daily living and had moderately impaired cognitive skills. The resident's medication administration record indicated that both cholecalciferol and Miralax were scheduled to be given via G-tube at 9 AM, along with other medications. During a medication pass observation, the LVN administered all other scheduled medications but omitted cholecalciferol and Miralax without realizing the error at the time. Upon review and interview, the LVN acknowledged the omission and stated that medications could be given within a one-hour window before or after the scheduled time, but did not administer the missed medications during the observed period. The Director of Nursing confirmed that the LVN should have followed the physician's orders and administered all scheduled medications as prescribed. Facility policy required medications to be administered safely, timely, and in accordance with prescriber orders, which was not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during a medication administration observation. Out of 33 opportunities for medication administration, two errors were identified, resulting in a medication error rate of 6.06 percent. The errors involved a Licensed Vocational Nurse (LVN) not administering cholecalciferol and Miralax to a resident as ordered by the physician during the scheduled medication pass. The resident involved had a complex medical history, including a gastrostomy tube, respiratory failure, and a peritoneal abscess, and was assessed as having moderately impaired cognitive skills and being dependent on staff for all activities of daily living. The resident's medication orders included cholecalciferol and Miralax to be administered via G-tube once daily at 9 AM, along with other medications. During the observed medication pass, the LVN administered all other scheduled medications but omitted cholecalciferol and Miralax. Upon review, the LVN acknowledged not realizing the omission at the time and stated that medications could be given within a one-hour window before or after the scheduled time. The Director of Nursing confirmed that the LVN should have followed the physician's orders and administered all medications as scheduled. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.
Failure to Provide Timely Dental Services for Resident with Denture Issues
Penalty
Summary
The facility failed to promptly provide dental services for a resident who experienced pain and difficulty when wearing dentures. The resident, who had a history of hypertension, dysphagia, protein-calorie malnutrition, and bipolar disorder, reported that her dentures did not fit for months and caused pain when eating. She stated that she had informed staff about her inability to chew food due to the pain, but no dental referral was set up. Certified Nurse Assistant (CNA) 1 confirmed that the resident had complained about denture pain on multiple occasions and that these concerns were reported to Licensed Vocational Nurses (LVN) 3 and 4. However, LVN 3 admitted to only notifying the Speech Therapist and not the attending physician or Social Services Director (SSD), which was necessary for initiating a dental referral. The SSD was unaware of the resident's denture issue and emphasized the importance of timely communication to resolve such problems. Speech Therapy notes indicated that the resident's dentures were loose and that she did not want to wear them, but it could not be confirmed if this information was communicated to nursing staff or SSD. The resident's care plan included monitoring dental condition and referring for evaluation if needed, and the facility's policy required dental referrals within three days for damaged or lost dentures. Despite these protocols, there was a delay in addressing the resident's dental needs, resulting in ongoing pain and poor food intake.
Failure to Ensure Safe and Appropriate Handling of Food Brought in by Family
Penalty
Summary
The facility failed to ensure that food brought in by family members for a resident with complex medical needs met the prescribed diet and food safety requirements. The resident in question had diagnoses including end stage renal disease, dependence on hemodialysis, heart failure, protein-calorie malnutrition, and hypertension, and was on a renal diet with fluid restrictions. Despite these needs, the resident and family were allowed to bring in home-cooked foods without documented education or monitoring to ensure compliance with dietary and safety guidelines. Interviews and record reviews revealed that the care plan for the resident did not address the issue of food brought in by family, nor did it document any education provided to the resident or family regarding the prescribed diet, fluid restrictions, or food safety. Both the Dietary Service Supervisor and the Registered Dietician acknowledged awareness of the family bringing in food since admission but failed to include this in the care plan or provide the necessary education. There was also no documentation of interdisciplinary team discussions regarding this matter. The facility's policy required staff to provide families with information on safe food handling and to discuss nutrition goals when outside food was brought in frequently. However, there was no evidence that these steps were taken for this resident, and the policy was not implemented as required. This lack of action resulted in a failure to ensure the resident's dietary and safety needs were met as outlined in the facility's own procedures.
Failure to Lock Bed for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was assessed as high risk for falls due to severe cognitive impairment, muscle weakness, osteoarthritis, osteoporosis, and poor safety awareness, experienced a fall. The resident's care plan specifically required that the bed be kept in a locked position to reduce the risk of injury from falls. However, during an observation, it was found that the bed was not locked and could be moved easily, which was confirmed by nursing staff. The resident had previously fallen when attempting to get up from the bed, and staff interviews confirmed that the bed should always be locked to prevent such incidents. Record reviews, including the resident's Minimum Data Set and Morse Fall Assessment, indicated a high risk for falls and dependence on staff for most activities of daily living. Facility policies on safety and fall risk management emphasized the importance of identifying and implementing interventions tailored to each resident's specific risks, including keeping beds locked for those at risk of falling. Despite these policies and the resident's care plan, the failure to keep the bed locked directly contributed to the resident's fall.
Inaccessible Call Lights for Residents at Risk
Penalty
Summary
The facility failed to ensure that the call light device, a critical communication tool for residents to request assistance, was within reach for two of the three sampled residents. Resident 2, who was admitted with diagnoses including dementia and hypertension, was found to have a call light on the floor, out of reach, despite being at high risk for falls as indicated by a Morse Fall Assessment score of 75. The care plan for Resident 2 specifically required the call light to be within reach at all times due to the resident's fall risk and cognitive impairments. During an observation, a Licensed Vocational Nurse confirmed that the call light was not accessible to Resident 2, which contradicted the care plan's directives. Similarly, Resident 3, who was admitted with quadriplegia and respiratory failure, was also found to have an inaccessible call light. The resident's care plan, which highlighted a fall risk due to various factors including cognitive impairment, required the call light to be within reach. However, during an observation, the call light was found wrapped around the side rails and facing the floor, making it inaccessible. An LVN confirmed this observation, and the Assistant Director of Nursing acknowledged that call lights should always be within reach. The facility's policies and procedures also emphasized the importance of ensuring call lights are accessible to residents to provide prompt assistance.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents, leading to an unsanitary condition and potential risk for injury. Resident 3, who was admitted with quadriplegia, respiratory failure, and hyperlipidemia, was found to be at risk for falls with a score of 17 on the Fall Assessment. The resident was severely impaired in cognition and dependent on assistance for personal care activities. Resident 4, admitted with asthma, sepsis, and an overactive bladder, also had a fall risk score of 45 on the Morse Fall Assessment. This resident was cognitively intact but required assistance for personal care activities. During an observation, it was noted that the trash can outside the room shared by these residents was overflowing with used personal protective equipment, and the floor was cluttered with a black plastic bag, used tissue papers, and alcohol pads. The Licensed Vocational Nurse (LVN) confirmed the presence of clutter and acknowledged the need for trash cans to be emptied regularly to prevent infection control issues. The Assistant Director of Nursing (ADON) also emphasized the importance of maintaining clutter-free rooms for the safety of residents and staff, as clutter can lead to falls or accidents. The facility's policy on maintaining a homelike environment was not adhered to, as it requires a clean, sanitary, and orderly setting.
Failure to Ensure LAL Mattress Functionality
Penalty
Summary
The facility failed to ensure that a Low Air Loss (LAL) mattress, intended to prevent and treat pressure ulcers, was switched on for a resident. This resident, who was admitted on 8/22/2023, had diagnoses including lack of coordination, muscle weakness, and dementia, which severely impaired their cognitive skills for daily decision-making. The resident was dependent on assistance for personal care and had a stage 2 pressure ulcer on the sacrococcyx. The resident's care plan included the use of an LAL mattress for pressure distribution and skin integrity management every shift. During an observation and interview, it was found that the LAL mattress was turned off, with the plug disconnected from the electrical source. The Licensed Vocational Nurse (LVN) and the treatment nurse confirmed that the mattress was supposed to be on at all times to support pressure distribution and aid in wound healing. The Assistant Director of Nursing (ADON) acknowledged the absence of a specific policy regarding the LAL mattress being plugged in or switched on continuously, noting that all equipment should be in good functioning condition to prevent pressure ulcers.
Failure to Follow Physician's Orders and Implement Care Plans
Penalty
Summary
The facility failed to follow Physician's Orders and implement care plan interventions to prevent potential accidents for two residents. Resident 68, who has severe cognitive impairment and a history of self-inflicted injuries, was observed kicking the footboard of his bed without any padding in place. Despite the care plan indicating the need for padded side rails to prevent injury, no intervention was documented or implemented to address the kicking behavior, which was observed on multiple occasions. The Assistant Director of Nursing acknowledged the issue and stated that the care plan would be updated, but this had not been done at the time of the surveyor's observations. Resident 84, who has muscle weakness, lack of coordination, and is at high risk for falls, was found with their bed in a high position, contrary to the physician's order and care plan that specified the bed should be kept in the lowest position to prevent injury. During an observation, the bed was approximately three feet above the floor, and a Registered Nurse confirmed that the bed was not in the lowest position as required. The nurse acknowledged the importance of following the physician's order for the resident's safety, but this had not been adhered to. The facility's policies and procedures for following physician's orders and implementing comprehensive, person-centered care plans were not followed in these instances. The failure to implement these interventions had the potential to affect the safety and increase the risk of injury for both residents. The deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents on oxygen therapy. For Resident 79, the nasal cannula (NC) oxygen tubing was observed sprawled out along the wheelchair seat and touching the wheelchair wheels, and the humidified oxygen NC tubing was found touching the floor. These observations were confirmed by the Infection Preventionist (IP) and a Licensed Vocational Nurse (LVN), who both stated that the tubing should have been stored in a bag to prevent contamination and reduce the risk of respiratory infection. Resident 79 was moderately impaired with cognitive skills and dependent on assistance for daily activities, making proper respiratory care crucial for their well-being. For Resident 85, the facility failed to ensure that the continuous positive airway pressure (CPAP) machine had an active physician's order and that the CPAP mask was stored properly when not in use. The CPAP mask was observed hanging behind the bed and on top of the bedside drawer, rather than being stored in a bag. The Assistant Director of Nursing (ADON) confirmed that there was no active physician's order for the CPAP machine and that the care plan should have been revised to include CPAP machine and mask care. Resident 85 was also moderately impaired with cognitive skills and required substantial assistance with daily activities, making proper respiratory care essential. The facility's policies and procedures for infection prevention and control, as well as specific guidelines for respiratory therapy and CPAP/BiPAP support, were not followed. These policies indicated that oxygen cannula and tubing should be stored in a plastic bag when not in use and that the CPAP machine settings and mask care should be included in the physician's order. The failure to adhere to these guidelines put both residents at risk for respiratory infections due to potential contamination of their respiratory equipment.
Failure to Ensure Control and Accountability of Controlled Substances
Penalty
Summary
The facility failed to ensure control and accountability of controlled substances (CS) awaiting final disposition, as the Narcotic and Hypnotic Record accountability logs for March and May 2024 did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN). This was contrary to the facility's policy and procedures, which require such signatures to maintain accurate accountability of all controlled drugs. During an interview, the DON admitted to the inconsistency in signing the logs and acknowledged the need to fully implement the process to ensure each CS dose was accounted for until disposed of properly. A review of the facility's policies indicated that controlled substances are subject to special handling, storage, disposal, and recordkeeping in accordance with federal and state laws and regulations. The policies also specified that the DON, in collaboration with the consultant pharmacist (CP), is responsible for maintaining compliance with these laws. The failure to include verifying signatures on the accountability logs increased the risk of CS diversion and accidental exposure of residents to harmful medications, potentially impacting their health and wellbeing.
Failure to Monitor Side Effects of Eliquis
Penalty
Summary
The facility failed to include appropriate monitoring to ensure a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not monitor Resident 119 for signs and symptoms of bleeding for 15 days while the resident was on Eliquis, a medication used for atrial fibrillation. This oversight was identified through interviews and record reviews, which revealed that the resident's clinical record lacked documentation for monitoring the side effects of Eliquis, such as bleeding and bruising. Additionally, there was no care plan with measurable goals for managing the resident's atrial fibrillation and Eliquis use. Resident 119 was admitted to the facility with a diagnosis of atrial fibrillation and was prescribed Eliquis 5 mg to be taken twice daily. The resident's Minimum Data Set indicated severe cognitive impairment and varying levels of assistance required for daily activities. Despite these needs, the Medication Administration Record for May 2024 showed no documentation for monitoring the side effects of Eliquis. Interviews with Licensed Vocational Nurses and the Director of Nursing confirmed the absence of necessary monitoring and care planning. The Pharmacy Consultant also acknowledged the lack of monitoring and care planning for Resident 119's use of Eliquis. The facility's policy on Medication Regimen Review, which aims to minimize adverse consequences and potential risks associated with medications, was not followed. The policy specifically requires monitoring for adverse consequences, including bleeding, which was not done in this case. This failure to monitor and care plan for the resident's condition and medication use had the potential to cause serious harm to Resident 119.
Improper Food Handling Practices
Penalty
Summary
The facility failed to follow proper food handling practices as per their policy and procedure. During an observation in the kitchen, it was found that a bag of chocolate cookies was not labeled with a best-by date, a milk container was dirty and lacked an open date and expiration date, and a precooked ham container was not sealed properly. Additionally, a bowl of lettuce and finely chopped fruits was incorrectly dated due to a broken label maker machine. Further observations revealed that the lid of a Ground Italian Seasoning container was left open, and a bottle of red wine vinegar was expired but not discarded. The juice machine cleaning log was also not updated for several days, indicating it was not cleaned on those days. Interviews with the Dietary Supervisor (DS) and kitchen staff confirmed these deficiencies. The DS acknowledged that all food items should be labeled with open and expiration dates, and containers should be sealed properly to prevent contamination. The facility's policies and procedures were reviewed, which indicated that all food should be labeled, dated, and stored properly. The DS also confirmed that the juice machine should be cleaned regularly and logs should be maintained. These failures in food handling practices had the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Failure to Maintain Advance Directives in Medical Charts
Penalty
Summary
The facility failed to follow its policy and procedure regarding Advance Directives for two residents, resulting in the absence of these critical documents in their medical charts. For Resident 102, who was admitted with cerebral ischemia and sepsis, the Advance Directive was not found in the clinical record despite being acknowledged in the resident's forms. Interviews with the Registered Nurse and Social Services Director confirmed the absence of the document, which should have been readily accessible according to the facility's policy. The Director of Nursing emphasized the importance of having the Advance Directive available to ensure the resident's wishes are followed in an emergency. Similarly, Resident 324, who had severe cognitive impairment and multiple diagnoses including Type 2 Diabetes Mellitus and dementia, also did not have their Advance Directive in the medical chart. The MDS Nurse confirmed that the document was missing and stated that without it, the resident would be treated as a Full Code, contrary to their potential wishes. The facility's policy mandates that Advance Directives be maintained in the resident's medical record and be easily retrievable by staff. The failure to ensure that Advance Directives were readily accessible in the medical charts of Residents 102 and 324 could lead to conflicts with the residents' healthcare wishes. Both the Social Services Director and the Director of Nursing acknowledged the oversight and the necessity of having these documents available to guide staff in providing appropriate care during emergencies.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, sanitary, and homelike environment for one of nine sampled residents by not ensuring that the resident's bathroom toilet was free of fecal matter. The resident, who was admitted with diagnoses including muscle weakness, abnormal posture, and hypertension, required substantial maximal assistance with toileting and personal hygiene. During an observation, a Licensed Vocational Nurse noted that the toilet seat in the resident's bathroom had dry stool, which should have been cleaned. The Housekeeping staff confirmed that the toilet should be completely clean and free of any marks or fecal stains. The Director of Nursing reviewed the facility's Policies and Procedures, which indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment. The policy emphasized that the facility staff and management should maximize the characteristics of the facility to reflect a personalized homelike setting, including maintaining a clean, sanitary, and orderly environment. The failure to clean the toilet properly resulted in an unsanitary environment, potentially placing the resident at risk for infection and injury.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for Resident 119 by including a diagnosis of schizophrenia without evidence to support this diagnosis in the resident's clinical record. Resident 119 was admitted with diagnoses including atrial fibrillation, hypertension, and a urinary tract infection, and was prescribed quetiapine for anxiety and agitation. However, there was no confirmed diagnosis of schizophrenia in the resident's General Acute Community Hospital (GACH) discharge records, the History and Physical (H&P) by Medical Doctor 1, or the Initial Psychiatric Evaluation by Medical Doctor 2. The MDS Nurse and the Director of Nursing (DON) acknowledged that the schizophrenia diagnosis was likely inferred from the quetiapine prescription, despite the absence of supporting documentation in the resident's medical records. During interviews, both the MDS Nurse and the DON confirmed that the MDS assessment inaccurately included schizophrenia as a diagnosis for Resident 119. The DON emphasized the importance of accurate MDS assessments to ensure residents receive appropriate care and maintain their highest level of functionality and quality of life. The facility's policy and procedures for resident assessments, dated November 2019, indicate that the Resident Assessment Coordinator is responsible for ensuring timely and appropriate resident assessments by the Interdisciplinary Team. The inaccurate MDS assessment for Resident 119 highlights a failure in adhering to these procedures, potentially impacting the resident's care and treatment.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for two residents, leading to deficiencies in their care. Resident 103, who was admitted with diagnoses including Type 2 diabetes mellitus, dementia, and hypertension, did not have a care plan addressing the use of Donepezil for dementia or monitoring for cerebrovascular accidents (CVA) and deep vein thrombosis (DVT) prophylaxis with Plavix. Despite being prescribed these medications, there was no documentation of monitoring for side effects or measurable goals and outcomes related to these conditions and treatments. Interviews with the Director of Nursing (DON), Assistant DON, and MDS Nurse confirmed the absence of these care plans and the importance of having them to ensure proper monitoring and treatment adjustments for Resident 103's conditions and medications. Similarly, Resident 119, who was admitted with a diagnosis of atrial fibrillation and schizoaffective disorder, did not have a care plan that included measurable goals and outcomes for monitoring atrial fibrillation, the use of Eliquis, or the use of Quetiapine for schizoaffective disorder. The Medication Administration Record (MAR) for Resident 119 showed prescriptions for Eliquis and Quetiapine, but there was no documentation of monitoring for side effects such as bleeding or bruising. Interviews with the Licensed Vocational Nurse (LVN), DON, and Pharmacy Consultant (PC) revealed that there was no individualized care plan for these conditions and medications, which is crucial for ensuring resident safety and effective treatment. The facility's policies and procedures require comprehensive, person-centered care plans that include measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to these policies for Residents 103 and 119, resulting in a lack of proper monitoring and individualized care. This deficiency had the potential to negatively impact the residents' overall well-being and treatment outcomes.
Failure to Inform Physicians and Follow Care Plans
Penalty
Summary
The facility failed to provide services in accordance with its policy and procedure for two residents. For Resident 323, the facility did not inform the primary physician about the resident's rashes on both arms and back, which were observed on 5/12/2024. The rashes were not referred to dermatology for further treatment as indicated in the care plan. The resident had a history of major depressive disorder and adult failure to thrive, with severe cognitive impairment. Despite a previous treatment order for the rashes, the condition was not addressed promptly, leading to physical discomfort for the resident. The facility's policy required systematic skin inspections and reporting of abnormalities to the primary physician, which was not followed in this case. For Resident 53, the facility failed to inform the primary physician that the resident had been refusing to elevate his right leg on a pillow, which was necessary to manage his chronic right foot pitting edema. The care plan indicated the use of bilateral TED hose, but there was no physician's order for this, and the resident only needed it for the right leg. The resident had a history of hypertension and hyperlipidemia and was unable to walk 10 feet. The failure to communicate the resident's refusal and verify the need for TED hose with the physician resulted in the resident's right leg not being elevated, as observed on 5/13/2024. The facility's policy on comprehensive person-centered care plans required measurable objectives and timetables to meet the resident's needs, which was not implemented for Resident 53. The lack of communication and adherence to care plans for both residents highlights deficiencies in the facility's processes for managing and reporting health conditions, leading to potential delays in treatment and physical discomfort for the residents.
Failure to Elevate Head of Bed During G-Tube Feedings
Penalty
Summary
The facility failed to follow the physician's order and implement care plan interventions for Resident 68, who was receiving g-tube feedings. The physician's order specified that the head of the bed (HOB) should be elevated to at least 30 degrees during g-tube feedings to prevent aspiration. However, multiple observations revealed that Resident 68's HOB was not consistently elevated to the required degree. On one occasion, the HOB was elevated only 20-25 degrees, and on another, the resident was lying flat in bed while receiving g-tube feeding. Interviews with the licensed vocational nurse (LVN) and the assistant director of nursing (ADON) confirmed that the resident's HOB should have been elevated to at least 30-45 degrees to prevent aspiration pneumonia, but this was not done consistently. Resident 68 had severe cognitive impairment and physical limitations, including dysphagia, dementia, and gastro-esophageal reflux disease (GERD), which made proper positioning during g-tube feedings crucial. The facility's policy on enteral feeding safety precautions, revised in November 2018, also required the HOB to be elevated at least 30 degrees during and for one hour after feedings. Despite these guidelines, the facility failed to ensure that Resident 68 was positioned correctly, putting the resident at risk for aspiration pneumonia. The ADON acknowledged that the resident was not in the correct position and should have had positioning pillows to maintain proper alignment.
Failure to Address Trazadone Use and Monitor Sleep Hours
Penalty
Summary
The facility failed to address the use of Trazadone for a resident (Resident 61) in accordance with their medication regimen review (MRR) policy. Resident 61, who had diagnoses of major depressive disorder, anxiety disorder, and delusional disorder, was prescribed Trazadone for depression manifested by an inability to sleep. However, the order should have been for insomnia, and there was no separate order to monitor the hours of sleep to check the effectiveness of the medication. The Pharmacist Consultant (PC) acknowledged that the Trazadone order should have been reviewed during the April and May MRRs, and the Assistant Director of Nursing (ADON) confirmed that the order should have been clarified and the resident's sleep hours monitored. The facility's policy and procedure for MRR, revised in May 2019, indicated that the consultant pharmacist should review the medication regimen of each resident at least monthly to prevent, identify, report, and resolve medication-related problems. The policy also stated that irregularities include the use of medication without adequate monitoring. In this case, the failure to review and clarify the Trazadone order and monitor the resident's sleep hours led to the potential for unnecessary medication administration, which could result in serious harm to Resident 61.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from the unnecessary use of psychotropic drugs in accordance with their policy and procedure. For Resident 119, the facility did not provide specific, measurable target behaviors related to the use of Quetiapine, an antipsychotic medication. Despite recommendations from the pharmacy consultant to specify the types of visual and auditory hallucinations the resident was experiencing, the facility did not update the medication order, leading to potential inaccurate assessments and monitoring of the resident's condition. Interviews with the Director of Nursing, Licensed Vocational Nurses, and the pharmacy consultant confirmed that the necessary updates were not made, which could affect the efficacy of the medication regimen for Resident 119. For Resident 61, the facility failed to monitor the hours of sleep for the use of Trazadone, a medication prescribed for depression manifested by an inability to sleep. The pharmacy consultant and Assistant Director of Nursing both indicated that the order should have been clarified to specify insomnia and that the resident's hours of sleep should have been monitored to assess the effectiveness of the medication. The lack of monitoring since the medication was prescribed meant that the facility could not accurately determine the medication's impact on the resident's condition. The facility's policies and procedures for antipsychotic and psychotropic medication use were not followed. These policies require that medications be used only when necessary to treat specific conditions and that adequate monitoring for efficacy be conducted. The failure to adhere to these policies for Residents 119 and 61 resulted in the potential for significant adverse consequences from the use of unnecessary psychotropic drugs, which could impair or decline the residents' mental, physical, functional, and psychosocial status.
Failure to Accurately Measure Cereal Portions
Penalty
Summary
The facility failed to ensure that cereal portions were accurately measured using a measuring cup for five of seven residents. During an observation in the facility's kitchen, a kitchen staff member was seen scooping cereal with her gloved hand and transferring it to bowls, rather than using the designated measuring cup. This practice was confirmed during an interview with the kitchen staff member, who acknowledged the importance of using a measuring cup to ensure proper caloric intake for residents, some of whom need to gain or lose weight. The facility's policy on portion control, dated 2023, mandates the use of portion control equipment to ensure that the portions served match the sizes listed on the menu. The kitchen staff member admitted to preparing seven portions of corn flakes by hand, despite knowing that the regular portion size is 3/4 of a cup and that a white scoop should be used for accurate measurement. This failure to follow the policy had the potential to result in meal dissatisfaction and improper nutritional intake for the residents involved.
Failure to Ensure Arbitration Agreement Signed by Legal Representative
Penalty
Summary
The facility failed to ensure that Resident 20, who lacked the mental capacity to understand and make decisions, had the arbitration agreement explained and signed by his legal representative. Resident 20 had diagnoses including traumatic subdural hemorrhage, advanced dementia, and bipolar disorder, and was under a conservatorship. Despite this, the arbitration agreement was signed by Resident 20 and a facility representative, without the signature of the legal representative, as required by the facility's policy and procedure. Interviews with the Admissions Director and the Director of Nursing confirmed that the arbitration agreement should have been signed by Resident 20's conservator. The review of Resident 20's medical records, including the History and Physical and Minimum Data Set, indicated severe cognitive impairment and lack of decision-making capacity. The failure to have the legal representative sign the arbitration agreement resulted in Resident 20 and his conservator not being informed of their rights under the agreement.
Washing Machine Not Maintained in Good Repair
Penalty
Summary
The facility failed to keep one of three washing machines in good repair. During an observation and interview with the Infection Preventionist (IP) and the Maintenance Supervisor (MS) in the dirty laundry room, a washing machine on the furthest left side of the room was found to have a large gash-like hole on the top of the left panel. The MS explained that a tube containing sanitizing chemicals had leaked, causing the left side panel to erode and form a large hole. The facility's policy and procedure, revised in December 2009, indicated that the Maintenance Department is responsible for maintaining equipment in a safe and operable manner at all times, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 324, who was admitted with diagnoses including Type 2 diabetes mellitus, dementia, and a history of falling. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for daily activities such as toileting hygiene, showering, and dressing. The Morse Fall Risk Assessment scored Resident 324 at 55, indicating a high risk for falls. Despite the care plan specifying that the call light should be within reach, an observation revealed that the call light was placed on the bed, out of the resident's reach, while the resident was in a wheelchair in the middle of the room. A Certified Nursing Assistant had to move the call light to the bedside table for the resident to access it. Interviews with a Licensed Vocational Nurse confirmed that the call light should have been within reach and could be placed on the wheelchair or bedside table. The facility's policy and procedure, dated September 2022, stated that each resident should have a means to call staff for assistance from their bed, toileting, and bathing facilities. However, the facility did not adhere to this policy for Resident 324, who was at high risk for falls and had severe cognitive impairment. This deficiency had the potential to prevent the resident from calling for help or assistance, especially during an emergency.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the Daily Posted Nurse Staffing information was accurate according to their policy and procedure. On multiple occasions, the posted nurse staffing information did not reflect the correct total number and actual hours of licensed and unlicensed nursing staff directly responsible for resident care. For instance, on 5/10/2024, the posted information indicated eight CNAs for the 10:30 PM to 6:30 AM shift, while only seven CNAs actually worked. Similar discrepancies were found on 5/11/2024, 5/12/2024, and 5/14/2024, where the posted numbers for CNAs, RNs, and LVNs did not match the actual staff who worked those shifts. The Director of Staff Development (DSD) acknowledged these inaccuracies during interviews and stated it was his responsibility to ensure the information was accurate. The Director of Nursing (DON) also confirmed that the DSD was assigned to ensure the accuracy of the Nurse Staffing Information. The DON emphasized that accurate staffing information is crucial for informing residents, their families, and visitors about the nursing coverage available to provide quality care. The facility's policy, revised in August 2022, mandates that daily staffing data, including the number of nursing personnel responsible for direct care, be posted accurately for each shift. The repeated inaccuracies in the posted nurse staffing information indicate a failure to adhere to this policy, potentially impacting the facility's ability to provide adequate care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
