Two Palms Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 2637 E. Washinton Blvd, Pasadena, California 91107
- CMS Provider Number
- 055464
- Inspections on file
- 15
- Latest survey
- May 29, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Two Palms Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found with mittens on both hands, applied by a CNA without a physician's order, care plan, or consent. The mittens restricted the resident's movement and were not easily removable, classifying them as restraints. Facility staff confirmed the mittens were applied without proper authorization or documentation, violating the facility's policy on restraint use.
The facility failed to follow its policy on Advance Directives for three residents, resulting in deficiencies in providing information and ensuring the ADs were placed in the residents' medical records. The DON and MRD confirmed the missing ADs, which should have been accessible in the residents' charts.
The facility failed to provide activities based on the preferences and assessments for two residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being needs. Both residents had multiple days in March 2024 with no recorded activity participation due to time constraints on the Activities Director's part.
The facility failed to provide proper respiratory care and infection control for two residents receiving oxygen therapy. One resident's nasal cannula tubing was improperly stored and unlabeled, and there was no cautionary sign on the door. Another resident's nebulizer bag and tubing were found touching the floor, posing an infection risk.
The facility failed to ensure that Cook 1 followed the prescribed menu for 16 residents on a mechanical soft diet by using a #12 scoop instead of the required #10 scoop, potentially affecting the residents' nutritional intake and overall well-being.
The facility failed to maintain the dignity and privacy of two residents. One resident was assisted with dinner while the CNA stood next to the bed instead of sitting at eye level. Another resident was left exposed during a bed bath, contrary to the facility's policy. Interviews confirmed the importance of these practices for maintaining resident dignity.
The facility failed to ensure the call light was within reach for two residents, one with difficulty walking and another with a history of falls, leading to potential delays in receiving assistance.
A facility failed to develop a baseline care plan for a resident at risk for developing a pressure ulcer and who had undergone a surgical procedure for a pressure ulcer. The resident was readmitted with diagnoses including type 2 diabetes and cervical disc disorder. Despite observations and interviews confirming the resident's condition, care plans were only initiated weeks later, missing critical interventions.
A facility failed to manage a resident's stage 4 pressure ulcer by not ensuring the low air loss (LAL) mattress was set to alternating therapy. The resident, with diagnoses including type 2 diabetes and cervical disc disorder, was observed on a static mode mattress, which is inappropriate for continuous use. Staff were unaware of the correct settings, potentially delaying the ulcer's healing.
The facility failed to monitor and document the presence of sediments in a resident's suprapubic catheter tubing, which could indicate a possible infection. Despite observations of sediments, the LVN did not check the catheter, and the ADON confirmed the sediments but found no documentation or physician notification, contrary to facility policies.
The facility failed to provide an appropriate food texture for a resident with chewing difficulties, leading to significant weight loss and potential malnutrition. Despite being on a fortified diet, the resident struggled with the food provided and consumed only 30-40% of meals.
A facility failed to ensure an LVN properly flushed a resident's gastrostomy tube (GT) before and after medication administration, as per the facility's policy. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, had an order to flush the GT with 20 cc of water before and after medication. However, the LVN used incorrect amounts, leading to water spilling on the resident's clothing.
The facility failed to attempt appropriate alternatives before installing a bed rail for a resident with Alzheimer's and anxiety disorder. The resident was observed with her legs inserted between the siderails, posing a safety hazard. The ADON confirmed that only frequent monitoring was attempted as an alternative, contrary to the facility's policy requiring a thorough evaluation of alternatives.
The facility failed to conduct and complete the annual performance evaluation for an LVN who had been working full-time since January 2022. The Director of Staff and Development confirmed the absence of documentation, and the Director of Nursing acknowledged the responsibility to conduct these evaluations annually to ensure competent care.
A resident prescribed Cyanocobalamin (vitamin B12) was incorrectly given vitamin B1 by an LVN. The error was acknowledged by the LVN and the DON emphasized the importance of following the seven rights of medication administration to ensure resident safety.
A resident was prescribed Seroquel for psychosis, but the facility failed to adequately monitor the target behaviors, only allowing nurses to initial the MAR without documenting the frequency of behaviors. The ADON acknowledged the issue and stated it was being fixed.
The facility failed to ensure the medication room was free from expired medication, specifically a bottle of Lorazepam Intensol Oral Concentrated. The medication, labeled with a resident's name and dated 10/23/2023, was found in the medication refrigerator during an inspection. The DON confirmed that the medication had expired 30 days after opening and should have been discarded, but the staff forgot to do so.
A resident with hypertension and dementia was not offered a pneumococcal vaccine according to CDC guidelines, despite the facility's policy to provide education and offer the vaccine. The resident had not received the vaccine since 2016, and the Infection Preventionist Nurse confirmed that neither the resident nor their Responsible Party was informed or offered the vaccine.
The facility failed to ensure proper disposal of trash for one of two dumpsters, leading to potential pest attraction. Cook 1 confirmed that both kitchen and resident trash were disposed of in these dumpsters, and the Administrator could not provide a relevant waste management policy.
The facility failed to post accurate nurse staffing information, with discrepancies noted between the posted data and actual staffing sign-in sheets. The information was not posted in visible areas, potentially misleading residents and visitors.
The facility failed to provide a minimum of 80 square feet per resident area for fourteen out of eighteen resident rooms. Despite staff and residents stating that there was enough space for care and movement, the rooms did not meet the required space standards, leading to a deficiency.
The facility failed to report alleged misappropriation of property for a resident with dementia and other diagnoses. Despite being aware of the missing ring reported by the resident's son, the facility did not notify the authorities as required by their policies.
Unauthorized Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by regulations. The resident, who was admitted with severe cognitive impairment and total dependence on staff for daily activities, was found with mittens on both hands. These mittens were applied by a Certified Nursing Assistant (CNA) without a physician's order, care plan, or consent. The CNA applied the mittens after observing the resident attempting to remove his clothes and pull out his gastrostomy tube. The mittens restricted the resident's freedom of movement and were not easily removable by the resident, classifying them as restraints. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Registered Nurse Supervisor, confirmed that the mittens were applied without proper authorization or documentation. The facility's policy requires that physical restraints be used only when necessary to treat a medical symptom and that alternative methods be attempted and documented before restraint use. The lack of communication and documentation among staff members led to the resident wearing the mittens for an extended period without the necessary approvals or oversight.
Failure to Follow Advance Directives Policy
Penalty
Summary
The facility failed to follow its policy on Advance Directives (AD) for three residents, resulting in deficiencies in providing information and ensuring the ADs were placed in the residents' medical records. Resident 15 was admitted with diagnoses including difficulty walking, dysphagia, and depression. Despite having intact cognitive skills and the ability to make daily decisions, Resident 15 was not provided with information regarding ADs upon admission. The Director of Nursing (DON) confirmed that there was no AD screening for Resident 15, which is against the facility's policy that mandates providing AD information upon admission. Resident 17, who had a history of falling and Chronic Obstructive Pulmonary Disease (COPD), had severely impaired cognitive skills and required moderate assistance with daily activities. Although Resident 17 had an executed AD, the Medical Records Director (MRD) was unable to find it in the resident's chart. Similarly, Resident 29, who was admitted with diagnoses including attention to gastrostomy and dementia, had an executed AD that was also missing from the medical records. The MRD and DON both acknowledged that the ADs should be in the residents' clinical records for immediate access in case of an emergency. The facility's policy clearly states that ADs should be placed in the medical records upon admission, but this was not followed for Residents 17 and 29.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to provide activities based on the preferences and activity assessments for two residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being needs. Resident 7, who was readmitted with metabolic encephalopathy and bipolar disorder, preferred room activities such as watching TV, playing ballgames, and hand spa. However, the Activities Director (AD) noted that there were five consecutive days in March 2024 when Resident 7's activity attendance record was blank, indicating a lack of engagement in preferred activities due to time constraints on the AD's part. Similarly, Resident 40, admitted with Alzheimer's disease and anxiety disorder, also had a preference for room activities including TV/radio, hand spa, and ballgames. The AD confirmed that there were five consecutive days in March 2024 when Resident 40's activity attendance record was blank. The AD admitted that there were days when she was unable to provide daily in-room activities for residents who preferred to stay in their rooms. The facility's policy and procedure on activities program emphasized the importance of encouraging resident participation in activities to support their physical and mental capabilities, but this was not consistently implemented for Residents 7 and 40.
Failure to Provide Proper Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure proper respiratory care and services for two residents receiving oxygen therapy, in accordance with the facility's Oxygen Administration policy and professional standards of practice. For Resident 17, the nasal cannula tubing was found unlabeled, rolled, and inserted into the handle of the oxygen concentrator instead of being stored in a labeled storage bag. Additionally, there was no cautionary sign posted on Resident 17's door indicating that oxygen was in use, which is necessary to remind everyone not to smoke inside the room due to the flammability of oxygen. These observations were confirmed by Licensed Vocational Nurse 1 and the Director of Nurses, who acknowledged the deviations from the facility's policy and infection control practices. For Resident 15, the nebulizer bag and its connecting tubing were observed touching the floor, which poses an infection control risk. The Infection Preventionist Nurse confirmed that the nebulizer bag and tubing should be kept off the floor to prevent contamination. The facility's policy on Oxygen Administration, revised in 2017, specifies that oxygen items should be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use, and that an 'Oxygen in Use' sign should be placed on the door frame of rooms where residents are using oxygen therapy. These failures indicate a lack of adherence to the facility's established procedures for respiratory care and infection control.
Failure to Follow Prescribed Menu for Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that Cook 1 followed the prescribed menu for 16 residents on a mechanical soft diet. During a kitchen observation, it was noted that Cook 1 used a #12 green scoop for portioning ham instead of the required #10 scoop as indicated in the Spring Cycle Menu for Week 1 Sunday Menu. The #12 scoop has a capacity of 2 2/3 ounces, while the #10 scoop has a capacity of 3 1/4 ounces, resulting in a difference of 0.58 ounces. Cook 1 admitted to using the #12 scoop because the kitchen did not have a #10 scoop, despite having requested it from the Dietary Services Supervisor (DSS). The DSS confirmed that the kitchen had not needed the #10 scoop until the new menu started approximately two weeks prior to the observation. The facility's Diet Type Report indicated that there were 16 residents on a mechanical soft diet. The Spring Menu from 3/4/2024 to 3/23/2024 showed that the #10 scoop was required for 14 out of 21 days. The facility's Policy and Procedure (P&P) for the Dietary Department, dated 10/24/2022, stated that the dietary department is responsible for meeting the nutritional needs of the residents, maintaining accurate records, and providing effective supervision and training of food service personnel. The failure to use the correct scoop size had the potential to cause weight loss and affect the overall well-being of the residents on a mechanical soft diet.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, Resident 41 and Resident 23. For Resident 41, the deficiency occurred when a Certified Nursing Assistant (CNA2) assisted the resident with dinner while standing next to the bed, rather than sitting at eye level. This action was contrary to the facility's policy and procedure, which emphasizes maintaining residents' dignity and respect by promoting independence and dignity in dining. Interviews with CNA2, CNA1, and the Infection Prevention Nurse confirmed that staff should sit at eye level when assisting residents with meals to maintain their dignity and respect their rights. For Resident 23, the deficiency was observed during a bed bath. CNA3 failed to cover Resident 23's body while washing and drying different parts, leaving the resident exposed. This action was against the facility's policy and procedure for bed baths, which requires covering the resident's body parts not being washed to maintain privacy and dignity. Interviews with CNA3 and the Director of Staff Development confirmed the importance of keeping residents covered during bed baths to prevent feelings of exposure and loss of self-respect.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, Resident 15 and Resident 17. Resident 15, who had difficulty walking, dysphagia, and depression, was observed sitting in a wheelchair with the call light handler under the bed, out of reach. The Infection Preventionist Nurse confirmed that the call light was not accessible, and Resident 15 stated that it should be within reach to prevent accidents. Resident 15 required substantial assistance for transfers and moderate assistance for personal hygiene, making the accessibility of the call light crucial for timely help and safety. Resident 17, who had a history of falling and chronic obstructive pulmonary disease, was assessed as high risk for falls. The care plan indicated that the call light should be within reach, but during an observation, it was found hanging on the upper right side of the bed, out of reach. The Licensed Vocational Nurse confirmed that Resident 17 could not reach the call light and emphasized the importance of its accessibility to prevent accidents. The Director of Nursing also stated that the call light should be within reach to ensure timely assistance and maintain safety. The facility's policy indicated that call cords should be placed within the resident's reach, which was not followed in these cases.
Failure to Develop Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was at risk for developing a pressure ulcer and had undergone a surgical procedure for a pressure ulcer. The resident was initially admitted on 8/20/2023 and readmitted on 2/21/2024 with diagnoses including type 2 diabetes and cervical disc disorder with radiculopathy. The resident's Minimum Data Set (MDS) dated 3/6/2024 indicated that the resident was rarely able to express ideas and wants and was rarely able to understand verbal content. During an observation on 3/31/2024, a Certified Nursing Assistant (CNA) was providing incontinent care to the resident, who had an intact dressing on the sacral coccyx area. However, there was no care plan for altered skin integrity or the pressure ulcer upon readmission on 2/21/2024, as confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews on 3/31/2024. The care plans for the resident's potential for pressure ulcer development and actual impairment to skin integrity were only initiated on 3/6/2024 and 3/8/2024, respectively. The DON acknowledged that the facility should have developed a care plan specific to the resident's pressure ulcer upon admission on 2/21/2024. The DON stated that if a care plan had been developed, interventions such as turning and repositioning, encouraging the resident to eat, keeping the resident clean and dry, and limiting wheelchair time could have been implemented. The Wound Consultant's progress notes dated 2/29/2024 indicated that the resident returned from the hospital on 2/21/2024 after a procedure to close the sacral wound with sutures.
Failure to Properly Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate treatment to manage and promote the healing of a stage 4 pressure ulcer for a resident. The resident, who had diagnoses including type 2 diabetes and cervical disc disorder with radiculopathy, was observed lying on a low air loss (LAL) mattress that was set to static mode instead of alternating therapy. This setting was not appropriate for continuous use and was only meant for specific situations like cleaning, changing positions, or turning the resident. The Assistant Director of Nursing (ADON) was unaware that the static mode needed to be off, and the Director of Nursing (DON) confirmed that the static setting should not have been used continuously as it prevents the mattress from providing the necessary alternating pressure to aid in pressure ulcer healing. The user manual for the LAL mattress and the facility's policy on pressure ulcer prevention both indicated the importance of alternating therapy for effective pressure ulcer management. The resident's Minimum Data Set (MDS) indicated that the resident was rarely able to express ideas and wants, and was rarely able to understand verbal content, highlighting the resident's vulnerability and dependence on staff for appropriate care. The failure to ensure the LAL mattress was on the correct setting had the potential to delay the healing of the resident's stage 4 pressure ulcer, as the static mode does not provide the necessary alternating pressure to minimize soft tissue distortion and promote improved blood flow. This deficiency was identified through observation, interviews with staff, and a review of the resident's records and the facility's policies.
Failure to Monitor and Document Sediments in Catheter Tubing
Penalty
Summary
The facility failed to assess and monitor for the presence of sediments on the suprapubic catheter tubing for Resident 11. The resident, who was admitted with diagnoses including cerebral infarction and cystostomy, had sediments observed on the catheter tubing during an observation. Despite this, the Licensed Vocational Nurse (LVN) did not check the catheter and moved it to the left side, making the tubing not visible. The Assistant Director of Nursing (ADON) confirmed the presence of sediments and stated that such observations should be documented and reported to the physician as they could indicate a possible infection. However, there was no documentation of the sediments in Resident 11's urine or on the catheter tubing, and the physician was not notified of this potential change in the resident's condition. The facility's policies and procedures require monitoring for discharge, redness, and sediments in residents with a suprapubic catheter and notifying the physician of any significant changes in the resident's condition. The ADON and LVN both acknowledged that monitoring the urine for color and presence of sediments is part of the nursing assessment for residents with a urinary catheter. The failure to document and report the presence of sediments in Resident 11's urine and on the catheter tubing represents a deficiency in catheter care and monitoring, which could lead to a delay in treatment and potential urinary tract infection.
Failure to Provide Appropriate Food Texture
Penalty
Summary
The facility failed to provide an appropriate food texture to fit the needs of Resident 41, who had difficulty chewing. Despite being on a fortified Consistent, controlled carbohydrate diet with regular, cut-up meat texture, Resident 41 experienced a four-pound weight loss within a week. Observations and interviews revealed that Resident 41 had poor oral intake, consuming only 30-40% of food, and had difficulty chewing the food provided, such as chopped boiled eggs and sandwiches. The resident was able to consume soup and high-protein nutrition drinks without difficulty. Interviews with the resident's responsible party, a CNA, an LVN, and the Director of Nursing confirmed that Resident 41 had difficulty chewing and required a more appropriate food texture to prevent further weight loss and malnutrition. The facility's policy on weight management indicated that the interdisciplinary team should update the care plan to reflect individualized goals and approaches for managing weight changes, but this was not adequately done for Resident 41, leading to the deficiency.
Failure to Properly Flush Gastrostomy Tube Before and After Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly flushed a gastrostomy tube (GT) before and after medication administration for a resident. The resident, who was admitted with a diagnosis that included the need for a gastrostomy and dementia, had an order to flush the GT with 20 cc of water before and after medication administration. However, during a medication pass observation, the LVN flushed the GT with only 10 cc of water before administering medications and 30 cc of water after, which resulted in water spilling on the resident's clothing. The Director of Nursing (DON) confirmed that the GT should be flushed with 20 cc to 30 cc of water before and after administering medication to prevent clogging, as per the facility's policy and procedure titled 'Feeding Tube - Administration of Medication.' The policy indicated that the tube should be flushed with approximately 30 cc of water before and after medication administration. The resident's medical records indicated that they did not have the capacity to understand and make decisions, and their cognition for daily decision-making was severely impaired. The resident was dependent on staff for oral hygiene, toileting, showering, and personal hygiene. The failure to follow the prescribed procedure for flushing the GT had the potential to result in inconsistent effectiveness of medication for the resident. The facility's policy and procedure, revised in 2017, clearly outlined the correct process for flushing the GT, which was not adhered to by the LVN during the observed medication pass.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing a bed rail for Resident 40, who was admitted with diagnoses including Alzheimer's disease and anxiety disorder. The resident's MDS indicated that she sometimes could express ideas and understand verbal content, requiring maximal assistance with rolling and being dependent on lying to sitting mobility. During an observation, the resident had removed the padding from the siderails and inserted her legs between them, indicating a potential safety hazard. The Assistant Director of Nursing (ADON) confirmed that the only alternative attempted before using siderails was frequent monitoring, and no other appropriate alternatives were tried. The ADON acknowledged that siderails could pose an accident hazard, putting residents at risk for entrapment. The facility's policy required an evaluation of alternatives to bed rails, which should be appropriate, safe, and address the resident's medical conditions, symptoms, or behavioral patterns. However, this was not followed in the case of Resident 40.
Failure to Conduct Annual Performance Evaluation for LVN
Penalty
Summary
The facility failed to ensure competent nursing staff by not conducting and completing the performance evaluation for one of five staff members, specifically a Licensed Vocational Nurse (LVN 4). LVN 4 had been working full-time at the facility since January 27, 2022. During a record review and interview with the Director of Staff and Development (DSD) on March 31, 2023, it was revealed that there was no documentation of LVN 4's performance evaluation being conducted by the Director of Nursing (DON). The DSD confirmed that performance evaluations should be conducted annually by the DON. In a subsequent interview with the DON, it was confirmed that the DON is responsible for conducting these evaluations to ensure staff can provide competent care to residents. The facility's policy, reviewed in May 2022, indicated that performance evaluations should be conducted annually around the staff member's anniversary date.
Failure to Administer Prescribed Medication Correctly
Penalty
Summary
The facility failed to administer Cyanocobalamin (vitamin B12) as ordered to one of six sampled residents. Resident 5, who was readmitted to the facility with diagnoses including anemia and vitamin D deficiency, was prescribed Cyanocobalamin oral tablet 100 mcg to be taken once daily. However, during a medication administration observation, Licensed Vocational Nurse 3 (LVN 3) administered vitamin B1 100 mg instead of the prescribed Cyanocobalamin 100 mcg to Resident 5. During an interview, LVN 3 acknowledged the error, stating the importance of ensuring the right resident, right drug, right dose, right route, and right time during medication administration to avoid errors. The Director of Nursing (DON) reiterated that licensed staff should adhere to these checks to ensure resident safety and health. A review of the facility's policy on medication administration confirmed that medications should be administered by a licensed nurse per the physician's order, emphasizing the seven rights of medication administration.
Failure to Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of unnecessary psychotropic drugs by not adequately monitoring the target behavior for the use of Seroquel. The resident, who was readmitted with diagnoses including paraplegia and contracture of bilateral elbows and knees, had an order for Seroquel 25 mg at bedtime for psychosis manifested by episodes of yelling, screaming, delusions, and hallucinations. However, the facility's Medication Administration Record (MAR) did not allow staff to document the number of times these behaviors occurred, only allowing for the nurse's initials. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the monitoring system was inadequate and stated that it was being fixed to allow licensed nurses to tally the number of occurrences per shift. This deficiency had the potential to place the resident at risk for significant adverse consequences from the use of unnecessary psychotropic drugs, as the facility could not determine if the medication was effective or if there was an opportunity for a gradual dose reduction.
Expired Medication Found in Storage Room
Penalty
Summary
The facility failed to ensure the medication room was free from expired medication, specifically a bottle of Lorazepam Intensol Oral Concentrated. This medication, labeled with a resident's name and dated 10/23/2023, was found in the medication refrigerator during an inspection. The Director of Nursing (DON) confirmed that the medication had expired 30 days after opening, per the facility's policy, and should have been discarded. The medication was not on the resident's current medication list, and the resident had not been taking it since the prescription expired on 12/6/2023. The DON acknowledged that the staff forgot to discard the expired medication, which could potentially result in the resident using ineffective medication, causing a decline in health conditions. A review of the facility's Policy and Procedure titled, Medication Storage in the Facility, dated 1/2022, indicated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse is required to place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. All expired medications are to be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The facility's failure to adhere to this policy led to the presence of expired medication in the storage room.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 8 according to the CDC's recommended schedule guidelines. Resident 8, who was readmitted to the facility with diagnoses of hypertension and dementia, had received one dose of the Pneumovax vaccine on 1/4/2016 before being admitted to the facility. The Minimum Data Set (MDS) dated 3/16/23 indicated that Resident 8 rarely/never understood others and rarely/never made self-understood. The Immunization Audit Report (IAR) showed that no other pneumococcal vaccine was provided to Resident 8 from 1/5/2016 to 3/31/2024. During an interview, the Infection Preventionist Nurse (IPN) confirmed that Resident 8 had not been offered another dose of the pneumococcal vaccine, which should have been administered around early 2021 according to CDC guidelines. The facility's policy and procedure titled 'Pneumococcal Disease Prevention,' revised on 8/28/2024, indicated that the facility would provide education and offer the pneumococcal vaccine to residents to prevent and control the spread of pneumococcal disease. However, the IPN admitted that Resident 8 or their Responsible Party (RP) was not given education on the pneumococcal vaccine, nor was the vaccine offered. This failure had the potential to leave residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease, as the facility did not adhere to its own policy or CDC guidelines in this case.
Improper Trash Disposal
Penalty
Summary
The facility failed to ensure proper disposal of trash for one of two dumpsters. During an observation with Cook 1, it was noted that one dumpster was full of trash and the lid could not be closed completely. Cook 1 confirmed that both kitchen and resident trash were disposed of in these dumpsters and that garbage collection occurred twice a week. Cook 1 acknowledged that the dumpsters needed to be covered to prevent attracting pests such as rats and flies. The Administrator was unable to provide a policy on waste management for both resident and kitchen trash, only providing a policy on Medical and Pharmaceutical Waste Management Program.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. During an observation, it was noted that the staffing information was not posted in the nurses' station or visible areas. The Regional Director of Staff Development (RDSD) confirmed that the staffing information should be posted in visible areas for easy access by staff, visitors, and residents. However, the staffing information was missing, which could mislead residents and visitors about the number of nurses available for care. Further review revealed discrepancies between the posted nurse staffing information and the actual staffing sign-in sheets. On a specific date, the posted information indicated that one Registered Nurse (RN) and five Certified Nurse Assistants (CNAs) were on duty for the night shift, while the sign-in sheet showed no RN and only four CNAs worked that shift. The Director of Staff Development (DSD) acknowledged the importance of accurate staffing information to meet staffing requirements and avoid creating inaccuracies for staff and visitors. The facility's policy and procedure required posting the total number and actual hours worked by nursing staff per shift in a prominent place, but this was not adhered to in this instance.
Failure to Meet Minimum Space Requirements for Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident area for fourteen out of eighteen resident rooms. This deficiency was identified during a Health Recertification Survey, where it was observed that the rooms in question did not meet the required space standards. Despite this, the facility's Administrator requested a room waiver, stating that each resident had sufficient personal space, including privacy curtains, closets, and nightstands. The waiver also claimed that there was enough space for routine and emergency nursing care, as well as for maneuvering wheelchairs and walkers, without any adverse effects on the residents' health, safety, and welfare. Interviews with staff and residents corroborated the Administrator's claims. Certified Nurse Assistant 1 and Licensed Vocational Nurse 2 both stated that there was enough space in the rooms to provide care and move wheelchairs and walkers without issues. Additionally, a resident confirmed that he could move his wheelchair in and out of the room comfortably. Despite these observations, the facility's failure to meet the minimum space requirements for resident rooms constitutes a deficiency.
Failure to Report Alleged Misappropriation of Property
Penalty
Summary
The facility failed to report alleged violations of misappropriation of property as required by law and facility policy for one resident. Resident 1, who was admitted with diagnoses including dysphagia, dementia, and malignant neoplasm of the prostate, had a missing silver white ring and a broken necklace. The facility's Administrator (ADM) was aware of the missing ring reported by Resident 1's son but did not report the incident to the authorities because the item was not documented in the resident's inventory. Despite the facility's policy requiring the reporting of such allegations within 24 hours, the ADM stated that the facility conducted its own investigation and did not notify the proper authorities. Interviews with various staff members, including the Social Services Designee (SSD), Licensed Vocational Nurse (LVN1), and Certified Nursing Assistant (CNA1), confirmed awareness of the missing ring and the requirement to report misappropriation of property. The facility's policy on Abuse Prevention and Prohibition Program and Theft Prevention mandates reporting allegations of misappropriation to the Department of Public Health, Ombudsman, and law enforcement officials within 24 hours. However, the facility did not adhere to these policies, resulting in a failure to report the alleged theft of Resident 1's property in a timely manner.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
