The Orchard - Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Whittier, California.
- Location
- 12385 E. Washington Blvd, Whittier, California 90606
- CMS Provider Number
- 055706
- Inspections on file
- 41
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at The Orchard - Post Acute Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions reported feeling very uncomfortable, nervous, and scared during bedside therapy provided by a male therapist, describing leg movements that seemed sexual in nature. The resident stated she told social services and several staff, and a family member later relayed to facility staff that the therapist had repeatedly moved the resident’s leg in a circular way without counting, after which the resident did not want to see that therapist again. The DSD, SSD, Director of Rehab, and Administrator all treated the concern as a preference for therapist gender rather than an allegation of abuse, did not obtain detailed information, did not identify the therapist involved, did not document the report, did not initiate an abuse investigation, and did not report the allegation to the Administrator or to State/Federal agencies as required by the facility’s abuse policy.
A resident with metabolic encephalopathy, gait abnormalities, muscle weakness, and severely impaired cognition reported that a male rehab staff member touched her inappropriately and made her feel scared, and her family member relayed similar concerns to facility staff. The SSD, DSD, and DOR each received information that the resident felt uncomfortable with a male therapist but did not clarify details, did not investigate to identify the therapist, did not document the concerns, and did not report the allegation to the State Agency. The ADM understood the situation only as a therapist preference and confirmed no report was made, contrary to facility policy requiring immediate reporting of all abuse allegations to the ADM and appropriate agencies.
Three residents did not receive accurate MDS assessments, with one resident's left arm ROM limitations and another's bilateral leg ROM limitations not properly documented, despite clinical evidence and direct observation. Additionally, a resident with dementia and on antipsychotic medication was not coded for these conditions on the MDS, even though medical records and orders confirmed both. Facility staff acknowledged the discrepancies and confirmed the MDS assessments were not accurate.
The facility did not develop or implement person-centered care plans for four residents with complex needs, including those with dementia, depression, recent UTI, and mobility concerns. For example, a resident with dementia lacked a care plan for behavior monitoring, another receiving escitalopram had no plan for medication supervision, a resident with a recent UTI had no plan for monitoring or prevention, and a resident with mobility issues and repeated RNA refusals had no care plan or IDT intervention. Staff interviews confirmed these omissions and the absence of required care planning processes.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Two residents' medical records were found to be incomplete and inaccurate: one resident's use of antipsychotic and antidepressant medications was not properly documented in the Nursing Summary Weekly despite ongoing administration, and another resident's frequent refusals of Restorative Nursing Assistant (RNA) services were not recorded, with staff confirming that refusals were omitted from daily and weekly documentation.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident with moderately impaired cognition and a primary language of Spanish was not provided with a communication board or translation material, as required by facility policy. Staff confirmed the absence of these tools, which are necessary for residents who do not speak English to communicate their needs during ADLs. The DON acknowledged the importance of having communication boards available in resident rooms.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
A resident with a history of UTI and total bladder incontinence was found with a soaked brief several hours after the last change, with staff relying on the resident's verbal report rather than physical checks. The facility lacked a care plan for UTI prevention and had no policies for incontinence care, and documentation did not specify the frequency of incontinence care provided.
A resident with multiple medical conditions and moderate cognitive impairment was not weighed upon readmission as required by facility policy, resulting in a six-day delay in identifying significant weight loss and initiating nutrition interventions. Staff interviews and record reviews confirmed the omission, which postponed the Registered Dietitian's evaluation and the implementation of necessary dietary measures.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not ensure that a resident received both routine and 24-hour emergency dental care, resulting in unmet dental needs.
A dietary aide failed to label individually packaged cups of cottage cheese, yogurt, and pudding with 'Use By' dates before refrigerating them. This was observed by staff, and the dietary supervisor confirmed the aide was aware of the labeling policy, which requires all prepared or opened foods stored for more than 24 hours to be marked accordingly.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery for residents.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all assessed needs. Documentation and planning did not fully reflect the resident's requirements, as observed in the care planning records.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The environment was not maintained to minimize risks, and supervision was insufficient to prevent incidents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple comorbidities and at risk for pressure ulcers did not receive timely referrals or follow-up for vascular and wound specialist care, despite physician orders and documented changes in condition. Delays in assessment, inadequate documentation, and lack of comprehensive care planning contributed to worsening wounds, infection, and eventual transfer to acute care, where the resident was later discharged to hospice and passed away.
A resident with a history of falls and high fall risk factors was not provided adequate supervision and a safe environment, leading to multiple falls. The facility failed to ensure the resident's room was well-lit and did not implement a bowel and bladder schedule as recommended. These deficiencies resulted in the resident suffering a right hip fracture and requiring surgical intervention.
The facility failed to store food properly, with moldy cantaloupes and onions found in storage, and did not follow hand hygiene practices, as a Dietary Aid handled clean items after touching a trash bin without washing hands. These actions violated the facility's infection control policies.
The facility failed to adhere to its infection control policies for four residents, leading to potential infection risks. A resident's nasal cannula tubing was not changed weekly, another's was reused after contamination, a G-tube formula bottle tubing was undated, and a PIV dressing lacked a date. These oversights were confirmed by staff, highlighting risks of respiratory and other infections.
The facility failed to ensure a safe and sanitary environment for two residents. A resident's wheelchair footrest was left blocking a doorway, posing a fall risk, while another resident's urinals were not emptied promptly, leading to unsanitary conditions. Staff acknowledged these oversights, which violated facility policies on safety and infection control.
A resident's privacy and dignity were compromised when an LVN administered an insulin injection without closing the door or privacy curtain, while the resident's roommate was present. The resident, who had severe cognitive impairment and required assistance with daily activities, was exposed during the procedure, violating facility policies on maintaining resident privacy.
A resident with a history of cerebral infarction and hemiplegia was unable to reach their call light, which was placed behind their television. Despite the resident's care plan and facility policy requiring the call light to be within reach, staff failed to ensure this, compromising the resident's ability to call for assistance. Interviews with staff confirmed the expectation that call lights should always be accessible.
A resident with a history of UTI and hemiplegia experienced dysuria, but the facility failed to develop a comprehensive care plan to address this condition. Despite a Change in Condition Evaluation indicating the resident's complaints, no care plan was documented. Interviews with staff confirmed the oversight, which was contrary to the facility's policy requiring a person-centered care plan for each resident.
A resident, dependent on staff for daily living activities, was not shaved after a bed bath, despite his care plan indicating a preference for being shaved. This oversight was confirmed by facility staff, including a CNA, LVN, RN, and the DON, as a violation of the resident's rights and dignity. The facility's policy emphasized treating residents with dignity and ensuring they are well-groomed, which was not followed in this case.
A facility failed to provide necessary respiratory care by not labeling and replacing a resident's oral suctioning canister. The resident, with conditions including hemiplegia and dysphagia, required oral suction for secretions. Observations showed the canister was unlabeled, and staff were unaware of replacement protocols, risking infection. Facility policy lacked specific guidance on canister maintenance.
Two residents experienced unmanaged pain due to the facility's failure to follow its pain management policy. One resident, with a history of cellulitis and amputation, did not receive timely pain reassessment, while another resident with fractures was not given prescribed pain medication. The facility did not adhere to its procedures for pain evaluation and response, resulting in deficiencies in care.
A facility failed to provide an accessible hemodialysis emergency kit for a resident with acute kidney failure and hypertension, who required dialysis three times a week. During an observation, it was found that the emergency kit was missing from the resident's bedside, contrary to the facility's standard practice. Both an LVN and RN confirmed the absence of the kit, which should have been available for immediate access in emergencies. The DON acknowledged that staff should know the kit's location and contents, highlighting a gap in staff training and awareness.
The facility failed to administer medications with food as ordered for two residents, leading to potential adverse effects. One resident did not receive PreserVision with food, risking stomach irritation, while another did not receive Metformin with meals, risking hypoglycemia. The DON confirmed the importance of following physician orders to prevent these issues.
A resident with protein-calorie malnutrition received a hamburger at 102.9°F, below the facility's standard of 120°F for hot entrees. The resident reported that cold food decreased his appetite. The Dietary Supervisor and DON acknowledged that improper food temperature could lead to dissatisfaction and decreased intake, contrary to the facility's policy.
Failure to Recognize, Investigate, and Report Resident’s Allegation of Abuse by Therapist
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention and reporting policy when a cognitively impaired resident reported feeling uncomfortable and scared during therapy provided by an unidentified male therapist. The resident had diagnoses including metabolic encephalopathy, gait and mobility abnormalities, and muscle weakness, and an MDS showing severely impaired cognition, with the ability to usually understand others. Therapy records showed multiple male PTs and OTAs provided services to the resident in the weeks prior to the allegation. During an interview, the resident stated that while lying in bed in a gown and diaper, a male therapist held her leg and moved it from side to side without counting repetitions, and that his movements made it seem like he was having an erection and seemed sexual. The resident reported feeling nervous, scared, and confused about why she felt that way, and said she had told the Social Services Director about the incident about two weeks earlier and had also mentioned it to several other staff. The Director of Staff Development reported that the resident’s family member had told her the previous week that the resident felt uncomfortable with a male therapist and the way he moved during therapy, and that the resident preferred another therapist. The DSD acknowledged she did not ask the resident for additional details, did not identify which male therapist was involved, and did not investigate the incident, instead only telling the rehab scheduler not to assign the previously assigned male therapist. The Social Services Director similarly stated that the resident had told her the previous week that she felt uncomfortable with a male therapist and did not want any male therapist except one specific OTA. The SSD did not clarify details of the incident at that time, did not determine which therapist was involved, did not document the report, and did not initiate an investigation. She later stated that when she asked the resident why she was uncomfortable, the resident said she did not like that the therapist did not do anything therapy-wise and did not count, but the SSD still did not treat this as an allegation of abuse and did not report it to the abuse coordinator or outside agencies. The Director of Rehabilitation stated he had been informed that the resident felt uncomfortable with male therapists but believed it was a preference rather than a problem, and therefore did not interview the resident, did not attempt to identify the specific therapist, and did not initiate an investigation. He acknowledged that several male therapists had worked with the resident and that it “could be anybody,” but no one in the rehabilitation department was suspended because the concern was treated as a preference. The Administrator similarly stated that the incident was not reported because the information relayed by the DSD and SSD was only that the resident was uncomfortable and preferred a certain therapist, and that this did not constitute an allegation in their view. In contrast, the resident’s family member reported that she had told the SSD that a male therapist had been at the bedside, grabbed the resident by the ankle/heel, repeatedly pushed her legs up and down in a circular way without counting, and that the resident felt very nervous and scared and did not want to see or be near him. Despite the facility’s written policy requiring that all allegations of abuse be promptly reported to the Administrator, thoroughly investigated, and reported to State or Federal agencies within required timeframes, the staff did not recognize the resident’s and family member’s reports as an allegation of possible mental or sexual abuse, did not conduct an investigation, and did not make required external reports.
Failure to Report Resident’s Allegation of Potential Abuse
Penalty
Summary
The facility failed to immediately report an allegation of potential abuse involving one resident. The resident, who had diagnoses including metabolic encephalopathy, abnormalities of gait and mobility, and muscle weakness, and whose MDS documented severely impaired cognition but that she usually understood others, reported that a male staff member from the rehabilitation department had touched her inappropriately about two weeks prior. She stated she informed the Social Services Director (SSD) at that time and had also told three or four other staff members, though she could not recall who. The resident’s family member later reported to the Director of Staff Development (DSD) that the resident had described a male physical therapist at her bedside performing a movement “up and down” in a circular way without counting, which made the resident feel very nervous and scared and not want to see or be near him, though she was not refusing therapy in general. Despite these reports, multiple staff members did not recognize or act on the information as an allegation of potential abuse and did not report it to the State Agency as required by facility policy. The DSD acknowledged that the family member had told her about the allegation but stated she did not ask the resident for additional details, did not investigate the identity of the therapist, and did not consider it an allegation of abuse, so she did not report it. The SSD stated the resident had mentioned an incident with a male therapist and feeling uncomfortable but the SSD did not clarify what happened, did not ask why the resident felt uncomfortable, did not investigate, did not document the report, and did not report it to the State Agency. The Director of Rehabilitation (DOR) stated he was informed the resident felt uncomfortable but did not know which therapist was involved, did not investigate to identify the therapist, and did not report the allegation. The Administrator stated he was told only that the resident was uncomfortable and preferred a certain therapist, believed no formal allegation had been received, and confirmed the incident was not reported. These actions and inactions were inconsistent with the facility’s abuse prevention policy, which required all allegations of abuse, neglect, misappropriation, or exploitation to be reported immediately to the Administrator and to appropriate State or Federal agencies within required timeframes.
Inaccurate MDS Assessments for Functional Limitations and Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between documented assessments and the residents' actual conditions. For one resident with a history of left-sided hemiplegia, hemiparesis, and left hand contracture following a stroke, the MDS was coded to indicate no range of motion (ROM) limitations in both arms. However, the resident's Joint Mobility Evaluation (JME) and direct observation revealed significant ROM limitations in the left arm, including minimal to maximal limitations in the elbow, fingers, and shoulder, and the resident was observed wearing a splint and unable to move the left arm due to paralysis. The MDS nurse confirmed the MDS was coded incorrectly and should have reflected the resident's ROM limitations. Another resident, admitted with right-sided hemiplegia and hemiparesis, had a JME indicating moderate ROM limitations in the right hip, knee, and ankle, and minimal limitations in the left knee. Despite this, the MDS was coded as having no ROM limitations in both legs. Observation confirmed the resident was unable to actively move both legs, and the MDS nurse acknowledged the coding error, stating the MDS should have indicated ROM limitations in both legs. The Director of Nursing also confirmed the importance of accurate MDS coding for appropriate care assessment. A third resident, with diagnoses including dementia and major depressive disorder, was not accurately represented on the MDS, which failed to list dementia as a diagnosis and did not indicate the resident was receiving antipsychotic medication, despite physician orders and medication administration records showing ongoing use of Seroquel for psychosis. The MDS nurse and Director of Nursing both confirmed these omissions, noting that the resident's condition and medication use were not captured in the MDS, contrary to facility policy requiring comprehensive and accurate assessments.
Failure to Develop and Implement Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, each with specific needs that were not addressed according to their medical conditions and assessments. For one resident with severe cognitive impairment and diagnoses including dementia, depression, and schizoaffective disorder, the care plan did not include interventions or monitoring related to dementia-related behaviors, despite the resident receiving antipsychotic and antidepressant medications. Staff interviews confirmed the absence of a dementia-specific care plan and acknowledged that such a plan should have been in place to guide care and interventions. Another resident with severe cognitive impairment and major depressive disorder was prescribed escitalopram oxalate for depression, but the care plan did not address how the resident would be monitored for side effects or supervised while on this medication. Staff confirmed that the lack of a medication-specific care plan meant that potential side effects or behavioral changes could go unmonitored, and the care plan did not reflect the necessary guidance for staff to provide appropriate care. A third resident, with a recent history of urinary tract infection (UTI) and sepsis, did not have a care plan developed to monitor for signs and symptoms of UTI or to implement interventions to prevent recurrence. Staff interviews revealed that no care plan was created upon the resident's readmission, and as a result, there was no structured approach to monitoring or prevention. Additionally, a fourth resident with left-sided hemiplegia, contracture, and a history of consistent refusals of restorative nursing aide (RNA) services did not have a care plan or interdisciplinary team (IDT) conference to address the refusals, investigate the reasons, or update interventions. Staff acknowledged that the pattern of refusals was known but not formally addressed through care planning or IDT processes.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Failure to Accurately Document Medication Use and Restorative Care Refusals
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical records for two residents. For one resident with diagnoses including dementia, schizoaffective disorder, and major depressive disorder, the Nursing Summary Weekly did not accurately reflect the use of prescribed antipsychotic and antidepressant medications, despite physician orders and the Medication Administration Record confirming daily administration of these medications. Both the LVN and DON confirmed that the Nursing Summary Weekly was inaccurate and should have indicated the resident was receiving these medications. The facility did not have a specific policy on nursing documentation or charting, but the existing policy required comprehensive and accurate documentation of resident assessments and care. For another resident with left-sided hemiplegia, hemiparesis, left hand contracture, and a left above-knee amputation, the facility failed to accurately document refusals of Restorative Nursing Assistant (RNA) treatments. Although the resident frequently refused RNA services, the RNA daily flowsheets and weekly summaries consistently indicated that the resident was seen for treatment five times a week with zero refusals. Interviews with the RNAs and the DSD confirmed that the resident refused RNA services at least one to two times daily, but these refusals were not documented as required. The RNAs admitted to ceasing documentation of refusals due to their frequency, and the DSD acknowledged awareness of the ongoing refusals and the lack of accurate documentation. The facility's policy on RNA services required appropriate documentation of the resident's tolerance and participation in the program. However, the failure to document refusals and actual services provided resulted in an inaccurate reflection of the care delivered and the resident's response to the RNA program. This lack of accurate documentation was confirmed by multiple staff members and was evident in the resident's medical records.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Communication Tool for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or device that translated to a language understood by a resident whose primary language was Spanish and who did not speak English. This resident, admitted with diagnoses including prostate cancer and anemia, had moderately impaired cognition and lacked the capacity to understand and make decisions. Observations and interviews revealed that there was no communication board or translation material present in the resident's room, despite the facility's policy requiring such tools to be available at the bedside for residents who do not speak English. Certified Nursing Assistants confirmed the absence of translation or communication tools in the resident's living area and emphasized the importance of these materials for residents to communicate their needs, especially during activities of daily living (ADLs). The Director of Nursing also acknowledged that every resident room should have a communication board posted to assist residents in expressing their needs, and that the lack of such a board could negatively impact the delivery of care. The facility's policy and procedure specified that communication boards with universally known drawings should be supplied and kept at the resident's bedside, but this was not followed for the resident in question.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Provide Adequate Incontinence and UTI Prevention Care
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bladder and had a recent history of urinary tract infection (UTI) was not provided with adequate incontinence care. The resident, who was dependent on staff for all aspects of toilet hygiene and had moderately impaired cognition, was observed with a soaked incontinent brief at 10:35 AM, despite having last been changed at approximately 7:45 AM. The certified nursing assistant (CNA) responsible stated she planned to check and change the resident again at 11:30 AM, and admitted to relying on the resident's verbal report of being dry without physically checking. Documentation showed the resident was only assisted with toilet hygiene one or two shifts per day, with no specific frequency recorded per shift or day. Further review revealed that there was no care plan developed for the resident's UTI, despite a recent hospital treatment for the infection. The licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that a comprehensive care plan should have been created upon the resident's readmission, but this was not done. Additionally, the facility lacked policies and procedures for incontinence care or UTI prevention. Staff interviews indicated that incontinence briefs should be checked every two hours, but this protocol was not followed, and there was no system in place to ensure consistent monitoring and intervention.
Failure to Weigh Resident Upon Readmission Delays Nutrition Management
Penalty
Summary
The facility failed to follow its policy and procedure for Nutrition Status Management by not weighing a resident upon readmission, which delayed the identification and management of significant weight loss. The resident, who had a history of atherosclerosis, coronary artery bypass grafts, UTI, and sepsis, was moderately cognitively impaired and dependent on staff for several activities of daily living. Upon readmission, physician orders required weekly weights and nutritional supplements, but the resident was not weighed until six days after readmission. The Registered Dietitian did not conduct a nutrition evaluation or identify the resident's weight loss until this delayed weigh-in occurred. Record reviews and staff interviews confirmed that the initial weight was not documented in the electronic health record as required by facility policy. The resident experienced a notable decrease in weight over a short period, and the delay in weighing resulted in a late response to her nutritional needs. Both nursing and dietary staff acknowledged that earlier intervention could have occurred if the weight had been taken and reviewed as per protocol. The facility's policy clearly stated that residents are to be weighed upon admission, but this was not followed in this instance.
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.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for each resident as required. This deficiency indicates that residents did not have access to necessary dental services, both for ongoing routine care and in urgent situations, as observed by surveyors during the review.
Failure to Label Refrigerated Food with Use By Dates
Penalty
Summary
A deficiency was identified when a dietary aide failed to label individually packaged cups of cottage cheese, yogurt, and pudding with a 'Use By' date before placing them in the refrigerator. During an observation, a food tray containing 20 individually wrapped dessert cups was found in the refrigerator without any labeling to indicate when the food should be used by. The dietary aide responsible for wrapping and storing the food admitted to not labeling the items and acknowledged that he should have ensured proper labeling for food safety. The dietary supervisor confirmed witnessing the dietary aide wrapping the dessert cups and stated that the aide was aware of the standard practice to label food when refrigerating it. The facility's policy and procedure on labeling and dating foods requires that all prepared or opened foods intended for storage longer than 24 hours be marked with a 'Use By' date. The failure to follow this policy was directly observed and confirmed through staff interviews and policy review.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision was not sufficient to prevent such incidents from occurring. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Provide Timely Pressure Ulcer and Vascular Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident at risk for developing pressure ulcers and complications, as required by facility policy, the care plan, and physician orders. Licensed staff did not ensure timely referral and follow-up for the resident's appointments with a vascular physician and a wound specialist, despite recommendations and orders from the nurse practitioner. The resident was not evaluated by a vascular physician until several months after the initial recommendation, and the wound specialist referral was delayed by 19 days after the order was given. These delays were compounded by a lack of documented attempts to seek alternative providers or escalate the issue when scheduling difficulties arose. The resident had a complex medical history, including diabetes mellitus, chronic kidney disease, end-stage renal disease on hemodialysis, and peripheral vascular disease (PVD). The resident was identified as being at moderate risk for pressure injuries, with multiple care plans and assessments documenting the presence and progression of pressure ulcers and ischemic wounds on the lower extremities. Despite these risk factors and documented changes in the resident's skin condition, there were lapses in wound assessment documentation, failure to measure and stage wounds consistently, and inadequate communication with the physician regarding changes in the resident's condition. Interviews with facility staff revealed that verbal orders for specialty referrals were not always documented or acted upon, and there was confusion regarding responsibility for follow-up. The director of nursing acknowledged that no alternative arrangements were made when the primary referral system was unavailable, and there was no comprehensive care plan developed for the resident's PVD or related complications after significant diagnostic findings. As a result of these deficiencies, the resident experienced delays in wound assessment and intervention, leading to worsening gangrene, infection, and ultimately transfer to an acute care hospital, where the resident was later discharged to hospice and subsequently passed away.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident with a history of falls, leading to multiple incidents. The resident, who had dementia, muscle weakness, and osteoporosis, was at high risk for falls as indicated in their care plan and fall risk evaluation. Despite this, the facility did not ensure the resident's room was well-lit, as required by the care plan, which contributed to the resident's fall on two occasions. On one occasion, the resident attempted to use the bathroom in a dark room, resulting in a fall and a right hip fracture. The care plan for the resident did not adequately address the high-risk factors identified in the fall risk evaluation. The plan lacked measurable objectives and interventions to prevent falls, such as a bowel and bladder schedule to manage the resident's incontinence and reduce the risk of falls. Although the interdisciplinary team recommended implementing a bowel and bladder schedule after the first fall, this was not put into practice, and the resident was not offered scheduled toileting assistance. The facility's failure to implement the recommended interventions and maintain a safe environment resulted in the resident experiencing severe pain and requiring surgical intervention after the second fall. The facility's policy and procedure for fall management were not followed, as the care plan was not updated with necessary interventions, and the resident was not provided with the appropriate supervision and assistance to prevent further falls.
Infection Control and Food Safety Deficiencies
Penalty
Summary
The facility failed to implement its infection control policy by not storing food in a sanitary manner, which could prevent the growth of microorganisms that cause foodborne illnesses. During an observation, several cantaloupes and onions were found in the dry storage area with visible mold and spoilage. The Dietary Supervisor acknowledged the presence of mold and spoilage on the cantaloupes and onions and admitted that these items should have been disposed of. The Corporate Registered Dietitian indicated that spoiled parts of the food could be removed and the rest used, but did not recognize this as a violation of the food safety code. The facility's policy required checking and disposing of spoiled items, which was not followed. Additionally, the facility did not adhere to hand hygiene practices as outlined in its policy. A Dietary Aid was observed moving a trash bin and then handling clean items without washing her hands. The Dietary Supervisor confirmed that the Dietary Aid should have washed her hands after touching the trash bin. The facility's handwashing policy clearly stated that hands should be washed after touching trash cans, which was not followed in this instance.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to implement its infection control policy for four residents, leading to potential infection risks. For Resident 102, the nasal cannula tubing was not changed every seven days as required, with the tubing observed to be dated beyond the seven-day limit. This oversight was confirmed by the MDS nurse, who acknowledged the potential risk for respiratory infection due to the outdated tubing. Resident 25's nasal cannula was improperly stored, with the tubing touching the trashcan and floor, and was reused without being discarded. The CNA admitted to reusing the contaminated nasal cannula, which was against the facility's policy. The Director of Staff Development confirmed that the nasal cannula should have been discarded once it was observed to be improperly stored, as it posed a risk of respiratory infection. For Resident 108, the G-tube formula bottle tubing was not dated, which is necessary to track when it was last changed. Both the LVN and RN acknowledged that the lack of dating could lead to bacterial growth and infection. Similarly, Resident 454's peripheral intravenous dressing was not dated, making it unclear when it was last changed. The LVN and RN noted that this could lead to infiltration or infection, as the dressing should be dated to ensure timely changes and prevent infection.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for Resident 255 by not ensuring that the footrest of a wheelchair was properly placed. The footrest was left on the floor by the doorway, blocking the entrance and exit of the resident's room. This was confirmed during an observation and interview with the resident and a Licensed Vocational Nurse (LVN), who acknowledged the potential risk for falls and injuries due to the obstruction. The facility's policy on incidents and accidents, which requires measures to avoid hazards, was not adhered to in this instance. Additionally, the facility did not maintain a sanitary environment for Resident 64 by failing to timely empty two used urinals filled with urine. During an observation and interview, the resident complained about the foul odor and feeling unsanitary due to the unemptied urinals. A Certified Nurse Assistant (CNA) admitted to noticing the urinals during rounds but chose to wait until the end of the shift to empty them. The Director of Staff Development and the Director of Nurses both stated that the urinals should have been emptied immediately to prevent discomfort and maintain sanitation, as per the facility's infection prevention and control policy.
Violation of Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident during a medication pass. A Licensed Vocational Nurse (LVN) administered an injection of Insulin Glargine into the abdomen of a resident without closing the door or pulling the privacy curtain, while the resident's roommate was present and in view. This action violated the resident's right to privacy and dignity, as the resident was exposed during the procedure. The resident involved had been admitted to the facility with diagnoses including muscle weakness and type 2 diabetes mellitus. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policies and procedures clearly stated that residents should be treated in a manner that maintains their privacy, including closing doors and drawing curtains during examinations and treatments. The LVN acknowledged forgetting to close the curtain and admitted to violating the resident's privacy and dignity.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 108, by not ensuring that the call light was within reach. This deficiency was observed during a concurrent observation and interview with a CNA and an LVN, where it was noted that the call light was placed behind the resident's television, making it inaccessible. The resident, who had a history of cerebral infarction, dysarthria, and hemiplegia affecting the right side, required assistance with various activities of daily living. Despite being capable of using the call light, the resident was unable to reach it, which was confirmed by the CNA and LVN present during the observation. The facility's policy and procedure, as well as the resident's care plan, emphasized the importance of keeping the call light within reach to accommodate the resident's needs and ensure safety, especially in emergencies. Interviews with the RN and DON further reinforced the expectation that call lights should always be accessible to residents. The resident's care plan included specific interventions to ensure the call light was within reach due to risks associated with falls, communication problems, and potential pressure ulcer development. However, these interventions were not followed, leading to the deficiency.
Failure to Develop Comprehensive Care Plan for Dysuria
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident experiencing dysuria, which is pain or discomfort during urination. This deficiency was identified during a review of the resident's records, which showed that the resident had been admitted with diagnoses including a urinary tract infection (UTI) and hemiplegia. Despite a Change in Condition Evaluation indicating the resident's complaint of lower abdominal pain and dysuria, there was no documented evidence of a care plan being developed to address these issues. The resident required assistance with toileting and perineal care, and the lack of a care plan meant that these needs were not formally addressed. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that a care plan should have been developed following the resident's complaints and the Change in Condition Evaluation. The facility's policy requires a comprehensive, person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs. However, in this case, the necessary steps to create and implement such a plan were not taken, leaving the resident without a structured approach to manage their dysuria and prevent further complications.
Failure to Maintain Resident's Grooming and Dignity
Penalty
Summary
The facility failed to provide necessary care and services to a resident who was dependent on staff for activities of daily living, specifically in maintaining grooming and personal hygiene. The resident, who was admitted with diagnoses including congestive heart failure, muscle weakness, and mobility issues, required assistance with personal hygiene and preferred to be shaved as part of his routine care. Despite this preference being documented in his care plan, the resident was observed with a thick growth of facial hair, indicating he had not been shaved after his bed bath. Interviews with staff, including a CNA, LVN, RN, and the Director of Nursing, confirmed that the resident should have been shaved as part of his grooming care. The CNA admitted to not shaving the resident after his bath, which was acknowledged as a violation of the resident's rights and dignity by the LVN, RN, and DON. The facility's policy on resident rights emphasized the importance of treating residents with dignity and ensuring they are well-groomed, which was not adhered to in this instance.
Failure to Label and Replace Suction Canister
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident by not labeling and replacing the oral suctioning canister. The resident, who was originally admitted with diagnoses including hemiplegia and dysphagia, required oral suction as needed for excessive secretions. During an observation, it was noted that the suction canister in the resident's room was not labeled with the date and time of first use, and the nurse present was unaware of when it was last changed. This lack of labeling and replacement placed the resident at risk for respiratory infection. Interviews with nursing staff revealed a lack of knowledge regarding the frequency of changing the suction canister. The facility's policy and procedure on medical equipment did not specify when the canister should be emptied and cleaned, although the Director of Nursing stated that the standard practice was to replace it daily. The failure to adhere to this practice contributed to the deficiency, as the canister was not dated, labeled, or replaced as required to prevent potential infection.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to adhere to its policy on pain management for two residents, resulting in inadequate pain relief. For Resident 25, who had a history of cellulitis, a fracture, and an amputation, the facility did not ensure timely communication and reassessment of pain. On the morning of the incident, Resident 25 was observed in pain, but the CNA did not report this to the LVN promptly. Consequently, the LVN did not reassess the resident's pain after administering routine medication, leading to prolonged discomfort for the resident. Similarly, Resident 604, who was admitted for pain management following fractures, did not receive timely pain medication. Despite having a high pain level, the resident was not administered the prescribed Oxycodone/Acetaminophen on two occasions. The RN could not explain the oversight, and the DON acknowledged the failure to follow the nursing process for pain assessment and reassessment. The facility's policy required regular pain evaluation and documentation, as well as immediate response to pain complaints. However, these procedures were not followed, resulting in both residents experiencing unmanaged pain. The facility's failure to implement its pain management policy led to deficiencies in providing adequate care for these residents.
Failure to Provide Accessible Dialysis Emergency Kit
Penalty
Summary
The facility failed to provide an accessible hemodialysis emergency kit for a resident who required such services. The resident, admitted with acute kidney failure and hypertension, had severely impaired cognitive skills and required substantial assistance with daily activities. The resident was scheduled to receive hemodialysis three times a week. During an observation, it was noted that the dialysis emergency kit, which should have been available at the resident's bedside, was missing. Both the LVN and RN confirmed the absence of the kit and acknowledged that it should have been present to provide immediate access in case of an emergency. The facility's policy did not specifically mandate the placement of a dialysis emergency kit at the bedside, but it was a standard practice within the facility. The Director of Nursing confirmed that the kit should include gauzes and tourniquets and be placed on a hook attached to the resident's nightstand. The DON stated that all staff, including licensed nurses and central supply staff, should be aware of the kit's location and contents to prevent harm to dialysis residents during emergencies. However, the LVN admitted to not knowing the contents of the kit, indicating a gap in staff training and awareness.
Failure to Administer Medications with Food as Ordered
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for two residents, leading to potential adverse medication-related events. For Resident 21, who was admitted with diagnoses including muscle weakness and type 2 diabetes mellitus, the facility did not administer PreserVision with food as ordered by the physician. This was observed during a medication pass where the Licensed Vocational Nurse (LVN) administered the medication without providing food or a snack, contrary to the physician's order to administer it with food to prevent stomach irritation. Similarly, for Resident 22, who had severe cognitive impairment and was diagnosed with conditions including muscle weakness, cirrhosis of the liver, and type II diabetes mellitus, the facility failed to administer Metformin Hydrochloride with meals as ordered. During a medication administration observation, the LVN gave the medication without offering food, despite the physician's order to administer it with meals to prevent hypoglycemia. The Director of Nursing (DON) confirmed that the medications should have been administered with food, as per the physician's orders, to prevent potential adverse effects.
Deficiency in Food Temperature Compliance
Penalty
Summary
The facility failed to ensure that food served to a resident was palatable and at the appropriate temperature, as per the facility's policy. The deficiency was identified during an observation and interview with a resident who reported receiving cold food during lunch, which decreased his appetite. The resident, who was cognitively intact and had a history of protein-calorie malnutrition, was served a hamburger with a temperature of 102.9 degrees Fahrenheit, below the facility's standard of 120 degrees Fahrenheit for hot entrees. The Dietary Supervisor confirmed that the hamburger should have been served above 120 degrees Fahrenheit and acknowledged that undesired food temperature could lead to resident dissatisfaction and decreased appetite. The Director of Nurses also stated that serving hot food at a low temperature could make it unpalatable, discouraging residents from eating. The facility's policy emphasized the importance of serving meals at appropriate temperatures to meet residents' nutritional needs.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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