Veterans Home Of California - West Los Angeles
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 11500 Nimitz Avenue, Los Angeles, California 90049
- CMS Provider Number
- 555917
- Inspections on file
- 44
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Veterans Home Of California - West Los Angeles during CMS and state inspections, most recent first.
Staff failed to maintain professional boundaries and protect two residents from potential financial exploitation and misappropriation of funds. One resident with atrial fibrillation, ESRD, and moderate cognitive impairment reported that a CNA proposed marriage, discussed moving the resident into her home so he could help pay rent and expenses, accepted $50 for holiday food, and shared personal phone contact and photos, contrary to facility policy prohibiting gifts, personal information sharing, and romantic or emotional relationships with residents. Another resident with DM and mild cognitive impairment bought a CNA a meal worth about $20 after a long-standing personal acquaintance, while the CNA accepted the gift and communicated with the resident via personal cell phone, with conversations reportedly focused on money. These actions violated the facility’s Professional Boundaries and Ethics and Elder Abuse Prevention and Response policies, which forbid staff from accepting anything of value from residents, sharing personal contact information, or engaging in romantic or emotional relationships.
A resident with legal blindness and severe osteoarthritis, assessed as high risk for falls, was left unsupervised in the shower room according to her preference, but without appropriate care plan interventions or supervision. The resident fell while attempting to dress after showering, resulting in multiple injuries and hospitalization. Staff interviews and record reviews confirmed that the care plan did not address the need for supervision or assistance during showering, despite the resident's known risks.
Multiple allegations of abuse involving residents with specific diagnoses were not reported to local law enforcement, the Ombudsman, the state survey agency, or the facility Administrator within the required timeframe. In one case, a resident's report of abuse at an outside medical facility was not reported as required, and in another, staff failed to notify the state survey agency after witnessing resident-to-resident abuse. Facility policies and staff training did not align with federal reporting requirements.
The facility failed to follow food safety and sanitation guidelines, including staff not wearing hair restraints, dirty ice machines, expired water filters, dishwashers not reaching required temperatures, expired food items, and improper handwashing practices. These issues posed a risk for foodborne illness among the residents.
The facility's QAPI committee failed to address the need for a Director of Dietetics, compromising food safety for 144 residents. The current ADD was overseeing dietary services without proper focus on staff competency evaluations, as noted in the QAPI Meeting Minutes.
The facility failed to ensure kitchen staff were trained and evaluated for competency in operating dishwashers, leading to dishwashers not maintaining the required temperature. This posed a risk of serving food on unclean dishes to 118 residents. Observations and interviews revealed a lack of knowledge and formal training among staff, with evaluations either not conducted or not met.
The facility failed to serve therapeutic diets according to orders for three residents, risking choking and aspiration. A resident with a cerebral infarct received a hard cookie instead of a finely chopped one, contrary to their mechanical soft diet order. Another resident with Parkinson's and dysphagia also received an improperly chopped cookie. A third resident with esophageal issues faced the same issue. Staff confirmed the discrepancies, highlighting a systemic issue with diet adherence.
A resident with serious mental health conditions was incorrectly coded in the MDS, leading to missed specialized services. The RN misinterpreted the PASRR II results, coding the resident as not having a serious mental illness. This error resulted in the resident not receiving mental health rehabilitation, ADL training, and psychotherapy or counseling.
The facility failed to implement Safe Smoking Care Plans for two residents, leading to potential safety hazards. A resident with nicotine dependence and mild cognitive impairment was observed smoking unsupervised in a non-smoking area, contrary to their care plan. Another resident, with chronic conditions, was not offered a smoking apron as required by their care plan, posing a risk of injury.
Two residents were involved in smoking-related safety deficiencies. A resident with cognitive impairment was observed smoking unsupervised in a non-smoking area, contrary to their care plan. Another resident was not offered a protective smoking apron, as required by their care plan. These actions violated the facility's policy on safe smoking practices.
The facility did not follow its policy for labeling and dating food items brought by residents, family, or visitors, leading to unlabeled and expired food being stored in the communal refrigerator. RNs and the ADON confirmed that these items should have been discarded according to the policy, which mandates immediate disposal of any unlabeled or expired food.
The facility did not ensure that two of four outside dumpsters had lids, as required to prevent pest attraction. The Chief Engineer confirmed the absence of lids, and the Chief of Plant Operations was unaware of the requirement. The FDA Food Code and the facility's policy both mandate tight-fitting lids for dumpsters.
A resident received morphine sulfate without an active physician's order due to the facility's failure to follow its policy on unusable drugs. The medication was administered by an LVN after the order had expired, and staff interviews revealed a lack of adherence to procedures for handling expired narcotic orders.
A resident was administered morphine sulfate without a physician's order, resulting in a significant medication error. The LVN failed to verify the physician's order, which had expired, before administering the medication. The facility's policy requires that medications be administered only with a valid physician's order, and the six rights of medication administration must be followed.
The facility failed to maintain an effective infection control training program for Enhanced Barrier Precautions (EBP), leading to multiple breaches observed during a survey. Staff were unaware of EBP requirements, with only 35% trained, and new employees not receiving EBP training. The Infection Preventionist and Director of Nursing lacked coordination, and the facility's policies did not include specific EBP guidelines, compromising resident safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with wounds or MDRO, as staff did not follow proper protocols, such as wearing gowns and posting necessary signage. Additionally, staff in the Yellow Zone did not adhere to PPE requirements, including wearing N95 masks and eye protection, to prevent COVID-19 spread. These lapses in infection control measures were confirmed by the Infection Preventionist and Director of Nursing.
Two residents in the facility did not receive required neurological assessments following falls, as per physician's orders. One resident, with muscle weakness and mobility issues, missed multiple assessments after two separate falls. Another resident with cognitive impairment also missed several assessments. The facility's policy mandates such assessments for residents with head injuries or unwitnessed falls, but these were not conducted, potentially delaying the identification of neurological changes.
A facility failed to report an abuse allegation to the State Survey Agency when a male resident with dementia displayed inappropriate sexual behavior in front of a female resident with major depressive disorder and dementia. The incident, witnessed by dining hall staff, was reported to management, law enforcement, and the Ombudsman but not to the California Department of Public Health Licensing and Certification, as required by the facility's policy.
Failure to Prevent Staff–Resident Boundary Violations and Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from exploitation and misappropriation of funds by allowing CNAs to develop inappropriate personal relationships with residents, accept gifts, and share personal contact information and photos. For one resident with atrial fibrillation and end stage renal disease, admitted with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, the resident reported that a CNA knelt in front of him in a common area and asked him to marry her. The resident stated he agreed, that a wedding date of December 29 was discussed, and that the CNA offered to move him into her home so he could help pay rent and living expenses with money he would save by not living at the facility. The resident also reported giving this CNA fifty dollars around Thanksgiving to buy a turkey, mashed potatoes, and sweet potatoes. The facility’s social worker documented that the resident told her he was going to get married on December 29 to a nurse who had proposed to him and that he stated the proposal was serious when she asked if it might be a joke. The social worker later stated that the relationship between the CNA and the resident was “getting weird,” that the CNA had given the resident her personal phone number, and that she was sending pictures of herself to the resident, which the social worker said was not appropriate and against facility policy. The social worker also stated that although the resident was oriented to person, place, and time, he was “not great at knowing the situation,” as he wanted to move into the CNA’s house. The DON acknowledged that the resident had given the CNA fifty dollars, and the administrator stated that staff cannot receive gifts as individuals, while the facility’s Professional Boundaries and Ethics policy prohibited staff from accepting any gifts, including money or meals, from residents, from sharing personal contact information, and from engaging in sexual, romantic, or emotional relationships with residents. A second resident, admitted with diabetes mellitus with other specified complication and mild cognitive impairment, was also involved in boundary violations with another CNA. This CNA reported she had known the resident for about ten years and had previously invited him to dinner at her house, which he attended. She stated that the resident bought her a burger and fries on one occasion, which she accepted, and that she was unaware she could not accept this meal. The social worker documented that the resident admitted buying the CNA a twenty-dollar lunch and later reported that the resident’s daughter said the CNA was speaking with the resident on his personal cell phone and “talking a lot about money,” after which the resident changed his phone number. The DON stated that CNA 2 denied any prior personal relationship with the resident, while also acknowledging a gift from the resident to the CNA involving approximately twenty dollars in cash or food. These actions occurred despite facility policies on Professional Boundaries and Ethics and Elder Abuse Prevention and Response, which define financial abuse and prohibit staff from accepting anything of value from residents, sharing personal contact information, or engaging in romantic or emotional relationships with residents. Across both cases, the facility’s own policies clearly stated that employees must maintain professional relationships, set and maintain boundaries, not accept gifts or money from residents, not share personal phone numbers or other personal information, and not engage in sexual, romantic, or emotional relationships with residents, even if consensual. The documented interactions between the CNAs and the two residents—acceptance of money and meals, sharing of personal phone numbers, sending personal photos, discussion of marriage, and discussion of moving a resident into a staff member’s home—directly conflicted with these written policies. The facility’s failure to prevent or promptly address these boundary violations resulted in residents not being protected from potential financial abuse, misappropriation of property, and exploitation as defined in the facility’s Elder Abuse Prevention and Response policy.
Failure to Individualize Care Plan for High-Risk Resident Results in Fall and Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan that addressed all of a resident's needs and preferences, specifically regarding supervision and assistance during showering. The resident, a female with legal blindness, severe osteoarthritis, and a history of falls, was admitted with declining functional abilities and was assessed as high risk for falls. Despite these risk factors, her care plan did not include interventions for her preference to be left alone in the shower room, nor did it address the need for assistance or supervision during showering. On the day of the incident, the resident was left alone in the shower room by a CNA, who waited outside the bathroom. Within minutes, the resident lost her balance while attempting to put on her robe after showering, resulting in a fall. The CNA and other staff responded after hearing a yell and a loud noise, finding the resident on the bathroom floor. The resident sustained significant injuries, including a fractured breastbone, thoracic spine fractures, a scalp bruise, and required a two-day hospital stay. Interviews with staff confirmed that the resident's legal blindness and high fall risk were known, and that the fall could have been avoided if supervision or assistance had been provided during showering. Review of the care plan and assessments showed that while the resident's fall risk and vision impairment were documented, there were no specific interventions or measurable actions addressing her preferences or the need for supervision in the shower room, directly contributing to the incident.
Failure to Timely Report Alleged Abuse to Required Authorities
Penalty
Summary
The facility failed to ensure that multiple allegations of abuse involving residents with specific diagnoses were reported to the required authorities in accordance with federal regulations. In one instance, a resident reported being abused while at an outside medical facility. The Therapeutic Activities Staff (TAS) was informed of the allegation and relayed it to the Social Worker (SW), but neither the TAS nor the SW reported the allegation to local law enforcement, the Ombudsman, the state survey agency (CDPH), or the facility Administrator within the required two-hour timeframe. Interviews with the SW, Supervising Registered Nurse (SRN), and Nurse Practitioner (NP) revealed that they did not consider the report credible enough to warrant immediate reporting, citing the resident's medical condition as a factor. The Administrator confirmed he was not notified of the allegation within the required timeframe and was unable to provide documentation of timely notification. In a separate incident, another resident was witnessed by staff abusing a fellow resident in a common area. The Registered Nurse (RN) reported the incident to the Ombudsman and local law enforcement but did not notify CDPH, following facility training that such incidents did not require reporting to the state survey agency if the abuse was caused by a resident and did not result in serious bodily injury. The facility's policy and procedure, as well as staff interviews, confirmed that the protocol did not align with federal requirements for reporting all allegations of abuse to the state survey agency, regardless of the perpetrator or injury severity. These failures resulted in delays in the investigation process by local law enforcement, the Ombudsman, and the state survey agency. The facility's census at the time was 141, and the lack of timely and comprehensive reporting of abuse allegations was confirmed through interviews, record reviews, and examination of facility policies and staff training materials.
Plan Of Correction
F609 a) 1. Resident 1 was assessed on April 10, 2025, with no injuries or emotional distress noted, including no signs of [R]. Resident was assessed and placed on close monitoring following [R] at the outside facility on March 4, 2025. Resident had no complaints, including no complaints of headache, nausea, vomiting, or body soreness. No skin issues were noted. IDT for the alleged incident that occurred at the outside facility scheduled for April 11, 2025. Resident's [R] at outside facility were postponed until investigation conducted determined it was safe to proceed. SOC341 was filed on April 10, 2025, and CDPH, LTC Ombudsman, and CHP notified. The Therapeutic Activities Staff, Social Worker, Supervising Registered Nurse, Director of Nursing, Staff Nurse Instructor, Nurse Practitioner, and Administrator were all in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. 2. Resident 1 was immediately assessed after the alleged incident on April 4, 2025, with no injury noted. Residents 1 and 2 were immediately separated to ensure the safety of Resident 1. During immediate interviews conducted separately by Nursing and Social Work staff, Resident 1 denied any inappropriate physical contact between Resident 1 and Resident 2. Resident 1 denied any emotional distress related to the alleged event. Resident 1 was placed on close monitoring for emotional distress following the incident; none was noted. Resident 2 was placed on 1:1 nursing observation on April 4, 2025, to be in place indefinitely until IDT determines it is clinically appropriate and safe to taper. Resident 2 was assessed by psychiatric NP, and a medication change was ordered by [R] primary care physician, with daily monitoring for inappropriate behavior. Resident 1 and Resident 2 will continue to be housed in separate wings of the unit, with meals held in different dining rooms, to minimize potential contact. IDT meetings were held for both residents, and care plans updated at that time. SOC341 was sent to CDPH on April 10, 2025. RN, SRN, and Administrator were in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for all elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. b) The facility has determined that all residents have the potential to be affected. All incident reports and resident records from the past calendar year were audited for allegations of [R] by the Standards and Compliance manager and designee on April 10 and April 11, 2025. Through record review and audit, the facility has not found any other residents affected by the alleged deficient practice. c) An updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health, was created and distributed throughout the facility, including by email, on April 10, 2025. Unit television screens were updated to include slides of the updated mandated reporting tree on April 10, 2025. The SNF Administrator in-serviced all department supervisors on April 10, 2025, and they in turn will in-service all facility staff within their respective departments on F609, facility policy, "Elder Abuse Prevention and Response," the updated mandated reporting tree, updated instructions for whom to notify in-house for any suspicion of abuse or neglect, with emphasis on notifying the facility's Abuse Coordinator and the Standards & Compliance Manager, and the SOC341 form. In-services will be complete by May 11, 2025. d) Starting April 10, 2025, the Standards & Compliance Manager and/or designee began auditing all incident reports weekly to ensure any events that could be perceived as re-reported to all required entities and agencies. In addition, in-service trainings on elder abuse prevention, response, and mandated reporter requirements will be provided annually to all staff by the Director of Staff Development and as needed. In addition, Standards & Compliance staff will conduct quarterly random reviews and interviews with facility staff throughout the facility to ensure staff understanding of the mandated reporter requirements. All findings will be reported to the SNF Administrator and facility QAPI committee for monthly review and continuous quality improvement until the QAPI committee deems compliance has been sustained. Administration will revisit and modify the plan of correction as needed. e) Corrective action will be in place on or before May 11, 2025.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations and interviews. Two kitchen staff members were observed not wearing hair restraints while in the kitchen, which is against the facility's policy to prevent food contamination from falling hair. Additionally, two of the three ice machines were found to be dirty, with visible build-up and residue, and three water filters for the ice machines were expired, which was acknowledged as a maintenance oversight. Further deficiencies were noted in the dishwashing process, where two of the three dishwashers did not reach the minimum required temperature for the wash cycle. This was confirmed by the Chief of Plant Operations, who stated that the temperature should be maintained at 150 degrees Fahrenheit. Moreover, an expired bottle of rice wine vinegar was found in dry storage, which was confirmed by a culinary specialist who acknowledged the need for disposal according to FDA guidelines. Lastly, a kitchen staff member failed to wash hands between handling dirty and clean dishes, despite wearing two pairs of gloves. This was contrary to the facility's infection control policy, which mandates proper handwashing after removing gloves. These failures posed a risk for foodborne illness among the 144 residents who rely on the facility for their meals.
QAPI Committee Fails to Address Staffing Needs for Dietary Oversight
Penalty
Summary
The facility's QAPI committee failed to identify, prioritize, and address the staffing need for a Director of Dietetics, which is crucial for providing qualified oversight of all kitchen services. This oversight resulted in compromising food safety and posed a potential risk of severe foodborne illnesses and injuries to a medically fragile population of 144 residents. During a review of the QAPI Meeting Minutes from January to November 2024, it was noted that there was no focus on addressing the vacancy for a Director of Dietetics, which is essential for ensuring safe and sanitary food service and competent kitchen staff. Interviews with QAPI representatives, including the DON, SCM, and ADMIN, revealed that the current ADD was acting as the default overseer of dietary services alongside two Food Service Managers. Additionally, the QAPI Meeting Minutes did not mention any unmet kitchen staff competency evaluations being identified and addressed. The facility's QAPI Plan, which aims to ensure high-quality care and regulatory compliance, was not effectively implemented in this instance, as evidenced by the lack of action regarding the critical staffing need for a Director of Dietetics.
Inadequate Training and Competency Evaluation of Kitchen Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in operating dishwashers in the satellite kitchens, specifically in B207-Food Prep and B307-Food Prep. During observations, it was noted that the dishwashers did not maintain the required minimum temperature of 150 degrees Fahrenheit during the wash cycle. Interviews with Food Service Technicians (FSTs) revealed a lack of knowledge regarding the necessary temperature requirements for the dishwashers. The Food Service Supervisor (FSS) also indicated a lack of formal training on the dishwashers, relying instead on observing others. The Chief of Plant Operations confirmed that the dishwashers should maintain a temperature of 150 degrees Fahrenheit and that staff needed to allow time between wash cycles for the temperature to rise. Further review of staff duty statements and competency checklists showed that essential functions included operating dishwashing machines, but evaluations of staff competency in this area were either not conducted or not met. The facility's policy and procedure for warewashing indicated that the Food & Nutrition Services Director or designee was responsible for training employees, and specified that wash temperatures should be between 150-160 degrees Fahrenheit. The lack of proper training and evaluation of kitchen staff's competency in operating dishwashers had the potential to result in residents being served food on unclean dishes, posing a risk of foodborne illnesses to the medically fragile population of 118 residents.
Failure to Adhere to Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that the therapeutic diet was served in accordance with the diet order for three residents, which had the potential to cause choking and aspiration. Resident 102, who was admitted with a diagnosis of cerebral infarct, had an active order for a mechanical soft, finely chopped diet. However, during an observation, a snickerdoodle cookie on Resident 102's meal tray was found to be hard and not finely chopped as per the ordered diet. The Registered Nurse and Registered Dietitian confirmed that the cookie did not follow the ordered texture modification. Similarly, Resident 61, who had diagnoses including Parkinson's Disease and dysphagia, was also ordered a mechanical soft, finely chopped diet. An observation revealed that the snickerdoodle cookie on Resident 61's meal tray was not finely chopped, contrary to the diet order. The Food Service Supervisor confirmed that the cookie did not adhere to the finely chopped diet order. The Assistant Director of Dietetics acknowledged that all residents with a mechanical soft diet received the same type of cookie, which was not appropriate for their dietary needs. Resident 139, with diagnoses of esophageal obstruction and esophagitis, also had an active order for a mechanical soft, finely chopped diet. During an observation, the snickerdoodle cookie on Resident 139's meal tray was not finely chopped as required. The Food Service Supervisor confirmed the discrepancy, and the Assistant Director of Dietetics stated that the resources used for creating the Diet Manual included guidelines from the American Dietetic Association and the International Dysphagia Diet Standardization Initiative. Despite these resources, the facility's practice did not align with the dietary needs of the residents, as evidenced by the inappropriate serving of cookies.
MDS Coding Error Leads to Missed Specialized Services
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) was completed for a resident, identified as Resident 119, which had the potential to result in negative outcomes due to missed specialized services. Resident 119 was admitted with diagnoses including schizotypal disorder, obsessive-compulsive personality disorder, and anxiety disorder. A Preadmission Screening and Resident Review II (PASRR II) indicated that Resident 119 required specialized services due to a medical and/or mental health condition. However, during a review of the MDS, it was found that item A1500 was incorrectly coded as 0, indicating no serious mental illness, when it should have been coded as 1, indicating the presence of a serious mental illness. The error was attributed to a misinterpretation of the PASRR II results by Registered Nurse (RN) 2, who incorrectly coded the MDS. The Director of Nursing (DON) confirmed the coding error during an interview. As a result of this incorrect coding, the resident did not receive three out of seven recommended specialized services, including mental health rehabilitation, activities of daily living training, and psychotherapy or counseling, as confirmed by the Social Worker (SW).
Failure to Implement Safe Smoking Care Plans
Penalty
Summary
The facility failed to implement Safe Smoking Care Plans for two residents, leading to potential safety hazards. Resident 89, who has nicotine dependence and mild cognitive impairment, was observed smoking in a non-smoking area without supervision. Despite the care plan indicating that Resident 89 should be escorted to a designated smoking area under supervision, staff allowed the resident to smoke unsupervised and in inappropriate locations. Additionally, a staff member was observed escorting Resident 89 to a non-smoking area and providing a cigarette and lighter, contrary to the care plan directives. Resident 142, diagnosed with high blood pressure, chronic kidney disease, and tobacco use, was observed smoking without being offered a smoking apron, which was a requirement in the resident's care plan to prevent injury. The Charge Nurse confirmed that Resident 142 should have been offered a smoking apron while smoking. These oversights in implementing the care plans had the potential to cause severe injuries from fires and burns to the residents, other residents, staff, and visitors.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to implement measures to prevent smoking accidents for two residents, leading to potential safety hazards. Resident 89, who has nicotine dependence and mild cognitive impairment, was observed smoking in a non-smoking area without supervision. Despite the care plan indicating that Resident 89 should be escorted to a designated smoking area under supervision, staff allowed the resident to smoke in unauthorized areas. This was confirmed by multiple observations and interviews with staff, who acknowledged the resident's need for supervision and the requirement to use designated smoking areas. Additionally, Resident 89 was escorted by staff to smoke in a non-smoking area, contrary to the facility's policy and the resident's care plan. A CNA admitted to providing the resident with a cigarette and lighter before reaching the designated smoking area. The facility's policy clearly prohibits smoking in non-designated areas, yet this was not adhered to, as evidenced by the resident's repeated smoking in front of the building and the burning of a wheelchair cushion. Resident 142, diagnosed with high blood pressure, chronic kidney disease, and tobacco use, was observed smoking without a protective smoking apron, despite the care plan's directive to offer one. The resident confirmed not being offered an apron, and the charge nurse acknowledged the oversight. The facility's policy emphasizes promoting safe smoking practices, yet the failure to provide a smoking apron to Resident 142 represents a lapse in adhering to these safety measures.
Failure to Follow Safe Food Handling Protocols
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of food items brought in by residents, family, or visitors, which are stored in the communal refrigerator. During observations, it was noted that an opened jar of pickles and a container of dairy-free lemon ice cream were found in the refrigerator without labels or dates. Registered Nurses on Unit C2 confirmed that these items should have been discarded according to the facility's policy, which mandates that any food or beverage not labeled with a resident's name and date should be immediately discarded. Additionally, expired food items were found in the communal refrigerator, including a container wrapped in a plastic bag and two brown plastic bags duct-taped closed, all with old dates. The Assistant Director of Nursing and a Registered Nurse acknowledged that these items should have been thrown away. The facility's policy clearly states that all perishable foods must be labeled with the resident's name and the date stored, and any unlabeled or expired items should be discarded immediately. The failure to follow these protocols posed a risk of residents consuming expired or improperly stored food.
Failure to Maintain Proper Dumpster Lids
Penalty
Summary
The facility failed to ensure that two of four outside dumpsters had lids, which is a requirement to prevent attracting pests and rodents. During an observation and interview with the Chief Engineer in the loading dock area, it was confirmed that the dumpsters did not have lids. The Chief of Plant Operations was unaware of the need for lids on the dumpsters. A review of the U.S. Food and Drug Administration's Food Code from 2022 indicated that outside receptacles used with materials containing food residue must have tight-fitting lids. Additionally, the facility's policy on trash removal, dated March 7, 2024, stated that dumpster lids should remain closed.
Unauthorized Administration of Morphine Sulfate
Penalty
Summary
The facility failed to adhere to its policy and procedure for handling unusable drugs, resulting in the unauthorized administration of morphine sulfate to a resident without an active physician's order. The resident, who was admitted with osteoarthritis of the hip, had a physician's order for morphine sulfate that had expired. Despite this, a dose of morphine sulfate was signed out and administered by a Licensed Vocational Nurse (LVN) after the order had ended. Interviews with facility staff revealed a breakdown in communication and procedure. The LVN stated that expired narcotic orders should prompt the medication nurse to notify the Charge Nurse, who would then either obtain a new order or ensure the narcotics were taken to the pharmacy for destruction. The Pharmacy Manager confirmed that medications without active orders should not remain in active stock. The facility's policy on expired and unusable medications clearly stated that such drugs should be segregated and not administered, yet this protocol was not followed, leading to the deficiency.
Unauthorized Administration of Morphine Sulfate
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) administered morphine sulfate without a physician's order. The resident, who was admitted with a diagnosis of osteoarthritis of the hip, had a previous physician's order for morphine sulfate that expired on 10/12/24. However, on 10/18/24, LVN 1 signed out and administered a dose of morphine sulfate to the resident without verifying an active physician's order, as required by the facility's policy and procedure. Interviews with the Registered Nurse (RN) and Supervisor Registered Nurse (SRN) confirmed that the LVN did not follow the protocol of checking the physician's orders before administering medication. The facility's policy mandates that medications are administered only on the order of a physician, and the six rights of medication administration must be adhered to. LVN 1 admitted to administering the medication because the resident was in pain but failed to verify the physician's order, leading to the unauthorized administration of morphine sulfate.
Inadequate Infection Control Training on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control training program, specifically regarding Enhanced Barrier Precautions (EBP), which are designed to reduce the transmission of multidrug-resistant organisms. The deficiency was identified during a survey where multiple instances of breaches in EBP were observed. Certified Nursing Assistants (CNAs) were seen providing personal hygiene and toileting assistance to residents without wearing the required gowns, and there was a lack of signage on residents' doors to indicate their EBP status. Interviews with staff revealed a lack of awareness and training regarding EBP, with some staff only receiving training on the day of the survey. The facility's Infection Preventionist (IP) and Director of Nursing (DON) were responsible for overseeing the infection prevention program, but there was a lack of coordination and communication regarding EBP implementation. The IP relied on floor staff and the wound care nurse to determine which residents should be on EBP, while the DON confirmed that the IP and nurses should collaborate on these decisions. However, the training provided was insufficient, as only 35% of nursing staff and providers were trained in EBP, and new employees did not receive EBP training as part of their orientation. The facility's policies and procedures did not include a specific policy related to EBP, and the training program did not cover all necessary staff, such as environmental services and therapy/rehabilitation staff. The lack of a comprehensive training program and clear policies led to staff being unable to demonstrate infection control competency, potentially compromising the safety of the medically-compromised resident population.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four of thirteen sampled residents, which is a measure to reduce the transmission of germs between residents. The Infection Preventionist (IP) stated that EBP should be used for residents with wounds, indwelling devices, or colonization with Multidrug Resistant Organisms (MDRO). However, multiple staff members, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), did not follow these precautions. For instance, Resident 6, who tested positive for MDRO, did not have the required signage on their door, and staff did not wear gowns when providing care. Similarly, Resident 7, with a stage 2 pressure ulcer, and Resident 9, with a vascular wound, also lacked proper signage and staff adherence to EBP. Additionally, the facility failed to ensure that staff in the Yellow Zone, a designated area to limit the spread of COVID-19, wore the necessary personal protective equipment (PPE). Laundry Staff 1 was observed in the Yellow Zone without an N95 mask or eye protection, despite the requirement for all staff to wear these items in the area. The Director of Nursing (DON) and the Infection Preventionist confirmed that all staff, regardless of their role, should adhere to these PPE requirements to prevent the spread of COVID-19. The facility did not provide a policy related to the use of Enhanced Barrier Precautions during the survey, and the staff's lack of adherence to infection control measures was evident. The CMS Quality and Safety & Oversight Group memo and the facility's own policy on infection control emphasize the importance of these precautions, yet the facility's implementation was inconsistent, leading to potential risks of infection spread among residents, staff, and visitors.
Failure to Conduct Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to implement physician's orders for neurological assessments for two residents after they sustained falls. Resident 1, who was admitted with diagnoses including generalized muscle weakness and abnormalities of gait and mobility, experienced two falls. After the first fall on July 1, 2024, the physician ordered neurological checks for 72 hours post-fall. However, three scheduled assessments were missed. Following a second unwitnessed fall on July 27, 2024, 15 scheduled neurological assessments were not conducted. The Charge Registered Nurse confirmed these omissions during a review of the Neurological Check Flow Sheets. Resident 2, admitted with cognitive impairment, also did not receive the required neurological assessments following a fall. The physician's order dated June 26, 2024, specified neurological checks per protocol for 72 hours. However, seven scheduled assessments were missed. The Quality Assurance Supervising Registered Nurse acknowledged that the licensed staff should have conducted these checks as ordered. The facility's policy and procedure for Accident/Fall Prevention and Neurological Assessment require that residents with head injuries, unwitnessed falls, or impaired neurological responses undergo neurological assessments. These assessments are to be documented in the health care record, including initiation, results, changes from baseline, and completion of the assessment period. The failure to conduct these assessments as per the physician's orders and facility policy could potentially delay identifying changes in the residents' neurological status.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an abuse allegation to the State Survey Agency involving two residents. Resident 2, a male with a history of dementia and behavior disturbance, was observed by two dining hall staff members engaging in inappropriate sexual behavior in front of Resident 1, a female with a history of major depressive disorder and dementia. This incident occurred in the dining hall and was witnessed by staff, yet the facility did not report the incident to the California Department of Public Health (CDPH) Licensing and Certification, citing that both residents had dementia. The facility's Standards and Compliance Manager acknowledged that the incident was reported to management, law enforcement, and the Ombudsman office, but not to CDPH Licensing and Certification. The facility's policy on Elder Abuse Prevention and Response mandates reporting such incidents to Licensing and Certification, the Ombudsman, and local law enforcement. The failure to report this incident to the appropriate state agency resulted in undue emotional distress for Resident 1 and posed a potential risk for other residents.
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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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