View Park Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3737 Don Felipe Drive, Los Angeles, California 90008
- CMS Provider Number
- 555065
- Inspections on file
- 39
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at View Park Convalescent Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a history of anxiety experienced acute agitation and refused medication and hospital transfer. A nurse practitioner ordered a one-time dose of Ativan to manage the resident's behavioral distress and facilitate transport, but there was no documentation or recollection that informed consent was obtained prior to administration, contrary to facility policy requiring prescriber-obtained consent for psychotropic medications.
A resident with a history of falls, impaired cognition, and mobility issues experienced a fall resulting in a hip fracture after the facility failed to complete a thorough fall risk assessment and did not implement or document individualized fall prevention interventions such as tab alarms or regular rounding, despite facility policy and staff awareness of the resident's high fall risk.
A resident with complex medical and mobility needs missed multiple doctor's appointments and blood work because the facility arranged transportation that did not accommodate requirements for a bariatric van or gurney. Staff and documentation confirmed that the resident was dependent for transfers and that inappropriate vehicles were repeatedly sent, leading to appointment cancellations.
Kitchen staff did not label cilantro, lettuce, and carrots with delivery or use-by dates, and some vegetables were stored while brown and wilted. Additionally, a dietary staff member failed to wash hands after donning a hairnet and before handling food, contrary to facility policy.
Two residents with limited English proficiency and cognitive capacity were not treated with dignity and respect by a medication nurse, who failed to communicate in a language they could understand and responded dismissively when another resident attempted to assist. The DON acknowledged that miscommunication could cause frustration and that staff should facilitate interpretation, as required by facility policy.
Two residents with documented language preferences other than English were not provided communication in their preferred language, despite being cognitively intact and having these needs identified in their assessments. One resident reported difficulty communicating with medication nurses and was not offered interpretation or alternative communication methods. The DON confirmed that interventions such as obtaining staff to interpret should be used, but these were not implemented, resulting in unmet communication needs.
A resident with multiple chronic conditions and a language preference other than English did not receive ordered as-needed pain medication and was not educated about his pain medications in an understandable language. Despite active orders for both ibuprofen and Percocet, only ibuprofen was administered, and the resident was left confused about his pain management regimen.
Surveyors found that the facility did not maintain a clean and safe environment for all residents, as evidenced by a leaking pipe in one medication room and a cockroach infestation in another. The issues were not reported or addressed by staff or the Maintenance Supervisor, and pest control records showed no treatment for the affected area, despite facility policies requiring regular maintenance and pest control.
A cook did not follow the standardized recipe for Szechwan pork by adding salt, pepper, and garlic powder, which were not included in the approved recipe. This action was observed and confirmed by interviews with the cook, the RD, and the DON, all of whom stated that recipes must be followed to meet therapeutic dietary needs, especially for residents with hypertension.
A container of jelly with an open date beyond the allowed 30-day period was found in a refrigerator, and both the RD and DON confirmed it should have been discarded according to their understanding of safe food handling practices. Facility policy on storage duration conflicted with staff statements, but the outdated jelly remained in the refrigerator, indicating a lapse in proper food storage procedures.
Surveyors found a resident bathroom with three soiled towels, a used coffee cup, and a water pitcher and cup left above the sink, in violation of infection control protocols. Staff interviews confirmed these items should not have been present due to infection control concerns, and facility policy requires all staff to follow procedures to prevent the spread of communicable diseases.
Twenty resident rooms were found to be below the federally required minimum square footage for multiple occupancy, with each room housing three residents in less than 240 sq. ft. Despite residents reporting adequate space and observations showing sufficient room for movement and care, the facility did not meet the regulatory standard for room size.
A resident with diabetes, congestive heart failure, and hypertension was inaccurately documented as receiving insulin on the MDS assessment, even though the insulin order had been discontinued prior to the assessment period. This error was identified through record review and staff interviews, revealing that the MDS did not accurately reflect the resident's medication status.
A resident with multiple medical conditions and no natural teeth was not assisted in obtaining replacement dentures after her original set went missing. Despite documented care plans, a dental consult indicating interest in dentures, and staff awareness of the issue, the facility did not make a timely dental referral or provide adequate follow-up, resulting in ongoing difficulty with eating and poor meal intake.
A CNA failed to don the required PPE when entering an isolation room during an influenza outbreak, despite facility policies and training. The resident had severe cognitive impairment and was on droplet precautions due to RSV exposure. This lapse in protocol increased the risk of infection spread.
A facility failed to ensure a resident with a gastrostomy tube and NPO order had appropriate orders for blood sugar checks every six hours. The resident, with severe cognitive impairment and multiple diagnoses including diabetes, was dependent on staff for daily activities. Despite the care plan indicating the need for Accu-checks, there were no specific orders for NPO status or separate blood glucose checks. Interviews confirmed the absence of necessary orders, potentially leading to inaccurate monitoring.
A resident at an LTC facility fell and fractured their femur after Maintenance Worker 1 mopped the floor without notifying the resident or placing a wet floor sign. The resident, who had a history of falls and required assistance with mobility, slipped on the wet floor while attempting to go to the bathroom. The facility's policies on fall prevention were not followed, leading to the incident.
A facility failed to report an alleged abuse incident to CDPH within the required two-hour timeframe. The incident involved a resident with dementia hitting another resident. Although the incident was reported internally, it was not communicated to CDPH promptly, as confirmed by staff interviews and facility policy.
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. Observations and interviews with Registered Dietitians confirmed the presence of pests, and a review of pest control service reports indicated multiple cockroach findings and recommended intensive treatment. The facility's policy on pest control was not effectively implemented, posing a risk of food contamination and potential foodborne illnesses for the residents.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency, leading to incorrect sanitizing procedures and inconsistent adherence to the policy on residents bringing food from home. This could result in ineffective sanitization and increased risk of foodborne illnesses for residents.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper food labeling, poor air circulation in freezers, and unclean equipment. Observations revealed unlabeled, undated, and expired food, dirty storage areas, and cracked resident trays. Staff interviews confirmed the importance of proper food handling to prevent illness, but the facility did not adhere to its policies, resulting in multiple deficiencies.
The facility failed to properly dispose of garbage and refuse, with one black dumpster and one blue dumpster left uncovered and overflowing. The trash area was not maintained, with soiled gloves and debris scattered around. The Maintenance Supervisor confirmed the bins were not closed properly, potentially attracting pests and leading to cross-contamination.
The facility failed to properly store and dispose of medications according to their policies. An LVN was unable to identify unlabelled pills in a disposal container, and 34 multi-use medication containers lacked open dates. Both the LVN and DON were unaware of the facility's policies regarding medication disposal and labeling.
A resident with dementia and adult failure to thrive was given Aspirin without a specified dosage due to an incomplete physician's order. The LVN administered 81 mg by default, and the DON confirmed that the pharmacist did not complete the Medication Regimen Review. The facility failed to clarify the correct dosage with the physician until later, violating their medication labeling policy.
The facility failed to meet professional standards of quality for a resident with dementia and hypertension by not specifying the dosage in a physician's order for Aspirin. Staff administered 81 mg by default, which could lead to incorrect dosing. Both LVN 1 and the DON confirmed that the order should have included the dosage.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in missed showers and feelings of anger and uncleanliness. Despite requests, staff were too busy to assist, leading to multiple missed hygiene care days.
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of a resident. The resident, who required assistance for daily activities and was at risk for pressure sores, had their LALM set to 280 pounds while their documented weight was 184 pounds. This discrepancy was confirmed by the RNS and DON, who acknowledged that incorrect settings could lead to the development or worsening of pressure sores.
The facility failed to change the tube feeding formula for a resident within the 48-hour timeframe as required by both the manufacturer's instructions and the facility's policy. This oversight was confirmed by both an LVN and the DON, and it posed potential health risks for the resident, who had multiple medical conditions and was dependent on staff for daily care.
The facility failed to ensure that five staff members were assessed for competency upon hire and annually. Interviews and record reviews revealed that several staff members, including a Treatment Nurse and a Registered Nurse Supervisor, had not completed annual skills competency training. The facility's policy requires annual competency assessments, but this was not adhered to, potentially leading to inadequate or delayed resident care.
The facility failed to label 34 multi-use open medication containers in Medication Cart B, #2, with an open-for-use date as required by policy. Both an LVN and the DON were unaware of the labeling policy.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside. The resident had not been assessed for self-administration of medications, and facility staff were unaware of the medications' presence. This failure posed a risk of harm due to potential drug interactions and allergic reactions.
The facility failed to provide advanced healthcare directive information to the responsible parties of two residents, violating their rights. Both residents lacked the capacity to make medical decisions, and the facility did not ensure that their healthcare wishes were documented, potentially leading to situations where their wishes might not be honored.
The facility failed to provide a safe environment for a resident with dementia by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. The Maintenance Supervisor confirmed the danger, and the Director of Nursing acknowledged the issue, stating that CNAs should report such hazards. The facility's policy on avoiding environmental hazards was not followed in this case.
A resident with an anxiety disorder and moderately intact cognition was found with elevated bed side rails used as physical restraints without proper assessment, consent, or a care plan. Staff confirmed the absence of an order for restraints, and the Director of Nursing acknowledged the potential harm and rights violation.
A facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident with Type 2 Diabetes, mobility issues, and muscle weakness. The resident, who lacked decision-making capacity, was observed on a LALM without a corresponding order. Both an LVN and the DON confirmed that this practice could lead to inappropriate treatments and interventions, potentially worsening the resident's condition.
The facility failed to develop and implement care plans for a resident's low air loss mattress and another resident's full bed length side rails. Both the LVN and DON confirmed the absence of these care plans, which hindered the ability to monitor the effectiveness of the interventions.
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Despite the deficiency, resident interviews indicated no concerns, and observations showed ample space for movement and care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering a one-time dose of Ativan, an anti-anxiety medication, to a resident. The resident, an elderly female with multiple diagnoses including diabetes, COPD, hypertension, and a history of anxiety, experienced a change in condition characterized by agitation, refusal of medication and hospital transfer, and vital sign abnormalities. The nurse practitioner ordered Ativan to manage the resident's acute behavioral distress and facilitate safe transport to the hospital. However, there was no documentation or recollection by the LVN that informed consent was obtained before administering the medication, despite the resident being described as self-responsible and able to make her own decisions. Facility policy requires that informed consent be obtained by the prescriber prior to the initiation of any psychotropic medication, including anxiolytics such as Ativan. The DON confirmed that consent is required before administering such medications. The lack of documented informed consent prior to giving Ativan constituted a failure to ensure the resident's right to make an informed decision about her care, as required by facility policy and applicable regulations.
Failure to Develop Comprehensive Fall Prevention Plan and Complete Accurate Fall Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan and complete an accurate initial Fall Risk Evaluation for a resident identified as high risk for falls. The resident, who had a history of falling, hypertension, depression, impaired cognition, and required substantial assistance with activities of daily living, was admitted and readmitted to the facility. The Fall Risk Evaluation form for this resident was incomplete, with several key assessment questions left blank, resulting in an inaccurate fall risk score. The care plan noted the resident was at high risk for falls but only included a general intervention for staff to observe the resident frequently, without specifying detailed or individualized interventions to prevent repeated falls. Staff interviews revealed that the resident was confused, incontinent, had an unsteady gait, and was known to attempt to get up independently despite being unsafe to do so. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the resident was a fall risk and described facility practices such as using tab alarms and rounding every two hours for fall prevention. However, the resident did not have a tab alarm in place, and there was no documented evidence that two-hourly rounds or other specific interventions were consistently performed for this resident. The facility's own policies required monitoring and documentation of interventions for fall risk residents, but these were not followed or documented in this case. As a result of these deficiencies, the resident was found on the floor in pain after a fall, which led to a right hip fracture requiring hospitalization and surgery. The incomplete assessment and lack of individualized, documented interventions contributed to the failure to prevent the fall and subsequent injury. Facility leadership, including the MDS Nurse and DON, confirmed that the assessment was incomplete and that missing information could lead to inaccurate care planning and potential harm.
Failure to Arrange Appropriate Transportation Resulting in Missed Medical Appointments
Penalty
Summary
The facility failed to ensure proper transportation arrangements for a resident with significant mobility and medical needs, resulting in missed doctor's appointments and blood work. The resident, who had diagnoses including acute embolism and thrombosis, peripheral vascular disease, schizophrenia, and HIV, required either a bariatric van, gurney, or geriatric chair for safe transport. Documentation showed that the resident was dependent on staff for transfers and required maximal assistance for mobility. On multiple occasions, the facility arranged transportation that did not meet the resident's needs, such as sending a non-bariatric van or a non-gurney vehicle, leading to the cancellation of scheduled medical appointments. Interviews with the resident and multiple staff members, including an LVN, Social Services director, Director of Staffing Development, and DON, confirmed that the resident missed at least two doctor's appointments and associated blood work due to inappropriate transportation being provided. Staff acknowledged awareness of the resident's specific transport requirements and the repeated issue of the transportation company sending vehicles that could not accommodate these needs. The facility's policy indicated that social services would assist residents in obtaining transportation, but this was not effectively implemented for this resident, resulting in the deficiency.
Failure to Ensure Proper Food Labeling and Hand Hygiene in Dietary Department
Penalty
Summary
Kitchen staff failed to follow proper food labeling and handling procedures, as observed during a survey. Cilantro, lettuce, and carrots stored in the refrigerator were not labeled with delivery or use-by dates, and some vegetables were found to be brown and wilted. The Dietary Supervisor confirmed that the produce had not been labeled upon receipt and acknowledged that spoiled items needed to be discarded. Additionally, a bin containing various vegetables lacked any labeling, and some items inside were visibly spoiled. During the same observation, one out of three dietary staff members did not wash their hands upon entering the kitchen, after donning a hairnet, and before handling food in the refrigerator. The Dietary Supervisor admitted that handwashing should have occurred before entering the kitchen and touching the refrigerator. Review of facility policies confirmed that all food items should be properly covered, dated, and labeled, and that staff are required to follow safe food handling practices to prevent foodborne illness.
Failure to Ensure Dignity and Respect in Resident Communication
Penalty
Summary
Two residents with cognitive capacity and language preferences other than English were not treated with dignity and respect by a medication nurse during communication. One resident, who required substantial assistance with activities of daily living and had a history of hypertension, diabetes, arthritis, and above-the-knee amputation, reported being spoken to disrespectfully and with an attitude by the evening medication nurse. The resident also stated that the nurse did not attempt to communicate in a language the resident could understand or take steps to facilitate effective communication. Another resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, hypertension, and hyperlipidemia, witnessed the same nurse arguing with the first resident and attempted to assist with communication due to his partial understanding of English. His efforts were dismissed by the nurse, who told him to mind his own business. The Director of Nursing acknowledged that miscommunications could lead to frustration and suggested that an intervention would be to obtain another staff member to interpret for the residents. The facility's policy requires employees to treat all residents with kindness, respect, and dignity, which was not followed in these instances.
Failure to Communicate with Residents in Preferred Language
Penalty
Summary
The facility failed to ensure that two residents were communicated with in their preferred language, as required by their care needs and facility policy. Both residents were cognitively intact and had documented language preferences other than English in their Minimum Data Set (MDS) assessments. Despite this, interviews revealed that one resident experienced ongoing difficulty communicating with medication nurses, and no alternative communication methods or interpretation services were offered to assist him in understanding his care. The other resident also had a language preference documented but there was no evidence that this need was accommodated. The Director of Nursing acknowledged during an interview that lack of communication in a resident's preferred language could lead to frustration and that an appropriate intervention would be to obtain another staff member to interpret. The facility's policy on accommodating communication deficits stated that communication needs would be identified and appropriate interventions, including care planning, would be developed to meet those needs. However, the facility did not implement these interventions for the two residents, resulting in their communication needs not being met.
Failure to Provide and Communicate Ordered Pain Management
Penalty
Summary
A resident with a history of hypertension, type 2 diabetes, arthritis, and an above-the-knee amputation was admitted to the facility and was cognitively intact, with a language preference other than English. The resident was prescribed ibuprofen for mild pain and Percocet for moderate to severe pain, as needed. However, the resident reported not receiving the previously ordered pain medications and was only receiving Tylenol for pain. The resident expressed confusion about which pain medications were currently ordered and stated that information about pain medications was not communicated in a language he could understand. Record review showed that the resident had not received Percocet after a certain date, despite the orders still being active and available for administration if pain was present. The Medication Administration Record confirmed that only ibuprofen had been administered in recent days. The Director of Nursing verified that the Percocet orders were still active and could have been given. The facility's policy required prompt response to reports of pain and effective communication, but these were not followed, resulting in the resident not receiving appropriate pain management or education about his medications.
Failure to Maintain Clean, Safe, and Functional Environment Due to Leaking Pipes and Cockroach Infestation
Penalty
Summary
The facility failed to maintain a clean, safe, and functional environment for all 92 residents, as evidenced by multiple observations and interviews. In Medication Room A, a leaking pipe was found under the sink cabinet, with a grey wash basin placed to catch the water. The Registered Nurse Supervisor (RNS) was unaware of the leak, and no staff or the Maintenance Supervisor (MS) had reported it. The RNS acknowledged that unrepaired leaks could lead to mold, which could make residents and staff ill. In Medication Room B, multiple dead cockroaches were observed under the sink cabinet. The RNS, as well as the Director of Nursing (DON) and Administrator, confirmed that this infestation had not been reported to them. The Administrator stated that the MS is responsible for cleaning under sink cabinets and fixing leaks, and that pest control should be notified immediately in the event of an infestation. Pest control service records showed no indication that Medication Room B had been treated for cockroaches, despite the facility's policy of bi-monthly pest control visits. Interviews with the MS revealed that maintenance issues are to be logged at the nurses' stations and that he checks these logs daily. The MS stated he had last cleaned under the sink in station B two weeks prior and had not received any reports about cockroaches. He also confirmed he had no professional plumbing training and had not repaired the leaking pipe in Medication Room A. Facility policies reviewed indicated that the MS is responsible for maintaining plumbing and ensuring a clean, pest-free environment, but these responsibilities were not fulfilled as required.
Failure to Follow Standardized Recipe for Therapeutic Diets
Penalty
Summary
A deficiency occurred when a cook (CK) failed to follow the standardized recipe for Szechwan pork during lunch preparation. The recipe, as reviewed, did not include the addition of salt, pepper, or extra garlic powder. However, during observation, the CK admitted to adding these ingredients, specifically stating that salt was added to enhance the flavor of the pork. The CK acknowledged that the facility recipe should be followed and recognized that adding salt could negatively impact residents, particularly those with hypertension. Interviews with the registered dietician (RD) and the director of nursing (DON) confirmed that recipes are designed to meet therapeutic dietary needs and should be strictly followed, especially for residents with specific medical conditions such as hypertension. The facility's policy also requires that menus be prepared as written using standardized recipes, and that dietary staff are responsible for adhering to these guidelines to ensure nutritional adequacy and compliance with physician orders.
Failure to Discard Outdated Jelly in Refrigerator
Penalty
Summary
Surveyors observed that a container of jelly in one of the facility's refrigerators was labeled with an open date of 4/11/2024, which was beyond the 30-day period allowed for opened food items according to the registered dietician. The registered dietician confirmed during the observation that food items opened and stored in the refrigerator should be discarded after 30 days, and the jelly should not have remained in the refrigerator past this timeframe. The Director of Nursing also stated in an interview that food with a label date of 4/11/2024, whether open or closed, should not be present in the refrigerator due to potential harm. Facility policies reviewed indicated that food and supplies must be stored properly and safely, and that opened jellies, when refrigerated, are allowed for up to 6 months, which conflicted with the staff's statements. The presence of the outdated jelly in the refrigerator demonstrated a failure to follow safe food handling practices as observed and confirmed by staff.
Failure to Maintain Sanitary Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a sanitary environment in one of its resident bathrooms by not adhering to established infection control measures. During a facility tour, surveyors observed three visibly soiled towels hanging on the towel rack, as well as a used coffee cup with residue and a water pitcher and cup placed on a shelf above the bathroom sink. These items were not supposed to be present in the bathroom according to infection control protocols. Certified Nurse Assistant (CNA) 1 confirmed that the dirty towels, coffee cup, and water pitcher should not be in the bathroom due to infection control concerns, but was unaware of who left them there. Further interviews with the infection prevention nurse (IPN) and the Director of Nursing (DON) confirmed that the presence of dirty towels, cups, and water pitchers in the bathroom constitutes an infection control issue, as it can expose residents to disease-causing microorganisms. A review of the facility's infection prevention and control policy indicated that the program is designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. The policy applies to all staff, who are trained on these procedures upon hire and periodically thereafter.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in 20 out of 40 resident rooms, as mandated by federal regulations. Specifically, the rooms in question were designed for three residents each but measured less than the required 240 square feet, with individual room sizes ranging from approximately 201 to 236 square feet. This deficiency was identified through a review of facility records, including a waiver request letter submitted by the Administrator, which acknowledged the shortfall in room sizes. The federal regulation requires at least 80 square feet per resident in multiple occupancy rooms, and the rooms listed did not meet this standard. During observations conducted over several days, residents were seen to have sufficient space to move about, and there was adequate room for necessary furniture and care equipment. Additionally, during a resident council meeting, several residents expressed that their room sizes were adequate. Despite these observations and resident statements, the facility's failure to meet the minimum square footage requirement constitutes a deficiency as per federal standards.
Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's insulin status. Specifically, the MDS for a resident, completed on 2/19/2025, indicated that the resident received one injection of insulin during the seven-day look-back period. However, a review of the resident's medical chart and interview with the MDS Coordinator revealed that the insulin order had been discontinued on 2/6/2025, prior to the look-back period. This resulted in inaccurate documentation on the MDS regarding the resident's insulin administration. The resident involved had a medical history including congestive heart failure, hypertension, and diabetes mellitus, and was dependent on staff for several activities of daily living. Both the MDS Coordinator and the Director of Nursing confirmed that the MDS is used to guide care planning and that inaccurate entries could lead to an incorrect care plan. The facility's policy required comprehensive assessments to be conducted according to established criteria and timeframes, but this was not followed in this instance.
Failure to Assist Resident in Obtaining Dentures After Loss
Penalty
Summary
The facility failed to assist a resident in obtaining dentures after the resident's dentures went missing. The resident, who had a history of diabetes mellitus, muscle wasting, atrophy, and anemia, was admitted and later readmitted to the facility. Documentation showed the resident was edentulous and at risk for poor oral intake, with care plans indicating the need for dental assessment and referral as well as good oral hygiene. Despite a dental consult noting the resident's interest in dentures and an order for dental consult and treatment as needed, the resident reported that her request for dentures had not been addressed and that her dentures had been missing for a long time. Staff interviews confirmed the resident no longer had dentures and had difficulty eating certain foods, rarely finishing her meals. The facility's policy required referral for dental services within three days if dentures were lost, or documentation of actions taken and reasons for delay. However, there was no evidence that the facility made a timely referral or provided adequate follow-up to ensure the resident could eat and drink adequately while awaiting dental services. The Social Services Director acknowledged the resident's request for dentures and the potential for weight loss due to the lack of dentures. The DON confirmed that staff are responsible for following up on such requests and recognized the impact of not having dentures on chewing and weight maintenance.
Inadequate PPE Use During Influenza Outbreak
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program during an influenza outbreak. Specifically, a certified nursing assistant (CNA) entered an isolation room without donning the required personal protective equipment (PPE), which included a gown, mask, and face shield. The CNA only wore gloves when entering the room of a resident who was on droplet precautions due to exposure to respiratory syncytial virus (RSV). The CNA admitted to forgetting to put on the full PPE because he was only assisting the resident with water and the resident was not his assigned responsibility. The resident in question had a severely impaired cognitive function and was unable to communicate needs or make decisions regarding care. The facility's policy required staff to don and doff PPE properly before entering and exiting isolation rooms, as reiterated by the RN Supervisor, Director of Staff Development, and Infection Preventionist during interviews. Despite the facility's policy and training efforts, the CNA's failure to adhere to the protocol represented a break in infection control, potentially increasing the risk of spreading influenza within the facility.
Failure to Ensure Proper Blood Sugar Monitoring for NPO Resident
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube feeding and an NPO order had appropriate medical orders for fingerstick blood sugar checks every six hours. The resident, who was admitted with diagnoses including type two diabetes, hypertension, heart failure, gastrostomy, dysphagia, and muscle weakness, was dependent on staff for various activities of daily living due to severely impaired cognition. Despite the resident's condition and care plan indicating the need for Accu-checks as ordered, there was no specific order for NPO status or separate fingerstick blood glucose checks apart from insulin orders. During interviews and record reviews, it was confirmed by both an LVN and an RN Supervisor that the necessary orders were not present in the resident's chart. The RN Supervisor acknowledged that blood sugar checks should occur every six hours for an NPO resident, yet the existing orders only specified checks before meals and at bedtime. This oversight had the potential to result in inaccurate blood sugar monitoring for the resident, impacting the care and services provided.
Failure to Prevent Fall Due to Wet Floor
Penalty
Summary
The facility failed to provide a safe environment to prevent falls for a resident, identified as Resident 1, who slipped and fell due to a wet floor in their room. Maintenance Worker 1 (MW 1) mopped the floor in Resident 1's room but did not notify the resident or their roommate that the floor was wet. Additionally, MW 1 failed to place a wet floor sign to alert the residents of the hazard. As a result, Resident 1, who was attempting to go to the bathroom, slipped on the wet floor and fell, suffering severe pain in the left knee. Resident 1 had a history of falls and was at risk for falls due to general weakness, a history of left ankle fracture, osteopenia, and muscle weakness. The resident was admitted to the facility for physical and occupational therapy and required assistance with mobility, using a walker for support. At the time of the incident, Resident 1 was alert and oriented but had impaired vision and required assistance with daily activities. The fall resulted in a left femur fracture, and the resident was transferred to a hospital for treatment, where they underwent surgery for the fracture. Interviews with staff and the resident's roommate confirmed that MW 1 did not inform them of the wet floor, nor was a wet floor sign placed. The facility's policy and procedures require staff to identify and mitigate fall risks, including wet floors, but these protocols were not followed. The Director of Rehabilitation and other staff acknowledged that a wet floor is a fall risk, and the failure to notify residents and place a warning sign contributed to the incident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. This deficiency involved an incident between two residents, where one resident, diagnosed with dementia and lacking decision-making capacity, allegedly hit another resident on the arm after attempting to unplug their television. The resident who was hit did not require pain medication and expressed no fear of remaining in the facility, acknowledging the other resident's mental state. The incident was reported internally within the facility, with the Certified Nursing Assistant informing the Administrator, who then informed the Director of Staff Development. However, the Administrator did not report the incident to CDPH within the mandated two-hour period. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed the understanding that such incidents should be reported promptly to CDPH. The facility's policy, revised in March 2023, also stipulates that allegations involving abuse or serious bodily injury must be reported within two hours.
Sanitary Conditions in Food Services Department Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. During an observation and interview with the Registered Dietitian (RD 1), a dead cockroach and a live baby cockroach were found on the floor underneath the dishwashing sink. RD 1 acknowledged the presence of the insects and stated that the kitchen should be free of pests for food safety. Another observation and interview with Registered Dietitian (RD 2) confirmed the presence of pests, and RD 2 mentioned that a pest control service had recently treated the facility, but no cockroaches were found during their inspection. However, a review of the pest control service report from 3/28/2024 indicated that 12 cockroaches were found in the kitchen, and intensive roach treatment was recommended to prevent a kitchen shutdown. The report also recommended improving sanitation and keeping doors closed to prevent pest entry. Further inspection revealed a half-inch gap in the screen door leading to the trash area, which could allow pests to enter. The Administrator (ADM) reviewed a video clip of a cockroach in the dishwashing area and confirmed the presence of pests. ADM stated that the pest control service would return to inspect and treat the kitchen. A subsequent pest control service report from 4/3/2024 indicated that 30 German cockroaches were found in the kitchen, and intensive treatment was performed. The facility's policy on pest control, revised on 2/20/2024, stated that the facility should maintain an effective pest control program to keep the building free of insects and rodents. Despite these measures, the presence of cockroaches in the kitchen posed a risk of food contamination and potential foodborne illnesses for the residents.
Inadequate Training and Policy Adherence in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills. One dietary aide did not follow the manufacturer's guidelines when checking the concentration of the QUAT sanitizing solution. The aide dipped the test strip for only eight seconds instead of the required ten seconds and did not check the water temperature, which is necessary for accurate testing. The aide admitted to not being trained to test the water temperature and was unaware of the correct procedure. This failure to follow guidelines could result in ineffective sanitization of kitchen surfaces and dishes, potentially leading to foodborne illnesses for the residents. Additionally, staff members were not able to consistently verbalize the facility's policy regarding residents bringing food from home. Interviews with various staff members, including a Licensed Vocational Nurse, Activities Assistant, Activities Supervisor, and Director of Staff Development, revealed discrepancies in their understanding of how long food from outside sources could be stored. The staff provided conflicting information, ranging from one to three days, and some were unsure of the exact policy. This inconsistency in following the food storage policy could lead to residents consuming spoiled food, increasing the risk of foodborne illnesses. The facility's policy and procedures on food from outside sources were reviewed, indicating that while outside food is discouraged, it is allowed under certain conditions. The policy requires that the charge nurse be notified and that the food be checked to ensure it aligns with the resident's prescribed diet. However, the staff's lack of consistent knowledge and adherence to this policy highlights a significant gap in training and communication, which could compromise the safety and well-being of the residents.
Facility Fails to Ensure Safe and Sanitary Food Storage and Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Observations revealed improper storage of food, including unlabeled, undated pasta, ranch dressing, and expired cheese. Additionally, bacon slices were found uncovered, unlabeled, and undated. The resident's refrigerator contained unlabeled, undated, and expired food, along with staff's parmesan cheese, drink, and Italian dressing. Interviews with staff confirmed the importance of labeling and dating food to prevent residents from consuming expired food, which could lead to illness. The facility also exhibited poor air circulation in Freezers 3 and 4, which were observed to be full of food. The Registered Dietitian acknowledged the overcrowding and the need for proper air circulation to maintain food safety. Furthermore, equipment cleanliness was compromised, with dirt and debris found in Freezer 3, dust buildup in Refrigerator 2's vent, and black dirt debris in Refrigerator 1. The dry storage area also had dust buildup, dirty cans, and food debris on the floor. The ice machine, located outside, had significant dirt buildup on both internal and external parts, raising concerns about cross-contamination and infection. Additionally, two dented cans were stored with undented cans in the dry storage area, and seventeen cracked and chipped resident trays were found in use. Staff interviews highlighted the potential risks of using dented cans and damaged trays, which could lead to bacterial growth and cross-contamination. The facility's policies and procedures were reviewed, indicating the need for proper labeling, dating, and cleanliness of food storage areas and equipment. However, the facility failed to adhere to these guidelines, resulting in multiple deficiencies that could potentially harm the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly, as observed during a survey. One of two black dumpsters and one blue dumpster were not covered for an unknown amount of time. The blue dumpster was overflowing with cardboard boxes. The trash area was not maintained, with soiled gloves and other debris scattered around. The Maintenance Supervisor confirmed that the trash bins were not closed properly and that the area was not clean, which could attract pests and lead to cross-contamination and potential illness among residents. The facility's policies and procedures for waste control and disposal, as well as pest control, were not followed. The policies required that trash bins be covered at all times, outside garbage bins be kept closed, and surrounding areas be kept clean. Additionally, cardboard boxes were to be broken down and disposed of timely. The Food Code 2017 also mandates that waste handling units for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment. These lapses in following established protocols contributed to the deficiency observed by the surveyors.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and disposed of according to their policies and procedures. During an observation of Medication Cart B, an undated clear plastic container labeled 'Disposal Medication All Refusal' was found to contain 22 unidentifiable pills inside and four unidentifiable pills outside the container. The Licensed Vocational Nurse (LVN) could not identify the pills or determine if they were controlled substances. The Director of Nursing (DON) confirmed that refused medications should be discarded immediately in a locked storage room with a solution called a drug buster, but was unable to explain the consequences of not doing so. The facility's policy requires controlled medications to be destroyed in the presence of two licensed nurses and documented accordingly, which was not followed in this instance. Additionally, 34 out of 36 multi-use medication containers in Medication Cart B were found to be in use without an open date, contrary to the facility's policy. The LVN was unaware of the policy for labeling multi-use medication containers, despite being employed at the facility since July 2023. The DON also did not know that multi-use open medication containers needed to have an open date and was unfamiliar with the facility's policy on labeling open medications. The facility's policy mandates that the open date be labeled on medication containers once they are opened, which was not adhered to in this case.
Failure to Ensure Complete Medication Order for Resident
Penalty
Summary
The facility failed to ensure that Resident 3 was free from significant medication errors. Resident 3, who had diagnoses including adult failure to thrive and dementia, was readmitted to the facility with a physician's order for chewable Aspirin to be administered via G-tube once daily for cardiac prophylaxis. However, the order did not specify the dosage. During a medication administration observation, LVN 1 revealed that the computer system only indicated 'chewable aspirin' without a dosage, leading them to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name, dosage, and route of administration, and that an incomplete order could result in ineffective medication therapy or an overdose, which could be fatal to the resident. The Director of Nursing (DON) confirmed that the pharmacist did not complete the Medication Regimen Review (MRR) for the Aspirin, and the facility failed to clarify the correct dosage with Resident 3's physician until the day of the interview. The facility's policy on medication labeling, revised recently, mandates that all medications be properly labeled according to state and federal guidelines. The failure to ensure a complete medication order for Resident 3's Aspirin had the potential to lead to significant medication errors, including overdose or underdose, which could be fatal.
Failure to Specify Dosage in Medication Order
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 3, who was admitted with medical diagnoses including adult failure to thrive, dementia, and hypertension. The deficiency was identified when it was observed that the physician's order for Aspirin, dated 12/29/2023, did not specify the dosage. During an interview, LVN 1 admitted that the computer system only indicated 'chewable aspirin' without a dosage, leading staff to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name of the medication, dosage, and route of administration. The Director of Nursing (DON) confirmed that the aspirin order should have included the dosage and that the absence of this information could result in incorrect dosing. The review of Resident 3's Minimum Data Set (MDS) indicated that the resident had impaired cognition and was dependent on staff for various activities, including feeding and personal hygiene. The facility's Medication Pass Tips, revised on 2/20/2024, emphasized the importance of the 'ten rights' of medication administration, including the right dose. The failure to include the correct dosage in the medication order had the potential to cause underdosing, overdosing, and hospitalization, as confirmed by both LVN 1 and the DON during their interviews.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, resulting in feelings of anger and potential health risks. Resident 54, who has muscle weakness and Type 2 diabetes, was observed with unshaven facial hair and reported not receiving assistance with shaving or showers as scheduled. Despite requesting showers, Resident 54 was told by staff that they did not have time, leading to multiple missed showers and bed baths in March 2024. The resident expressed feelings of anger and uncleanliness due to the lack of proper hygiene care. Resident 6, diagnosed with morbid obesity and muscle weakness, also did not receive scheduled showers. The resident reported not having showered in about two weeks and stated that staff were too busy to assist with showers. Observations confirmed that Resident 6 was not provided with showers on multiple scheduled days in March 2024. The resident expressed frustration and anger over not feeling clean and not preferring bed baths. Interviews with staff, including the Director of Staff Development (DSD), Certified Nurse Assistants (CNAs), and Licensed Vocational Nurses (LVNs), revealed inconsistencies in reporting and providing showers. The facility's policy requires residents to receive showers twice a week unless they refuse or are sick. However, staff failed to adhere to this policy, leading to the identified deficiencies in resident care.
Incorrect LALM Settings for Resident
Penalty
Summary
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of Resident 9. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have the capacity to understand and make decisions. The resident's Minimum Data Set (MDS) indicated that they required assistance from facility staff for eating, hygiene, and toileting. Despite being at risk for developing pressure sores, as indicated in the care plan, there was no specific care plan for the LALM. During an observation, it was found that the LALM was set to 280 pounds, while the resident's documented weight was 184 pounds. This discrepancy was confirmed by the Registered Nurse Supervisor (RNS 1) and the Director of Nursing (DON), who both acknowledged that incorrect settings could lead to the development or worsening of pressure sores. The facility's policy and procedures for pressure-reducing mattresses indicated that the mattress should be set according to the patient's weight or a healthcare professional's suggestion. However, this was not followed in the case of Resident 9. The LALM was not set at the correct weight, which could potentially harm the resident by not providing the correct amount of airflow needed to prevent or treat pressure injuries. The failure to adhere to the correct settings for the LALM and the absence of a specific care plan for its use contributed to the deficiency observed by the surveyors.
Failure to Change Tube Feeding Formula in a Timely Manner
Penalty
Summary
The facility failed to ensure that the tube feeding product/formula was not hanged for more than 48 hours per manufacturer's instructions and facility's policy and procedures for one of the sampled residents. Specifically, Resident 3 had a bottle of Glucerna connected to their gastrostomy tube that was dated 3/26/2024 and had not been changed for 6 days. This was confirmed during an observation and interview with LVN 5, who acknowledged that the feeding bottle should have been changed to prevent infection and potential adverse effects such as an upset stomach. The Director of Nursing also confirmed that tube feeding bottles should be changed every 24 to 48 hours to prevent bacterial growth and associated complications like abdominal pain and loose bowel movements. Resident 3 was admitted to the facility with medical diagnoses including adult failure to thrive, dementia, and hypertension. The resident was dependent on facility staff for feeding, toilet use, oral hygiene, and personal hygiene. The facility's policy and procedures, as well as the manufacturer's instructions for Glucerna, both indicated that the maximum hang time for sterile formula in a closed system is 48 hours. The failure to adhere to these guidelines resulted in the potential for significant health risks for Resident 3.
Failure to Assess Staff Competency
Penalty
Summary
The facility failed to ensure that five out of five staff members were assessed for competency upon hire and annually. This deficiency was identified through interviews and record reviews. The Treatment Nurse, who had been employed for seven years, could not recall the last time they completed an annual skills competency training. Similarly, the Registered Nurse Supervisor, who had worked at the facility only twice, had never completed a competency checklist. The Laundry Aid, who had been employed for several years, also confirmed never having completed an annual skills competency evaluation. The Certified Nurse Assistant 2 was the only staff member who had recently completed an annual skills competency training. The Director of Staff Development and the Director of Nursing confirmed that the facility does not keep employee files for registry nurses and relies on a registry app to verify credentials and competencies, which they could not identify by name. A review of employee files for the Licensed Vocational Nurse/Treatment Nurse, Certified Nurse Assistant 2, Certified Nurse Assistant 3, and the Laundry Aid revealed that none contained a skills competency checklist or a completed staff competency assessment. The facility's policy and procedures, revised in February 2024, indicated that employees should be assessed for competency upon hire and annually. However, the facility failed to adhere to this policy, leading to a potential knowledge, training, and certification deficit among staff, which could result in inadequate or delayed resident care.
Failure to Label Multi-Use Medication Containers
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not adhering to its policy for labeling multi-use medication containers. During a record review and interview, it was found that 34 multi-use open medication containers in Medication Cart B, #2, were in use without an open-for-use date as required by the facility's policy. Licensed Vocational Nurse 4 (LVN 4) and the Director of Nursing (DON) both admitted to not knowing the facility's policy for labeling these medications. The facility's policy, revised on February 20, 2024, mandates that medications stored in a bottle or container must be labeled with the open date once the container is opened.
Failure to Prevent Unauthorized Medication Access
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering them. Resident 77, who had severe cognitive impairment and required assistance with daily activities, was found with three pills on their bedside drawer. The resident stated that a friend had brought the medications because the facility staff were not responding to requests for headache medication. The resident's medication administration record indicated an order for Norco, but there was no documented evidence that the resident was assessed to self-administer medication. During interviews, the Licensed Vocational Nurse and the Director of Nursing confirmed that Resident 77 did not have an order to self-administer medications and should not have had any medications at bedside. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, which had not been conducted for Resident 77. The Director of Nursing acknowledged that the presence of non-prescribed medications posed a risk for potential harm, including drug interactions and allergic reactions.
Failure to Provide Advanced Healthcare Directive Information
Penalty
Summary
The facility failed to ensure that advanced healthcare directive information was provided to the responsible parties (RPs) of two residents, resulting in a violation of their rights. Resident 1, who was diagnosed with Alzheimer's disease, schizophrenia, and hypertension, did not have the capacity to make medical decisions. Despite this, the facility did not contact Resident 1's power of attorney to complete the advanced directive acknowledgment (ADA) form. The Social Services Director (SSD) admitted that the ADA form was not completed and only sent an email regarding it on the day of the interview. This oversight meant that Resident 1's healthcare wishes were not documented in the chart, potentially leading to life-threatening situations where the resident's wishes might not be honored. Similarly, Resident 3, who was diagnosed with adult failure to thrive, dementia, and hypertension, also did not have the capacity to make medical decisions. The SSD confirmed that Resident 3's ADA form was not completed by the RP, which could result in the resident's healthcare wishes not being followed. The Director of Nursing (DON) emphasized the importance of completing the ADA form upon admission to ensure that the facility is aware of and can honor the residents' healthcare wishes. The facility's policy and procedures require compliance with healthcare decisions made by authorized persons, but this was not adhered to in these cases.
Failure to Secure Exposed Wires on Bed Side Rail
Penalty
Summary
The facility failed to provide a safe environment for Resident 29 by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. Resident 29, who was admitted with diagnoses including unspecified dementia, psychotic disturbance, and anxiety, did not have the capacity to understand and make decisions. The resident required assistance from staff for daily activities and exhibited behavioral symptoms of dementia such as anxiety and restlessness. During an observation, it was noted that the bed side rail had multiple exposed wires, which posed a risk of injury or harm to the resident. The Maintenance Supervisor confirmed that there was no request order for Resident 29's bed and acknowledged the danger posed by the exposed wires. The Director of Nursing stated that CNAs are responsible for reporting bed malfunctions to the maintenance supervisor and agreed that it was unacceptable for a resident to be on a bed with exposed wires. The facility's policy on avoiding environmental hazards indicated that items posing harm to residents should be removed, and direct caregivers should check the resident's unit to identify and remove such items. However, this policy was not followed in the case of Resident 29.
Inappropriate Use of Physical Restraints on Resident
Penalty
Summary
The facility failed to ensure that Resident 288 was free from physical restraints. Resident 288, who was admitted with an anxiety disorder and had moderately intact cognition, was observed with bilateral full-size bed side rails elevated. Certified Nursing Attendant 1 confirmed that the side rails were used to prevent the resident from falling, despite acknowledging the risk of the resident getting tangled in the rails. Licensed Vocational Nurse 2 and Licensed Vocational Nurse 3 both confirmed that there was no order for restraints in the resident's chart, and that the use of side rails without proper assessment, consent, or a care plan could potentially harm the resident. The Director of Nursing also confirmed that the side rails were elevated without an order or consent, emphasizing that this practice could disrespect the resident's rights and potentially cause harm. A review of the facility's policy on physical restraints indicated that any use of mechanical devices restricting freedom of movement requires an order from the attending physician, informed consent, and a detailed plan of care. The facility's failure to adhere to these policies resulted in the inappropriate use of physical restraints on Resident 288.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness. The resident, who lacked the capacity to understand and make decisions, was observed in bed on a LALM without a corresponding physician's order. This was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the absence of a physician's order could lead to inappropriate treatments and interventions, potentially worsening the resident's skin condition. The Director of Nursing (DON) confirmed that an order is required for the use of an air mattress and that it is not professional nursing practice to implement treatments without a physician's order. The facility's policy and procedures, dated 2/20/2024, also indicated that physician's orders must be obtained prior to the initiation of any medication or treatment. This deficiency had the potential to harm the resident by not providing appropriate treatment and interventions.
Failure to Develop and Implement Care Plans for Specialized Equipment
Penalty
Summary
The facility failed to develop and implement a care plan for Resident 9's low air loss mattress (LALM) and Resident 288's full bed length side rails. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have a care plan for the LALM despite requiring assistance for daily activities and lacking the capacity to make decisions. During an observation, Resident 9 was found lying on a LALM set to 280 pounds, and both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the absence of a care plan for the LALM, which hindered the ability to monitor the effectiveness of the intervention. Similarly, Resident 288, admitted with an anxiety disorder and requiring assistance for daily activities, did not have a care plan for the full bed length side rails observed in their room. The DON confirmed that no care plan for restraints was found in Resident 288's chart or electronic records. The facility's policy and procedures indicated that care plans should be reassessed and updated to reflect the current status of residents, but this was not adhered to in these cases.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Specifically, rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 116, 118, 120, 121, 122, 134, 137, 138, 141, and 142 were found to be deficient in this regard. The rooms in question had varying sizes but did not meet the minimum square footage requirements for the number of residents they housed. For example, rooms with three beds should have at least 240 square feet, but many of these rooms were significantly smaller. This deficiency was identified through observation, interviews, and record reviews during a recertification survey conducted from April 1 to April 4, 2024. Despite the deficiency, resident interviews indicated no concerns regarding the size of the rooms, and observations showed that residents had ample space to move freely and that there was sufficient space for nursing staff to provide care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety. During an interview, the administrator confirmed that a written request for the continued room waiver had been submitted. Measurements taken by the Maintenance Supervisor confirmed the room sizes, and it was noted that the measurements did not include any protrusions from the walls. The report recommends the continuation of the room size waiver.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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