Valley Vista Nursing And Transitional Care Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 6120 N. Vineland Ave, North Hollywood, California 91606
- CMS Provider Number
- 555132
- Inspections on file
- 93
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 55
Citation history
Health deficiencies cited at Valley Vista Nursing And Transitional Care Llc during CMS and state inspections, most recent first.
A resident with COPD, emphysema, and hypertensive heart disease experienced documented SOB over multiple consecutive days, with nursing notes repeatedly recording respiratory complaints and observations but no evidence of physician notification. Despite a care plan directing staff to assess respiratory status and notify the MD as indicated, the change in condition was not communicated until the resident developed severe SOB requiring EMS activation and transfer to an acute care hospital, where low oxygen saturation and several days of worsening symptoms were documented. This failure occurred despite facility policy requiring MD notification for significant changes in condition and for situations necessitating hospital transfer.
Two residents did not receive ordered topical medications and wound care as prescribed. One resident with multiple chronic conditions and moderately impaired cognition had physician orders for daily-shift Nystatin powder to abdominal folds for MASD and Mupirocin 2% ointment to both legs for cellulitis; review of the TAR with an RN showed no licensed staff initials for these treatments on two morning shifts, and the RN confirmed there was no documented evidence they were administered. Another resident with paraplegia and a stage 4 sacral pressure ulcer had detailed daily-shift sacral wound care orders involving Dakin’s solution, collagen, hydrocolloid, and foam dressings; the TAR similarly lacked licensed staff initials for two morning shifts, and the RN stated there was no documentation the treatment was completed. Facility policy required medications, including topical treatments, to be administered as prescribed and recorded on the TAR.
A resident with heart failure, epilepsy, COPD, and moderately impaired cognition, who depended on staff for multiple ADLs, experienced vomiting and an O2 saturation of 76% on room air, leading to transfer to an acute care hospital. Despite this significant change in condition, the resident’s comprehensive care plan was not revised to address the vomiting and desaturation, contrary to facility policy requiring the IDT to review and update care plans after significant changes or hospital stays. An RN confirmed that the care plan was not updated and that it serves as the essential guide for staff monitoring and care.
A resident with a history of liver disease and alcohol dependence left the facility AMA after being placed on a one-on-one sitter, but did not receive discharge instructions or information about the risks and benefits of leaving in their preferred language of Spanish. The AMA form was signed in the presence of two RNs who could not communicate in Spanish, resulting in the resident not being fully informed as required by facility policy.
A resident with a history of aggression physically assaulted another cognitively impaired resident, causing injury and pain. Despite prior documented aggressive incidents, there was no evidence of psychiatric evaluation or consistent monitoring, and required follow-up interventions were lacking. Staff confirmed the abuse and facility policies mandated protection from such incidents.
A resident with a history of alcoholic cirrhosis, malnutrition, and alcohol dependence left the facility AMA after being placed on one-on-one supervision. The resident's preferred language was Spanish, but discharge instructions and the AMA form were only provided in English, and staff present could not translate. As a result, the resident left without fully understanding the risks and benefits of leaving AMA.
A resident with schizoaffective disorder and dementia received PRN Haloperidol without an end date or required 14-day re-evaluation, and staff did not monitor or document behavioral symptoms to justify continued use. This failure did not comply with facility policy for antipsychotic medication management.
A resident was readmitted with a new indwelling catheter, but the care plan was not updated to include goals or interventions for catheter care. The omission was confirmed by an RN during record review and interview, despite facility policy requiring care plan updates after significant changes or readmission. The resident had multiple diagnoses and required maximal assistance with daily activities.
A resident with multiple chronic conditions and severe cognitive impairment experienced a significant change in condition with abnormal vital signs. Facility staff did not assess the resident's blood glucose level at the time, despite policy and professional standards requiring this assessment during such events. The omission was acknowledged by nursing staff and resulted in incomplete evaluation during the resident's acute episode.
A resident with severe cognitive impairment and multiple medical conditions was admitted with a new indwelling catheter, but staff failed to place orders for catheter care or monitoring, and there was no documentation of care or assessment as required by facility policy.
A resident with COPD, acute respiratory failure, and dementia did not receive prescribed continuous oxygen therapy or regular spO2 monitoring as ordered. Staff failed to reconnect the nasal cannula and turn on the oxygen concentrator after care, and documentation for oxygen administration and spO2 checks was missing for several shifts, contrary to facility policy.
Two residents with complex medical needs did not have discharge planning included in their person-centered care plans, despite facility policy and staff acknowledgment that social services are responsible for this process. Both the MDS assessments and interviews with the DON confirmed the absence of discharge planning interventions, which is required by facility policy and the Social Services Director's job description.
A resident with multiple chronic conditions requested transfer closer to family, and the Social Services Director engaged in discussions and outreach to potential facilities. However, there was no documentation in the medical record of these communications or actions, contrary to facility policy requiring all services and care planning activities to be recorded.
A resident with multiple medical conditions and total dependence on staff for care was found to have their call light on the floor and out of reach, contrary to their care plan and facility policy. Staff confirmed the importance of keeping the call light accessible, and facility policy required it to be within reach when the resident is in bed.
A resident with multiple respiratory diagnoses was found with her oxygen nasal cannula inside her mouth instead of her nose, despite a physician's order for continuous oxygen via nasal cannula. Staff interviews confirmed the importance of proper placement and adherence to orders, but the deficiency occurred when the device was not correctly positioned, resulting in the resident not receiving oxygen as prescribed.
A resident with depressive disorder, hypertension, and anxiety disorder was found to be living in a room and restroom that were not clean or homelike, with visible residue, rust, and broken fixtures. Both an LVN and the DON confirmed the lack of cleanliness, which did not meet facility policy for maintaining a sanitary and comfortable environment.
Three residents with various medical conditions and decision-making capacity were not provided with written information about their right to formulate an Advance Directive upon admission. Staff interviews and record reviews confirmed that required documentation and discussions did not occur, and the facility's process for informing residents about ADs was not followed.
The facility failed to obtain informed consent and properly monitor the use of psychotropic medications for several residents, including not documenting behavioral indications, adverse effects, or end dates for PRN orders. Staff did not follow required procedures for consent and ongoing evaluation, and behavior monitoring documentation was missing for multiple months for two residents receiving antipsychotic and antianxiety medications.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided, resulting in regulatory noncompliance.
A resident requiring dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's requirements.
Two residents experienced deficiencies in pharmaceutical services when an LVN failed to administer and accurately document prescribed medications, including amiodarone and famotidine, and did not seek supervisory assistance when confused. Additionally, Epogen was administered to another resident without required hemoglobin monitoring, contrary to physician orders and manufacturer guidelines.
A staff member did not level the scoop when serving egg noodles, resulting in larger portions than specified by the facility's menu and standardized recipe. This affected most residents receiving egg noodles, including those on a consistent carbohydrate (CCHO) diet, and was confirmed by observation, staff interview, and review of facility policies and recipes.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
A gap in a reach-in freezer door led to significant ice buildup, as observed by staff and confirmed through interviews with the Dietary Supervisor and Maintenance Supervisor. Despite awareness of the issue and a temporary fix with a metal plate, the freezer continued to have a gap, and the manufacturer's guidance was not sought. This deficiency affected the safe storage of food for medically compromised residents.
The facility did not maintain sanitary conditions in the kitchen, as flies were observed flying and landing on food preparation surfaces and equipment during trayline and food prep. The Dietary Supervisor confirmed that flies entered when staff opened doors to bring in supplies, and acknowledged the risk of cross-contamination. This failure had the potential to affect most residents receiving food from the kitchen.
Surveyors found that two residents with cognitive and physical impairments had their call lights placed behind their beds and out of reach. CNAs, an RN, and the DON confirmed that the call lights should have been accessible to allow residents to request assistance, in accordance with facility policy.
Two residents did not receive comprehensive care plans addressing their specific needs: one resident with a history of stroke and falls did not have a post-fall care plan developed after an actual fall, and another resident with multiple diagnoses did not have a care plan for bowel and bladder incontinence management or retraining. Staff interviews and record reviews confirmed that required care planning processes and facility policies were not followed.
The facility did not ensure that services provided met professional standards of quality, as evidenced by observations and record reviews showing inconsistent adherence to accepted guidelines.
A CNA was found to lack a CPR certification accredited by the ARC or AHA, contrary to facility policy requiring all CPR team members to hold such credentials. This was confirmed through interviews and record review with the DON and DSD, who acknowledged the oversight during the hiring process and the importance of compliance with the facility's emergency procedures.
A resident with end stage renal disease, COPD, and anemia received Epogen injections for anemia without a physician's order for hemoglobin monitoring. Nursing staff administered the medication on multiple occasions without ensuring hemoglobin levels were checked, contrary to both the manufacturer's guidelines and facility policy, which require regular monitoring to ensure safe administration.
A resident with intact cognitive function and multiple diagnoses was identified as a candidate for a bowel and bladder retraining program, but staff failed to initiate the program as required by facility policy. Interviews with the MDSC and DON confirmed the omission, which was not in line with established procedures for managing incontinence.
A resident with respiratory failure, CHF, and dementia who was dependent on staff for care was found with a nasal cannula disconnected from the oxygen concentrator, despite physician orders for continuous oxygen. Staff confirmed the tubing should always be connected and that monitoring is their responsibility, in line with facility policy.
Annual competency and performance reviews for two CNAs were not completed within the required 12-month period, as confirmed by the DSD and DON through interviews and employee file audits. Facility policy requires these evaluations to ensure staff competency in patient care and job responsibilities, but documentation was missing for both CNAs.
A resident with end stage renal disease and anemia received Epogen injections without weekly monitoring of hemoglobin levels as required by physician orders and manufacturer guidelines. Nursing staff and the DON confirmed that hemoglobin should have been checked prior to each dose, but the medication was administered without this verification, resulting in a deficiency related to unnecessary drug administration.
A medication error rate of 5 percent or greater was found during the survey, showing that the facility did not maintain medication administration errors below the required limit.
A resident with diabetes received subcutaneous insulin injections without proper rotation of injection sites, contrary to physician orders, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that injection sites should have been rotated, and the failure to do so was considered a medication error.
Therapeutic diets were not prescribed by the attending physician or properly delegated to a registered or licensed dietitian as allowed by State law, resulting in dietary orders lacking appropriate authorization.
Staff failed to keep a resident's indwelling urinary catheter drainage bag off the floor, despite facility policy and staff knowledge that this practice increases infection risk. Additionally, food items were found stored in the clean linen closet with residents' clothing and linens, contrary to facility procedures requiring sanitary storage. Both deficiencies were confirmed by staff and supported by facility policy reviews.
Rooms designated for multiple residents were found to be less than 80 square feet per resident, and single resident rooms were less than 100 square feet, as required by regulations.
The facility did not ensure that daily nurse staffing information was accurately posted, as required by policy. Staff confirmed that the posted information was outdated and should have reflected the current day's staffing. This resulted in inaccurate staffing data being available to residents, visitors, and staff.
Two residents did not receive or have documented physician-ordered wound care treatments, and one resident with diabetes did not have required provider notification for multiple elevated blood sugar readings. Nursing staff confirmed the lack of documentation and communication, which was not in accordance with facility policy and physician orders.
A resident with COPD, anxiety disorder, schizophrenia, and impaired cognitive functioning was admitted and readmitted, but the facility did not complete a baseline care plan within 48 hours as required. An LVN confirmed that neither the baseline nor the comprehensive care plan was updated after readmission, contrary to facility policy.
Two residents with cognitive impairments were involved in a physical altercation in the smoking patio, where one resident was choked and fell, resulting in pain and emotional distress. The incident occurred without staff supervision, and witnesses reported that no staff were present or immediately available, which was contrary to facility policy requiring supervision to prevent abuse.
A resident with hypertension and COPD, assessed as capable of self-administering inhaler medications, did not have a care plan developed or implemented to address this physician-ordered intervention. Despite facility policy requiring care plans for self-administration, the omission was confirmed during record review and interview with the DON.
A resident with multiple chronic conditions and a recent bladder infection did not receive cephalexin 500 mg as ordered, with several doses administered late or outside the facility's required time window. Staff interviews and record reviews confirmed the medication was not given within the prescribed timeframe on multiple occasions, contrary to physician orders and facility policy.
A resident with moderate cognitive impairment and multiple diagnoses, including urinary retention, repeatedly refused indwelling urinary catheter care and disposable brief changes. Despite these refusals, staff did not create or implement a care plan to address the resident's needs or guide staff actions, as confirmed by interviews and record review. Facility policy required individualized care plans and physician notification for repeated refusals, but these steps were not taken.
A resident with an indwelling urinary catheter did not have a physician's order for the device upon readmission, and required catheter care and monitoring were not performed or documented. The care plan's interventions for catheter care and infection monitoring were not followed, and nursing staff confirmed the lack of assessment and documentation, despite the resident's medical history and risk factors.
A resident with multiple chronic conditions did not receive proper respiratory care when staff failed to date oxygen tubing, store unused oxygen equipment in a dated plastic bag, and prevent oxygen tubing from touching unclean surfaces. The DON and QAN confirmed these lapses, which were not in accordance with facility policy.
Failure to Notify Physician of Resident’s Ongoing Shortness of Breath
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s primary physician of a significant change in respiratory status over several days. The resident was admitted with COPD, emphysema, and hypertensive heart disease and had moderate cognitive impairment, requiring partial to moderate assistance with activities of daily living. The resident’s care plan for impaired gas exchange and ineffective airway clearance related to COPD included interventions to assess respiratory function, monitor for respiratory changes, and notify the physician as indicated. Progress notes documented that, beginning on 2/7/2026, the resident experienced shortness of breath, initially while lying flat, and then on subsequent days continued to report and exhibit shortness of breath. These respiratory symptoms were documented on 2/7, 2/8, 2/9, 2/10, and 2/11, but there was no documentation or evidence that the resident’s physician was notified of this ongoing change in condition. Facility nursing staff, including an LVN and an RN, later acknowledged that the resident’s shortness of breath had been present since 2/7/2026 and that the physician should have been notified during that period. On 2/12/2026 at 3:26 a.m., an SBAR was completed identifying a COPD exacerbation with severe shortness of breath, and an order was entered at 4:34 a.m. to transfer the resident to an acute care hospital. Emergency medical services documented that the resident reported having shortness of breath for the past five days without help and was found to have an oxygen saturation of 82% on room air when picked up from the facility. The hospital emergency department record indicated the resident presented with progressively worsening shortness of breath over six days. The facility’s own policy on change in a resident’s condition required nursing staff to notify the attending physician when there was a significant change in the resident’s physical condition or a need to transfer the resident to a hospital, which did not occur during the days when the resident’s shortness of breath was repeatedly documented.
Failure to Administer and Document Ordered Topical Treatments and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and professional standards of practice for two residents. For one resident with depression, cirrhosis, heart failure, and COPD, the admission record showed the resident was readmitted in January 2026 and had moderately impaired cognition, with dependence on staff for personal hygiene, toileting hygiene, and lower body dressing. Physician orders included daily-shift topical Nystatin powder to abdominal folds for MASD starting 1/28/2026, and Mupirocin 2% ointment to both legs for cellulitis starting 1/29/2026. Review of this resident’s February 2026 Treatment Administration Record (TAR) with an RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials in the TAR boxes for the ordered Mupirocin ointment treatments to the left and right legs, and no licensed staff initials for the ordered Nystatin powder to the abdominal folds. The RN stated there was no documented evidence that these treatments were administered as ordered on those dates and times and acknowledged that failure to administer the treatments as ordered had the potential to negatively affect the resident’s care and potentially cause wound deterioration, infection, or delay of wound healing. For a second resident admitted with paraplegia, a stage 4 sacral pressure ulcer, and sacral osteomyelitis, the H&P indicated intact decision-making capacity, and the care plan for pressure ulcers directed staff to provide wound care per treatment orders. Physician orders dated 1/23/2026 specified a multi-step daily-shift sacral/coccyx stage 4 pressure ulcer treatment, including cleansing with Dakin’s solution, application of a collagen dressing cut to wound shape, application of a hydrocolloid dressing, and coverage with abdominal pads and Mepilex foam. Review of this resident’s February 2026 TAR with the RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials documenting completion of the ordered sacral pressure ulcer treatment. The RN stated there was no documented evidence the treatment was done and that failure to administer the treatment as ordered had the potential to cause complications such as infection and deterioration of the pressure ulcer. The facility’s medication administration policy, revised 1/2026, stated that medications are to be administered safely, timely, and as prescribed, and that topical medications used in treatments are to be recorded on the TAR.
Failure to Update Care Plan After Resident Desaturation and Vomiting Episode
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident after a significant change in condition involving desaturation and vomiting. The resident was admitted with diagnoses of heart failure, epilepsy, and COPD, and had moderately impaired cognitive functioning, requiring staff assistance for toileting hygiene, toilet transfers, showers, and lower body dressing. On review of the resident’s MDS and admission records, these needs and conditions were documented. The facility’s policy required that the comprehensive, person-centered care plan, which includes measurable objectives and timetables to meet physical, psychological, and functional needs, be reviewed and updated when there is a significant change in condition or when a resident is readmitted from a hospital stay. On a specific date, an SBAR Communication Form documented that the resident experienced an episode of vomiting and an oxygen saturation of 76% on room air, and was transferred to a general acute care hospital for further evaluation. During an interview and concurrent record review, an RN confirmed that the resident’s care plan had not been updated to address the episode of vomiting and desaturation. The RN stated that the care plan is an essential guide for staff to provide monitoring to ensure the resident’s condition does not deteriorate and acknowledged that the failure to update the care plan had the potential to delay care and monitoring for the resident.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in the resident's preferred language of Spanish when the resident left the facility Against Medical Advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was sometimes able to understand and be understood by others, with Spanish documented as the preferred language. On the day of the incident, the resident expressed a desire to leave after being placed on a one-on-one sitter following an alleged physical abuse incident with another resident. The resident signed an AMA form, which was witnessed by two RNs, neither of whom could speak or translate Spanish. The review of facility records and interviews confirmed that the AMA form and related discharge instructions were not provided in Spanish, and the resident did not receive information about the risks and benefits of leaving AMA in a language he understood. Facility policies require that residents be informed of their rights and responsibilities and be supported in exercising those rights, including being informed in a manner they can understand. The failure to provide instructions in the resident's primary language resulted in the resident not being fully informed to make an appropriate decision regarding leaving the facility AMA.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another in the hallway. On the morning of the incident, one resident, who had a documented history of verbal and physical aggression, stood up from his wheelchair, grabbed another resident, pinned them against a door, struck their head against the door, and punched them in the face. This resulted in the victim sustaining redness and pain to the left eye, with a pain rating of three out of ten. The incident was witnessed by both a CNA and an LVN, who confirmed the aggressive actions and the use of racial slurs during the altercation. The resident who committed the abuse had a care plan in place for aggression, which included monitoring behavior every shift. However, records revealed multiple prior incidents of aggressive behavior, including several change in condition (COC) events related to aggression in the months leading up to the incident. Despite these documented behaviors, there was no evidence of a psychiatric evaluation or consistent 72-hour monitoring following previous aggressive episodes. Additionally, progress notes did not indicate social services visits after aggressive incidents, suggesting a lack of follow-up and intervention. The victim of the abuse had severe cognitive impairment and a history of encephalopathy, major depressive disorder, and generalized anxiety disorder. The facility's own policies required protection of residents from abuse by anyone, including other residents. Interviews with staff and review of facility policies confirmed that the actions constituted both physical and verbal abuse, and that the facility failed to ensure the safety and well-being of the residents involved.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in their preferred language, Spanish, when the resident chose to leave the facility against medical advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was admitted with ongoing needs for long-term care. The Minimum Data Set indicated that the resident's preferred language was Spanish and that communication abilities were sometimes limited. On the day of discharge, the resident expressed a desire to leave after being placed on one-on-one supervision following an alleged incident of physical abuse with another resident. The resident informed staff of plans to go to a hotel, though no specific destination was provided. The resident had an active physician order allowing passes out of the facility for up to four hours. When the resident signed the AMA form, both registered nurses present were unable to communicate in Spanish or provide a translated version of the discharge instructions. Facility policies required that residents be informed of their rights and responsibilities and that discharge planning should address individual needs and preferences, including language. Despite these policies, the facility did not ensure the resident received information about the risks and benefits of leaving AMA in a language the resident could fully understand, resulting in the resident leaving without adequate comprehension of the implications.
Failure to Re-Evaluate PRN Psychotropic Medication and Monitor Behavioral Symptoms
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medication and chemical restraints for one resident by not providing ongoing re-evaluation of the need for PRN Haloperidol. The order for Haloperidol, prescribed for schizoaffective disorder, did not include an end date as required, and the medication was not limited to a 14-day period before re-evaluation by a physician. Additionally, there was no documented monitoring of the resident's behavioral manifestations related to schizoaffective disorder to determine the continued need for the medication. The resident involved had diagnoses including COPD, schizoaffective disorder, and unspecified dementia, with severely impaired cognitive functioning and required maximal assistance with daily activities. The facility's own policy required that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period, with PRN orders not to be renewed beyond 14 days without physician evaluation and documentation. These requirements were not followed, as confirmed by staff interviews and record reviews.
Failure to Update Care Plan for Resident with New Indwelling Catheter
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was readmitted with a new indwelling catheter. Upon review, it was found that the care plan did not reflect the presence of the catheter or include goals and interventions necessary for its care. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, and required maximal assistance with activities of daily living. The Minimum Data Set indicated severely impaired cognitive functioning, and the resident was unable to make medical decisions independently. During an interview and record review, a registered nurse confirmed that the care plan was not updated upon the resident's readmission, despite the facility's policy requiring care plan revisions after significant changes in condition or readmission from a hospital stay. The lack of an updated care plan meant that staff did not have documented guidance to monitor or address the resident's catheter care, which was necessary to meet the resident's physical and functional needs as outlined in the facility's policy.
Failure to Assess Blood Glucose During Change in Condition
Penalty
Summary
Facility staff failed to assess a resident's blood glucose level during a significant change in condition, despite the presence of abnormal vital signs including low blood pressure, elevated heart rate, increased respiratory rate, low oxygen saturation, and a mild fever. The last recorded blood glucose measurement for the resident was from a week prior to the incident. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, with severely impaired cognitive functioning and a need for maximal assistance with daily activities. During the change in condition, the facility's policy required staff to gather all relevant and pertinent information, including blood glucose levels, before notifying a healthcare provider. However, the staff did not obtain a current blood glucose reading at the time of the event. This omission was acknowledged by the registered nurse, who stated that assessing blood glucose is necessary during such events to rule out related complications. The failure to follow professional standards and facility policy resulted in the resident not receiving appropriate assessment and care during a critical change in condition.
Failure to Provide and Document Indwelling Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received proper care and monitoring. Upon admission, the resident had a new indwelling catheter, but staff did not place an order for catheter care or monitoring. Record review confirmed there was no documentation of catheter care or monitoring, and staff interviews revealed that the omission was recognized by both an LVN and an RN. The staff acknowledged that they did not monitor the resident for signs and symptoms of catheter complications, nor did they track intake and output as required. The resident in question had multiple diagnoses, including COPD, acute respiratory failure, and severe cognitive impairment, and required maximal assistance with activities of daily living. Facility policy required observation for catheter complications and documentation of catheter care, including assessment data and urine characteristics. However, these procedures were not followed, and there was no record of catheter care being provided or monitored for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and dementia. The resident required continuous oxygen therapy via nasal cannula at a prescribed flow rate, as well as regular monitoring of peripheral oxygen saturation (spO2) every shift, per physician orders. The care plan also specified returning the resident to their usual oxygen delivery method after meals and administering medications as ordered. During an observation, the resident was found lying in bed with the nasal cannula disconnected and wrapped around the oxygen concentrator, which was turned off. A Licensed Vocational Nurse (LVN) confirmed that the resident was not connected to oxygen and stated that staff should have ensured the oxygen was properly administered after providing care. A Registered Nurse (RN) also acknowledged that staff failed to administer oxygen as ordered, which could result in low oxygen levels and respiratory decline for the resident. Record review revealed that the Medication Administration Record (MAR) lacked staff initials for several shifts, indicating that both oxygen administration and spO2 monitoring were not documented as completed on multiple occasions. Facility policies required staff to check oxygen equipment for proper function and to administer medications, including oxygen, as prescribed and in a timely manner. These actions and omissions led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Develop and Implement Discharge Planning in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge planning for two residents. For one resident admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and atrial fibrillation, the Minimum Data Set (MDS) indicated substantial assistance was needed for activities of daily living. Despite the Social Services Director stating that discharge planning begins at admission and involves identifying the resident's discharge preferences and necessary resources, a review of the resident's care plan revealed no focus, goal, or intervention related to discharge planning. The Director of Nursing confirmed the absence of discharge planning in the care plan and acknowledged its importance for ensuring a safe and organized discharge process. Similarly, another resident admitted with seizures, hypertension, and depression, and assessed as requiring varying levels of assistance with daily activities, also lacked a care plan addressing discharge planning. The resident's MDS and medical history indicated the capacity to make decisions, yet the care plan did not include any discharge planning components. The Director of Nursing again confirmed that social services are responsible for this aspect of care planning and that its omission could lead to disorganized and stressful discharges. A review of the facility's policies and procedures confirmed that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, and that social services staff are responsible for transitions of care, including discharge planning. The job description for the Social Services Director also specified responsibilities for discharge-planning services, such as referrals, follow-up arrangements, and post-discharge care plans. Despite these documented requirements, the facility did not ensure that discharge planning was included in the care plans for the two residents reviewed.
Failure to Document Social Services Discharge Planning Communications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the communications and actions taken by social services regarding the resident's discharge planning. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and major depressive disorder, expressed a desire to be transferred to a location closer to family. The resident reported that discussions about discharge planning with facility staff had occurred weeks prior, and was open to various locations near her desired area. During interviews and record reviews, the Social Services Director confirmed ongoing communication with contacts at potential receiving facilities and discussions with the resident about discharge options. However, there was no documentation in the resident's medical record reflecting these communications or actions. The Director of Nursing also confirmed the absence of any progress notes or records of discharge planning discussions in the electronic medical record. This lack of documentation was not in accordance with the facility's own policies and procedures, which require all services and progress toward care plan goals to be documented.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to ensure that the call light for one resident was accessible and within reach, as required by the resident's care plan and facility policy. The resident had significant medical conditions, including lumbar spondylosis, neuropathy, and respiratory failure, and was dependent on staff for activities such as eating, toileting, personal hygiene, and dressing. The care plan specifically identified the resident as being at risk for falls and required that the call light be kept within reach to allow the resident to request assistance as needed. During an observation, the call light was found on the floor behind the resident's bed, out of reach. Staff interviews confirmed that the call light should be accessible to the resident at all times, and the facility's policy required the call light to be within reach when the resident is in bed. The deficiency was identified through direct observation, staff interviews, and review of the resident's records and facility policies.
Failure to Ensure Proper Placement of Oxygen Nasal Cannula
Penalty
Summary
A deficiency occurred when a resident with diagnoses of congestive heart failure, pleural effusion, and respiratory failure, who was dependent on staff for all activities of daily living, was observed with her oxygen nasal cannula improperly placed inside her mouth while she was sleeping. The resident's care plan required continuous oxygen via nasal cannula, and the physician's order specified oxygen at 2 liters per minute for shortness of breath, with the option to increase up to 5 liters if necessary. During the observation, a CNA acknowledged the importance of proper nasal cannula placement and stated that if it was found out of place, the charge nurse should be notified to address the issue. Further interviews with nursing staff and the DON confirmed that professional standards of practice require checking the placement of the nasal cannula during routine room checks and that the facility's policy specifies the nasal cannula should be placed approximately one-half inch into the resident's nose. The staff confirmed that the doctor's order for oxygen must be followed as written. The failure to ensure the nasal cannula was properly placed in the resident's nose resulted in the resident not receiving oxygen as prescribed.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and homelike environment for one resident by not ensuring the cleanliness of the resident's room and restroom. Observations revealed black residue on the floor and window frame, white residue at the bottom of the window, a dark red coating on the soap dispenser, and a broken metal door upon entering the restroom. The soap dispenser was found to be rusty, and the metal door frame at the bottom of the bathroom door was separating from the door. Additionally, the window and the edge of the sliding door were noted to be dirty and dusty. These findings were confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the room was not clean or homelike. The resident involved had diagnoses of depressive disorder, hypertension, and anxiety disorder, and was assessed as having intact cognitive functioning with a need for moderate assistance in personal hygiene and dressing. Facility policy required a clean, sanitary, and orderly environment, with regular cleaning of housekeeping surfaces and prompt cleaning of visibly soiled areas. The failure to adhere to these standards resulted in the resident not being provided with a clean and homelike environment, as required by facility policy.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that three residents were provided with written information regarding their right to formulate an Advance Directive (AD) upon admission, as required by facility policy and federal regulations. For each of the three residents reviewed, there was no documented evidence that the AD was discussed or that the AD Acknowledgment form was completed. Interviews with the Social Services Director (SSD) and nursing staff confirmed that the process for providing and documenting this information was not followed for these residents. One resident with diagnoses including end stage renal disease, diabetes, dementia, and sepsis was admitted and re-admitted to the facility. The resident was assessed as able to understand and make decisions, but the Social Service History and Initial Assessment Form was incomplete, and there was no documentation that the AD was discussed or that written information was provided. The SSD and nursing staff confirmed that the required AD Acknowledgment form was not completed, and the facility process was not followed. A second resident with hemiplegia, hemiparesis following a stroke, and anxiety disorder, and a third resident with anxiety disorder, bipolar disorder, neuropathy, and psychosis, were both found to have the capacity to understand and make decisions. However, neither had documentation in their records that the AD was discussed or that written information was provided. The SSD and RN confirmed that the AD Acknowledgment forms were not completed for these residents, and that the facility's process for informing residents about their rights regarding ADs was not followed.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by multiple deficiencies in the administration, monitoring, and documentation of such medications for three residents. For one resident with a history of hemiplegia, hemiparesis, depression, and anxiety, the facility did not obtain informed consent prior to administering certain psychotropic medications, specifically diazepam and duloxetine. The resident reported not being informed about the medications being administered, and staff interviews confirmed that the required consent process was not followed, contrary to facility policy and procedure. Additionally, the facility did not provide ongoing re-evaluation of the need for psychotropic medications for this resident, as there was no documented monitoring for measurable behaviors or adverse effects related to bupropion, diazepam, or duloxetine. Orders for PRN diazepam lacked specific, measurable behavioral manifestations and did not include an end date, both of which are required by facility policy to ensure appropriate use and regular reassessment of high-risk medications. Staff interviews confirmed that these omissions could result in the administration of unnecessary medications and potential harm to the resident. For another resident with dementia and anxiety disorder, the facility failed to monitor for measurable behaviors and adverse effects of Risperdal for a specified period and did not complete required behavior summary side effect documentation for several months for both Risperdal and Klonopin. The lack of behavior monitoring and documentation was acknowledged by staff, who stated that such monitoring is necessary to evaluate medication effectiveness and to support gradual dose reduction. These failures were in direct violation of the facility's policies regarding psychotropic medication use, monitoring, and resident rights.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Administer and Document Medications as Ordered and Monitor Lab Values Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer prescribed medications to a resident as ordered by the physician. Specifically, the LVN did not administer amiodarone and famotidine during a scheduled medication pass, despite both medications being ordered for the resident. The LVN incorrectly stated that amiodarone had already been given by the night shift and discarded the medication, while famotidine was not administered because it was not found in the medication cart. The LVN then documented in the medication administration record (MAR) that both medications had been given, even though they were not. The LVN admitted to being confused and acknowledged that the MAR was not accurate, and also failed to seek assistance from a supervisor when unsure about the medication administration process. The resident involved had multiple complex medical conditions, including metabolic encephalopathy, dysphagia, hypertensive heart disease with heart failure, anxiety disorder, depression, a cardiac pacemaker, and a gastrostomy tube. The resident was dependent on staff for all activities of daily living and required medications to be administered via the G-tube. The failure to administer and accurately document the prescribed medications was observed during a medication pass and confirmed through interviews and record reviews. Facility policy required medications to be administered as ordered and documented accurately, with any omissions or errors to be properly recorded and reported. A second deficiency was identified involving another resident who was prescribed Epogen for anemia. The facility failed to monitor the resident's hemoglobin levels prior to administering Epogen, as required by the physician's order and manufacturer guidelines. The MAR indicated that Epogen was administered on multiple occasions without any evidence that hemoglobin levels were checked beforehand. Both the registered nurse and the director of nursing confirmed that hemoglobin monitoring should have occurred weekly prior to each administration, but this was not done. The failure to monitor hemoglobin levels before administering Epogen was confirmed through interviews and record reviews.
Failure to Follow Standardized Portion Sizes for Egg Noodles
Penalty
Summary
The facility failed to follow its established menu and portion control procedures when a staff member did not level the number 8 scoop while serving egg noodles, resulting in portions larger than the standardized 1/2 cup specified in the recipe and menu. This was directly observed during trayline service, where the scoop was overflowing, and confirmed by the Dietary Supervisor, who acknowledged that the scoop should have been leveled. The facility's policies and procedures require adherence to standardized recipes and portion sizes to meet residents' nutritional needs and therapeutic diet requirements. This failure affected 64 out of 69 residents who received egg noodles, including 16 out of 20 residents on a consistent carbohydrate (CCHO) diet, which requires precise carbohydrate control for blood sugar management. The incident was documented through observation, staff interview, and review of facility records, including menus, recipes, and policies, all of which specified the correct portion size and the need for accuracy in food preparation and service.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of facility practices, which showed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Freezer Equipment Results in Ice Buildup and Food Storage Risk
Penalty
Summary
The facility failed to maintain the reach-in freezer according to the manufacturer's guidelines, resulting in a gap that allowed air to enter and caused significant ice buildup. Observations revealed ice accumulation by the door and shelves of the freezer, and interviews with the Dietary Supervisor confirmed ongoing issues with ice buildup due to air infiltration. The Dietary Supervisor acknowledged that a metal plate had been installed to prevent air from escaping, but a small gap remained, which was not acceptable as it could lead to food spoilage. The Maintenance Supervisor also confirmed the problem, stating that the freezer door was not sealing properly and that the gaskets were supposed to be changed, but instead, a metal plate was installed based on the administrator's decision. The Administrator stated that the issue with the freezer door not latching properly was discussed with the Maintenance Supervisor, and the decision was made to install a metal plate rather than consult the manufacturer for a solution. The Administrator was not aware that the ice buildup issue persisted. Review of facility policy indicated that equipment needing repair should be reported and maintenance records maintained, and the daily maintenance log showed ongoing awareness of the freezer's ice buildup problem. The deficiency had the potential to affect 64 of 69 medically compromised residents who stored food in the freezer.
Failure to Maintain Sanitary Food Service Conditions Due to Presence of Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of flies in the kitchen during food preparation and trayline activities. During multiple observations, flies were seen flying around and landing on food preparation surfaces and equipment, including a pan and a blender. The Dietary Supervisor acknowledged that flies entered the kitchen when staff opened doors to bring in supplies such as ice and stated the importance of keeping the kitchen free from flies to prevent cross-contamination of food. A review of the facility's pest control policy indicated that an ongoing pest control program should be in place to keep the building free of insects and rodents. Additionally, the Food Code 2022 requires premises to be maintained free of pests through routine inspections and control measures. Despite these policies, the presence of flies in the kitchen during food service had the potential to affect 64 of 69 residents who received food from the kitchen.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents with significant cognitive and physical impairments. For one resident with diagnoses including COPD, diabetes, and dementia, and who required maximal assistance with activities of daily living, the call light was observed behind the bed and out of reach. A CNA confirmed that the resident would not be able to access the call light in that position, and both the RN and DON stated that call lights should be within reach to allow residents to call for assistance. Similarly, another resident with diagnoses including CHF, COPD, epilepsy, and depression, and who required moderate assistance with daily activities, was also found to have the call light placed behind the bed and out of reach. The CNA present confirmed the resident could not reach the call light, and reiterated the importance of accessibility. Facility policy reviewed by surveyors stated that call lights should be within easy reach of residents when in bed or in a chair.
Failure to Develop and Implement Comprehensive Care Plans for Falls and Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to falls and incontinence management. For one resident with a history of hemiplegia, hemiparesis, cerebrovascular accident, and a high risk for falls, the care plan did not include a post-fall intervention after the resident experienced an actual fall. Despite the facility's policy requiring immediate reassessment and care plan updates following a fall, no post-fall care plan was created. Staff interviews confirmed that the process was not followed, and the lack of a post-fall care plan meant that new interventions to prevent further falls were not implemented. Another resident, admitted with diagnoses including anxiety disorder, bipolar disorder, neuropathy, and psychosis, did not have a care plan addressing bowel and bladder incontinence management or retraining. The resident's assessment indicated a need for assistance with activities of daily living, but the care plan failed to include interventions for incontinence. The MDS Coordinator and DON both acknowledged that a comprehensive care plan should have been developed to address these needs, as required by facility policy. Facility policies reviewed during the investigation specified that care plans must be individualized, comprehensive, and include measurable objectives and timetables to address each resident's medical, nursing, mental, and psychological needs. The policies also required care plans to be updated promptly in response to changes in a resident's condition, such as after a fall or when incontinence is identified. The failure to follow these policies resulted in incomplete care planning for both residents.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and record reviews indicating that the care and services delivered did not consistently adhere to accepted professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report. The report notes a general failure to meet professional standards but does not include further factual observations or events related to the deficiency.
Failure to Ensure CNA Maintained Required ARC/AHA-Accredited CPR Certification
Penalty
Summary
The facility failed to implement its policy and procedure regarding cardiopulmonary resuscitation (CPR) by not ensuring that one of three Certified Nursing Assistants (CNA) had a valid CPR certification credentialed by the American Red Cross (ARC) or the American Heart Association (AHA). During a review of the CNA's CPR certificate, it was found that the training was not accredited by either the ARC or AHA, as required by the facility's policy. The Director of Nursing (DON) confirmed that CNAs are part of the facility's CPR team and that the policy mandates all staff to be trained by the ARC or AHA. Further interviews and record reviews with the Director of Staff Development (DSD) revealed that the CNA's CPR training did not meet the facility's accreditation requirements and that this oversight occurred during the hiring process. The facility's policy specifies that key clinical staff, including non-licensed personnel such as CNAs, must obtain and maintain ARC or AHA certification in BLS/CPR. The deficiency was identified through interviews and documentation review, confirming that the CNA was not properly credentialed according to facility policy.
Failure to Obtain Physician Order for Hemoglobin Monitoring Prior to Epogen Administration
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease, chronic obstructive pulmonary disease, and anemia received treatment and care in accordance with professional standards of practice. Specifically, the facility administered Epogen injections for anemia without obtaining a physician's order for hemoglobin monitoring, as required by both the medication's manufacturer's guidelines and the facility's own policy. The resident's records showed that Epogen was given on multiple occasions, but there was no corresponding order or documentation for regular hemoglobin level checks prior to administration. Interviews with nursing staff and the Director of Nursing confirmed that there was no physician order for hemoglobin monitoring and that Epogen should not have been administered without this monitoring. The facility's policy required medication orders to include follow-up requirements such as repeat labs or therapeutic medication monitoring, which was not followed in this case. The manufacturer's guidelines for Epogen also specified weekly hemoglobin monitoring until stable, then at least monthly, to ensure safe administration.
Failure to Initiate Bowel and Bladder Retraining Program for Eligible Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a bowel and bladder retraining program for a resident who was identified as a candidate for such intervention. The resident, who was admitted with diagnoses including anxiety disorder, bipolar disorder, neuropathy, and psychosis, was found to have intact cognitive functioning and the capacity to make decisions. Despite being always incontinent of bowel and bladder and dependent on staff for lower body dressing and transfers, the resident's assessment and screening indicated eligibility for a retraining program. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the retraining program was not initiated as required by facility policy and clinical guidelines. The facility's policy specified that staff should screen for and manage urinary incontinence, provide appropriate services to restore or improve bladder function, and document toileting trials. The failure to initiate the retraining program was acknowledged by staff and was not in accordance with the facility's established procedures.
Failure to Ensure Oxygen Delivery Device Was Connected for Resident Requiring Continuous Oxygen
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with a history of respiratory failure with hypoxia, congestive heart failure, and dementia. The resident was dependent on staff for all activities of daily living and had a physician's order for continuous oxygen therapy via nasal cannula, with instructions to titrate as needed. During observation, the resident was found in bed with the nasal cannula placed near the nostrils, but the tubing was disconnected from the oxygen concentrator and hanging from the bed. Licensed staff confirmed that the oxygen tubing should always be connected to the oxygen source and that it is the responsibility of both licensed staff and certified nurse assistants to ensure the connection is intact. Interviews with the LVN and DON confirmed that staff are expected to routinely monitor oxygen tubing to ensure it is connected and functioning properly. Review of the facility's policy on oxygen administration indicated that staff should check tubing connections and ensure proper oxygen delivery. The failure to connect the nasal cannula to the oxygen concentrator was directly observed and acknowledged by staff, and the facility's own policy supports the need for such monitoring and connection.
Missed Annual Competency and Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews and competency skills checks for two Certified Nursing Assistants (CNAs) within the required 12-month period. Specifically, one CNA had not received a competency skills check for the year following her last evaluation, and another CNA also missed her annual competency review. The Director of Staff Development (DSD) confirmed during interviews and record reviews that these evaluations were overdue and not present in the employee files. The DSD stated that competency checks are intended to ensure that CNAs and licensed nurses possess the necessary skills to perform patient care, medication administration, and other job duties, and that these should be completed annually based on hire date and filed immediately. The Director of Nursing (DON) also confirmed that annual performance reviews and competency checks are standard practice for all CNAs and licensed nurses, and that these evaluations are necessary to ensure staff are capable of providing appropriate care and treatment. Review of the facility's policy and procedure indicated that job descriptions and performance evaluations are used to clarify responsibilities, prevent misunderstandings, and provide a basis for job evaluation. The absence of timely performance reviews and competency checks was verified through employee file audits and staff interviews.
Failure to Monitor Hemoglobin Prior to Epogen Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not monitoring hemoglobin levels prior to administering Epogen, a medication used to treat anemia. The resident in question had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, and anemia, and required varying levels of assistance with daily activities. According to the physician’s order, Epogen was to be administered weekly for anemia, with instructions to hold the medication if the hemoglobin level was greater than 11. However, review of the Medication Administration Record showed that Epogen was administered on at least two occasions without evidence that hemoglobin levels were checked beforehand. Interviews with nursing staff and the Director of Nursing confirmed that hemoglobin levels should have been monitored weekly prior to each administration of Epogen, in accordance with both the physician’s order and the manufacturer’s guidelines. The facility’s policy on medication administration also required medications to be given as prescribed and in a safe manner. The failure to monitor hemoglobin levels before administering Epogen constituted a deficiency, as it did not ensure the medication was indicated for the resident at the time of administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that medication administration errors remained below the acceptable threshold, as required by regulations. The deficiency was based on direct findings from the survey process.
Failure to Rotate Insulin Injection Sites Resulting in Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and facility policy. Review of the resident's Medication Administration Record (MAR) showed repeated administration of insulin in the same anatomical areas, specifically the left upper and lower quadrants of the abdomen and the right arm, over multiple days. Interviews with nursing staff, including an LVN and an RN, confirmed that insulin administration sites should have been rotated with each dose, and acknowledged that this was not done for the resident in question. The resident involved had a history of diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure, and was cognitively intact and able to make decisions. Facility policies and the manufacturer's guidelines for insulin glargine (Lantus) both required rotation of injection sites to prevent adverse effects. The Director of Nursing also confirmed that failure to rotate sites constituted a medication error. The deficiency was identified through review of records, staff interviews, and examination of facility policies and procedures.
Therapeutic Diet Orders Not Properly Authorized
Penalty
Summary
Therapeutic diets were not consistently prescribed by the attending physician, nor was there documentation that the responsibility for prescribing these diets was properly delegated to a registered or licensed dietitian as permitted by State law. This resulted in a failure to ensure that dietary orders for residents requiring therapeutic diets were authorized in accordance with regulatory requirements.
Failure to Maintain Infection Control: Catheter Bag on Floor and Food in Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. First, staff did not ensure that an indwelling urinary catheter drainage bag for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, dementia, and sepsis, was kept off the floor. Observations on two separate occasions found the drainage bag resting on the floor when the resident's bed was in its lowest position. Both a Licensed Vocational Nurse and a Registered Nurse acknowledged that this practice was not in accordance with facility policy and posed an infection control risk, as bacteria from the floor could contaminate the bag and potentially lead to infection. The facility's own procedures and policies explicitly required that catheter drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Additionally, the facility failed to maintain sanitary storage practices in the clean linen closet. During an inspection, food items including a bagel, banana, and a bottle of Gatorade were found stored alongside clean linens, beddings, towels, gowns, and residents' personal clothes. The Maintenance Supervisor confirmed that these food items belonged to an assistant and admitted to having previously instructed the assistant not to store food in the linen closet. The Director of Nursing also confirmed that food should not be stored in this area, as it could attract insects and compromise the cleanliness of residents' clothing and linens. Review of facility policies indicated that all housekeeping and laundry storage areas were to be kept clean and free from trash, rubbish, and other contaminants at all times. The presence of food in the clean linen storage and the improper handling of the catheter drainage bag both represented failures to follow established infection control procedures, as documented in the facility's own policies and procedures.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to provide rooms that meet the required minimum square footage per resident. Specifically, rooms intended for multiple residents did not meet the standard of at least 80 square feet per resident, and single resident rooms did not meet the required 100 square feet. This deficiency was identified based on the physical measurements of resident rooms during the survey.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nursing staffing information was accurate and up to date. During observations and interviews with facility staff, it was found that the posted nursing staffing information in the front lobby was dated several days prior and did not reflect the current date. Both the Minimum Data Set Coordinator and the Director of Staff Development confirmed that the information should have been updated to reflect the current day's staffing and that it is their responsibility to ensure the information is posted daily and accurately. A review of the facility's policy and procedure indicated that nursing staffing numbers are to be posted daily for each shift, with the shift supervisor responsible for computing and posting the numbers within two hours of the start of each shift. The failure to update the posted information resulted in inaccurate staffing data being available to residents, visitors, and staff, contrary to facility policy and regulatory requirements.
Failure to Administer and Document Physician-Ordered Treatments and Notify Provider of Critical Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with chronic conditions including COPD, diabetes, and dementia, the facility did not document administration of a prescribed Betadine treatment for a toe wound on a specific date, as required by the care plan and treatment administration record (TAR). The responsible LVN confirmed the absence of documentation and stated that the treatment was not recorded as given, which was contrary to facility policy requiring all topical treatments to be documented on the TAR. Additionally, the same resident had physician orders for regular blood sugar (BS) monitoring and specific instructions for notifying the provider if certain BS thresholds were met. Despite multiple elevated BS readings over several days, there was no record of provider notification as required by the order. Both the LVN and an RN confirmed that the provider should have been notified of these results, and the facility's diabetes protocol required staff to report such findings. For a second resident with diagnoses including anxiety disorder, alcoholic cirrhosis, and splenomegaly, the facility failed to document administration of a prescribed topical antibiotic (Mupirocin) for a toe infection on a specific date. The LVN confirmed the lack of documentation on the TAR, indicating the treatment was not recorded as administered. Facility policy required all medications, including topical treatments, to be administered as prescribed and documented accordingly.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of two sampled residents within 48 hours of admission. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, schizophrenia, and impaired cognitive functioning was admitted and later readmitted, but the baseline care plan was not completed within the required timeframe. Additionally, the comprehensive care plan was not updated after the resident's readmission. This was confirmed through record review and staff interview, where a Licensed Vocational Nurse acknowledged the omission and stated that the baseline care plan had not been completed as of several days after readmission. The facility's own policy requires a baseline care plan to be developed within 48 hours to address immediate health and safety needs.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse when a verbal altercation in the smoking patio escalated into a physical confrontation. One resident, who had moderately impaired thought processes and required moderate assistance with activities of daily living, was grabbed by the neck and choked by another resident. This resulted in the victim falling to the ground, experiencing pain in the right knee, and feeling shocked and scared. The incident was witnessed by another resident, who reported that staff were not present in the smoking patio at the time of the altercation and that no staff could be found at the nurses' station immediately after the event. The resident who was attacked had a history of osteoarthritis and hypertension and was assessed as having the capacity to understand and make decisions. After the incident, the resident reported pain and emotional distress, and a post-fall evaluation confirmed mild pain in the right knee. The aggressor, who also had moderately impaired thought processes and required supervision for transfers and ambulation, was reported to have left the area immediately after the incident. Staff interviews confirmed that the event was not witnessed by staff, and the initial response was triggered by a certified nursing assistant who heard a noise and found the victim on the floor. Both the Administrator and the DON acknowledged that staff should have been present in the smoking patio to ensure resident safety, as required by the facility's abuse prevention policy. The policy specifically states that residents have the right to be free from abuse, including abuse by other residents, and that the administration is responsible for protecting residents from such incidents. The lack of staff supervision in the smoking patio directly contributed to the occurrence of physical abuse between residents.
Failure to Develop and Implement Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had received a physician's order to self-administer inhaler medications. Despite documentation indicating the resident was capable of self-administering medications, including storing them securely, managing containers, and understanding medication schedules and refusals, there was no corresponding care plan addressing this aspect of care. The resident's medical record included a diagnosis of hypertension and COPD, with assessments showing moderately impaired thought processes and a need for maximal assistance with activities of daily living. Record reviews and interviews confirmed that the care plan did not reflect the physician's order or the resident's ability to self-administer medication, as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated to address the resident's physical and psychological needs related to self-administration of medication. Facility policies reviewed also specified that such care plans must be developed and implemented when self-administration is deemed safe and appropriate.
Failure to Administer Antibiotic as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering cephalexin 500 mg oral tablets at the scheduled times as ordered by the physician. The resident, who had diagnoses including chronic obstructive pulmonary disease, systemic lupus erythematosus, and type 2 diabetes mellitus, was admitted with a bladder infection and had a physician order for cephalexin to be given four times daily. Review of the medication administration history showed that the medication was administered late on multiple occasions, sometimes more than an hour after the allowed administration window, and in one instance, two doses were given together late at night. The facility's policy required medications to be administered within one hour of the scheduled time, and deviations were to be documented appropriately. Interviews with the MDS nurse, DON, and facility pharmacist confirmed that the medication was not administered within the required time frames on several dates. The DON acknowledged that the late administration of the medication could result in ineffective treatment, and the pharmacist noted that administering doses too close together could cause adverse effects such as abdominal pain and diarrhea. The facility's failure to follow physician orders and its own policy led to the resident not receiving timely medication as prescribed.
Failure to Develop and Implement Care Plan for Resident Refusing Catheter Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident who refused indwelling urinary catheter care. The resident, who was admitted with diagnoses including epilepsy, Parkinson's disease, and urinary retention, had documented moderate cognitive impairment and was dependent on staff for toileting hygiene. Despite multiple documented refusals of disposable brief changes and catheter care, there was no care plan created to address these refusals or to guide staff in managing the resident's needs related to urinary catheter care and toileting hygiene. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, confirmed that no care plan was initiated after the resident's refusals, and that such a plan is necessary to address the resident's problems and guide staff actions. Review of facility policies indicated that individualized care plans should be developed and revised as residents' conditions change, and that refusals of treatment should prompt notification of the attending physician. The lack of a care plan in this situation resulted in the resident's needs not being addressed as required by facility policy.
Failure to Provide and Document Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper care and services for a resident with an indwelling urinary catheter. Specifically, there was no physician's order for the catheter upon the resident's readmission from an acute care hospital, and the required catheter care and monitoring were not documented in the resident's medical records. The resident's care plan called for catheter care every shift, perineal care during bowel elimination, and monitoring for signs and symptoms of infection, but these interventions were not followed. The Treatment Administration Record did not reflect any catheter care or monitoring, and the licensed nursing staff confirmed that these actions were not performed or documented. The resident had a history of epilepsy, Parkinson's disease, urinary retention, and a prior history of urinary tract infection, making proper catheter care and monitoring especially important. Despite these risk factors, the facility did not assess or monitor the resident for urinary tract infection or other catheter-associated complications as required by both the care plan and facility policy. The Director of Nursing acknowledged that the necessary assessments and documentation were not completed for the resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide necessary respiratory care and services for a resident with chronic obstructive pulmonary disease, systemic lupus erythematosus, and type 2 diabetes mellitus. The resident had a physician's order for oxygen at two liters per minute and for oxygen tubing and humidifier to be changed weekly. During observation, the resident's nasal cannula tubing was found touching the floor while in use, and an additional oxygen mask and tubing were left on top of an overbed table. The oxygen cannula was not dated to indicate when it was last changed, and the unused oxygen equipment was not stored in a dated plastic bag as required by facility policy. Interviews with the Quality Assurance Nurse and the DON confirmed that oxygen supplies should be dated, changed every seven days, and stored in a dated plastic bag when not in use. Both acknowledged that the resident's oxygen equipment was not managed according to these protocols, and that the undated and improperly stored supplies had the potential to cause respiratory infection. Review of the facility's policy confirmed the requirements for changing and storing oxygen equipment, which were not followed in this instance.
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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