Villa Valencia Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laguna Hills, California.
- Location
- 25000 Calle De Los Caballeros, Laguna Hills, California 92653
- CMS Provider Number
- 555462
- Inspections on file
- 26
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Villa Valencia Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its own comprehensive, person-centered care plan policy for two residents with severe cognitive impairment. After an unwitnessed fall for one resident and an upper back abrasion identified for another, staff documentation and interviews with an RN and the DON confirmed that no care plans were created to address these specific conditions, and thus no individualized interventions or goals were established.
A resident with severe cognitive impairment experienced an unwitnessed fall, and an eINTERACT Change in Condition Evaluation was completed indicating the resident was not on an anticoagulant or antiplatelet agent. However, the medical record showed an active physician order for daily clopidogrel for CAD. During interviews, an RN and the DON acknowledged that the resident was on clopidogrel and that the change in condition form should have reflected this, resulting in inaccurate documentation of the resident’s condition.
A resident with limited English proficiency, who primarily spoke Cantonese and Vietnamese, was not provided with effective communication accommodations. Despite facility policies, staff did not provide a communication board in the resident's room or utilize interpreter services, resulting in the resident relying on family members to communicate needs. Staff were unable to demonstrate knowledge or use of translation resources, and the absence of these accommodations had the potential to impact the resident's psychosocial well-being and delay care.
A resident experienced low pulse rates and poor oral intake over several days, but nursing staff did not complete follow-up assessments, notify the physician, or document interventions as required by facility policy. The DON confirmed that abnormal vital signs and poor meal intake were not consistently treated as significant changes of condition, resulting in a lack of timely clinical response.
A CNA did not wear the required gown and gloves while providing high-contact care to a resident with a central line, despite facility policy and a physician's order for enhanced barrier precautions. Signage outside the room did not indicate the need for these precautions for the resident, and staff interviews confirmed the oversight in both PPE use and updating of precaution signage.
Two residents who used bilateral grab rails had their bed rail entrapment assessments inaccurately completed, with all seven zones marked as 'pass' instead of correctly identifying which zones were applicable. The maintenance supervisor used incorrect measurement methods, and both the DON and maintenance supervisor confirmed the assessments were not done according to policy or FDA guidance.
A resident admitted with a physician's order for apixaban to treat atrial fibrillation did not have a care plan developed to address the use of this anticoagulant medication. Multiple staff, including an RN, LVN, MRD, and MDS Coordinator, confirmed the absence of a care plan, despite facility policy requiring comprehensive, person-centered care plans for each resident. The lack of a care plan was verified through medical record review and staff interviews.
Surveyors observed that dietary staff did not consistently follow hand hygiene protocols, failed to use required hair restraints, and neglected to label or date prepared food items in refrigerators and freezers. Kitchen equipment and storage areas, including chopping boards, pans, and an ice cream freezer, were found with visible residue or ice buildup. These deficiencies were acknowledged by dietary management and affected nearly all residents receiving meals from the kitchen.
Surveyors identified multiple failures in infection control, including improper separation of soiled gown hampers and PPE carts, inaccurate documentation of infection onset dates, lack of follow-up on pending cultures, and lapses in hand hygiene. Staff and leadership confirmed that soiled gown hampers were often in contact with clean PPE carts, infection surveillance logs were not accurately updated, and hand hygiene was not consistently performed between resident care tasks.
Surveyors found that essential equipment, including medication and specimen refrigerators, a blood pressure machine, a glucometer, and an ice machine, were not properly maintained or documented. Ice buildup was observed in refrigerators, a blood pressure machine was held together with tape, glucometer calibration records were inconsistent, and the ice machine was unclean with no cleaning documentation. Staff were unable to provide explanations or records for these deficiencies.
Three residents were found with their call lights out of reach, contrary to facility policy requiring call devices to be accessible. One resident, dependent on staff for mobility, waited hours for assistance after using the call light and ultimately had to yell for help. Two other residents were also observed with call lights on the floor or hanging out of reach, as confirmed by staff. All residents had the capacity to use the call light, and staff acknowledged the devices should have been accessible.
A resident was admitted with physician's orders for Synthroid and Ajovy, but these medications were omitted from the facility's electronic health record during admission. The resident did not receive Synthroid for ten days, and Ajovy was not administered due to missing frequency information. Nursing staff did not clarify the orders or monitor the resident for changes in condition related to the missed medications.
Two residents with IV catheter devices did not have their upper arm circumference measured upon admission as required by facility policy. Nursing staff confirmed the omission, and care plans for both residents included monitoring for IV-related complications, but the necessary measurements were not performed or documented.
Surveyors found that three residents' respiratory equipment, including a nebulizer, CPAP mask, and nasal cannula, were not stored in set-up bags or cleaned according to facility policy. Staff confirmed the equipment was left unbagged and undated, and there was no documentation of required cleaning, indicating a failure to follow established procedures for respiratory care.
A nurse was unable to demonstrate proper competency in calibrating a glucometer, failing to follow manufacturer instructions and producing out-of-range results during control solution testing. Despite attending a prior in-service training, the nurse had not received annual skills checks, and the device was used for blood sugar checks for multiple residents.
A nurse administered ciprofloxacin eye drops to the wrong eye of a resident who had a left eye infection, despite the medication order and MAR specifying the left eye. Both the nurse and the resident confirmed the error during interviews and record review.
Surveyors found that medications and supplements were improperly stored in an unsecured tote bag on a medication cart, with additional issues such as unreadable medication labels, leaking and expired products, and medications left unattended or improperly stored in resident rooms and common areas. Some residents had medications at their bedside without proper assessment or physician orders, and unidentified pills were found on the floor, all in violation of facility policies requiring secure and proper medication management.
Two residents who used bed rails or grab bars for mobility and repositioning did not have documented entrapment assessments, and the facility did not conduct or document regular bed inspections as required by policy. Maintenance staff performed only visual checks without measuring entrapment zones, and neither nursing nor maintenance staff completed or documented the necessary assessments to identify potential entrapment risks.
The facility did not maintain an effective pest control program, resulting in the presence of flies in the kitchen where food for nearly all residents was prepared. Flies were observed near the dishwashing area, with stagnant water and food debris contributing to the issue. The CDM, Administrator, and DON acknowledged the findings, and pest control service reports confirmed ongoing pest activity and recommended cleaning for prevention.
The facility did not ensure proper disposal of garbage and refuse, as the outside dumpster was observed overflowing and unable to be fully closed. The Maintenance Supervisor confirmed the issue and acknowledged that the dumpster should always be closed to prevent attracting pests and rodents. The Administrator and DON were made aware of these findings.
A facility failed to ensure accurate completion of the McGeer criteria for infection surveillance, resulting in a resident receiving antibiotics for a UTI when only one of the required criteria was documented. The DSD/IP acknowledged the oversight in documentation, and the DON confirmed the findings during interviews and record reviews.
A resident's medical record was found to be incomplete and inaccurate, lacking documentation of admission time, staff involved, and details of refused care and assessments. The resident refused all care and left AMA, but the required documentation per facility policy was not present, and the Leaving Facility Against Medical Advice form contained an incorrect notification date. The DON confirmed these documentation gaps during review.
A facility failed to document interviews with all relevant staff during an abuse investigation involving a resident who was reportedly choked by her roommate. The facility's P&P requires thorough investigation, including interviews with all staff who had contact with the resident. However, the Administrator only documented statements from an RN and a CNA, neglecting to document other staff interviews, potentially impacting the resident due to incomplete investigation information.
The facility failed to ensure dietary staff used hair and beard restraints in the kitchen, as required by the USDA Food Code 2022 and the facility's policy. The Dietary Services Director and another staff member were observed without the necessary coverings, posing a risk of foodborne illnesses to residents. The Administrator confirmed the requirement for these coverings.
A resident was prescribed Levaquin for pneumonia, but neither the resident nor their responsible party (RP) was informed of the new medication order. The facility's policy requires notification of changes in medical treatment, but a review of the medical record confirmed no documentation of such notification. The ADON verified this oversight, indicating a deficiency in communication.
A resident experienced an unwitnessed fall, and the facility failed to promptly notify the resident's physician as per its policies. The fall occurred at 0145 hours, but the physician was not informed until 0700 hours. Interviews with staff confirmed the delay, acknowledging that the notification was not prompt, as required by the facility's P&P.
The facility failed to resubmit Level I PASARR screenings for two residents who stayed beyond 30 days, despite having mental health diagnoses. Staff interviews revealed a lack of awareness and oversight regarding the requirement to resubmit these screenings, with the DON, ADON, and Social Service Director all unaware of the need for compliance.
A resident was prescribed trazadone hydrochloride as a PRN psychotropic medication without a required 14-day stop date, and there was no monitoring for side effects, contrary to facility policy. Interviews with staff, including LVNs and the DON, confirmed the oversight and lack of adherence to protocols for monitoring and documentation.
Failure to Develop Care Plans After Fall and Abrasion Events
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for identified conditions, as required by its own policy. The facility’s policy titled "Care Plans, Comprehensive Person-Centered" (revised December 2016) states that a comprehensive care plan with measurable objectives and timetables must be developed and implemented for each resident to meet physical, psychosocial, and functional needs, and that the IDT must review and update the care plan when there is a significant change in condition. For one resident with severe cognitive impairment, an eINTERACT Change in Condition Evaluation dated 11/26/25 documented an unwitnessed fall. Review of this resident’s plan of care showed no care plan was developed to address the actual fall on that date. During interviews and concurrent record reviews, RN 2 and the DON both verified that there was no care plan for the fall and stated that the licensed nurse should have created one with appropriate interventions and goals. For another resident, also with severe cognitive impairment, a Post Fall IDT note dated 1/12/26 documented an upper back abrasion. Review of this resident’s plan of care showed no care plan was developed to address the upper back abrasion. In interviews with RN 2 and the DON, both confirmed that there was no care plan addressing the abrasion. RN 2 stated that the licensed nurse should have created a care plan so that interventions would be implemented and goals created, and the DON stated that a care plan should have been completed to address the resident’s upper back abrasion. These findings demonstrate that, for two of five sampled residents, the facility did not develop care plans reflecting their individual care needs following identified events and conditions, contrary to the facility’s written policy.
Inaccurate Change in Condition Documentation for Resident on Antiplatelet Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for one resident in accordance with its own charting and documentation policy. The facility’s policy, revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s medical, physical, functional, or psychosocial condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team. For a resident with severe cognitive impairment, an eINTERACT Change in Condition Evaluation V5 dated 1/12/26 documented an unwitnessed fall. On this form, the question regarding whether the resident was on another anticoagulant (direct thrombin inhibitor or platelet inhibitor) was answered “no.” Medical record review showed that, as of 12/25/25, there was a physician’s order for clopidogrel bisulfate 75 mg orally once daily for coronary artery disease, which is an antiplatelet medication used to prevent blood clots. During interviews with RN 2 and the DON, both confirmed that the resident was receiving clopidogrel and that the nurse completing the change in condition evaluation should have answered “yes” to the anticoagulant/antiplatelet question to ensure accurate documentation. The inaccurate response on the change in condition form constituted a failure to accurately document the resident’s status in the medical record as required by facility policy.
Failure to Provide Communication Accommodations for LEP Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with limited English proficiency (LEP) who primarily spoke Cantonese and Vietnamese. Despite facility policies requiring language assessments, notification of language access coordinators, and provision of communication aids such as interpreters and communication boards, the resident was not provided with effective means to communicate daily needs. Observations and interviews revealed that the resident could not effectively communicate with staff due to the absence of staff who spoke her language, lack of a communication board in her room, and no use of telephone translation services by staff. The resident's medical records indicated she was alert, oriented, and had moderate cognitive impairment, with a stated preference for communication in Cantonese and a need for an interpreter. During interviews, the resident reported having to wait for family members to communicate her needs, as staff did not use available translation resources. Staff members, including an LVN and CNA, were unable to locate a communication board in the resident's room and demonstrated a lack of knowledge regarding the use of language line services. The Director of Staff Development also failed to show that communication aids were available for the resident. Family members expressed concern about the resident's ability to have her needs met, especially during times when family was not present. They confirmed that staff had not used communication boards or translation services during the resident's stay. The facility's failure to provide these accommodations had the potential to negatively impact the resident's psychosocial well-being and could result in delayed provision of care, as the resident's needs may not have been effectively communicated or addressed.
Failure to Assess, Notify, and Document Changes in Resident Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure the highest practicable well-being for a resident, as required by professional standards and the facility's own policies. Specifically, the facility did not complete follow-up assessments, notify the physician, or document actions taken when the resident exhibited a low pulse rate and poor oral intake. The resident's medical records showed multiple instances of bradycardia, with pulse rates below 60 bpm, and there was no evidence that these abnormal findings were followed up with appropriate clinical interventions or physician notification, as outlined in the facility's policy for changes in a resident's condition. Additionally, the resident experienced a significant decline in meal intake over several days, with documented refusals and consumption of less than 25% of meals on multiple occasions. Despite this, there was no documentation of follow-up assessments, physician notification, or care plan adjustments in response to the resident's poor nutritional intake. Interviews with nursing staff confirmed that these changes were observed and reported to charge nurses, but the required documentation and clinical follow-up were not completed. The Director of Nursing (DON) indicated that abnormal vital signs alone were not considered a significant change of condition and did not expect licensed nurses to document follow-up entries after providing interventions. The DON also stated that a significant change of condition related to meal intake would only be recognized after three to four days of consecutive low intake with refusal. These practices were inconsistent with the facility's policy and contributed to the failure to ensure timely and appropriate care for the resident.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to wear the appropriate personal protective equipment (PPE) while providing high-contact care to a resident with an indwelling medical device. The facility's policy required staff to don both gown and gloves during high-contact care activities for residents with indwelling devices, such as central lines, to prevent the transmission of multidrug-resistant organisms (MDROs). During an observation, the CNA was seen wearing only gloves while assisting the resident with morning care and transferring them to a wheelchair, despite the resident having a physician's order for enhanced barrier precautions (EBP) due to a central line for dialysis access. The signage outside the resident's room indicated that only the roommate was on EBP, and did not reflect that the observed resident also required these precautions. The registered nurse (RN) confirmed that the signage should have included the resident, as per the physician's order, and stated that the Director of Staff Development (DSD) was responsible for updating such signage. The infection prevention (IP) nurse also confirmed that staff must wear both gown and gloves for residents with EBP orders and that she was responsible for ensuring proper signage and PPE availability. Interviews with facility staff, including the CNA, RN, IP nurse, and Director of Nursing (DON), confirmed awareness of the EBP requirements and the importance of following them to prevent infection transmission. However, the failure to update signage and ensure staff compliance with PPE protocols resulted in a lapse in infection control practices for the resident with a central line. This deficiency was identified through observation, interviews, and review of facility policies and the resident's medical record.
Inaccurate Bed Rail Entrapment Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed rails were accurately and completely performed for two residents who used bilateral grab rails. According to the FDA's guidance, there are seven zones in a bed system where entrapment can occur, and the facility's policy requires regular inspection and assessment of these zones to identify potential risks. However, the entrapment assessments for both residents were incorrectly completed, with some zones marked as 'pass' when they should have been marked as 'not applicable' based on the type of bed rails in use. For one resident, who had moderate cognitive impairment and used bilateral grab rails for mobility and transfers, the assessment marked all seven zones as 'pass' even though only certain zones were relevant for the type of rails installed. Similarly, for another resident who was cognitively intact and also used bilateral grab rails, the assessment again marked all zones as 'pass' instead of correctly identifying which zones applied. The maintenance supervisor, responsible for these assessments, was found to have used an incorrect method for measuring one of the zones and confirmed that the assessments were inaccurate. Observations and interviews with staff, including the Director of Nursing and the maintenance supervisor, verified that the entrapment assessments were not completed according to the facility's policy or the FDA guidance. The inaccurate assessments had the potential to negatively impact residents by failing to properly identify and mitigate entrapment risks associated with the use of bed rails.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who was prescribed an anticoagulant medication, apixaban, for atrial fibrillation. The resident was admitted with a physician's order for apixaban, and the medical record confirmed the resident had the capacity to understand and make decisions. Despite this, a review of the resident's medical record did not show any care plan addressing the use of the anticoagulant medication. Interviews with facility staff, including an RN, LVN, the Medical Records Director (MRD), the MDS Coordinator, and the Director of Nursing (DON), confirmed that no care plan was developed for the anticoagulant medication. The RN verified the existence of the physician's order but stated she was not responsible for developing care plans for anticoagulant use upon admission. The LVN emphasized the importance of having a care plan for anticoagulant medications to outline goals and interventions such as monitoring for side effects and reassessment of outcomes. Further interviews revealed that the MRD was responsible for auditing new admission charts for medication entries and baseline assessments, but the ADON and MDS Coordinator were responsible for reviewing and initiating care plans for medications. The MDS Coordinator confirmed that a care plan for anticoagulant use should have been initiated as soon as possible and acknowledged its absence in the resident's record. The DON was informed and acknowledged the findings.
Multiple Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as evidenced by multiple observed deficiencies during surveyor visits. Dietary staff were seen not following proper hand hygiene protocols, such as failing to wash hands after handling potentially contaminated items and not wearing gloves during food preparation. Additionally, staff did not consistently use required hair restraints, including beard covers, while working in food preparation areas, as confirmed by both observation and staff interviews. Food storage practices were also found to be deficient. Several prepared food items in the refrigerator, such as bowls of salad, fruit, and cups of iced tea, were not labeled or dated as required by facility policy. In the walk-in freezer, containers of mustard, sour cream, and cheese were either undated or had expired use-by dates. These issues were acknowledged by dietary staff and management during interviews. Sanitation of kitchen equipment and storage areas was inadequate. Observations revealed chopping boards and a nonstick pan with visible residue, and an ice cream freezer with significant ice buildup, all of which were verified by dietary management. These failures had the potential to cause foodborne illnesses for the 53 residents who consumed food prepared in the kitchen, as nearly all residents received meals from this area.
Deficiencies in Infection Control Practices and Documentation
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were identified through observations, interviews, and record reviews. Staff failed to maintain separation between clean PPE isolation carts and soiled disposable gown hampers in several resident rooms, with the hampers often touching the carts and, in some cases, overflowing and preventing lids from closing. These lapses were observed for multiple residents on enhanced barrier precautions (EBP) due to conditions such as indwelling urinary catheters, wounds, and gastrostomy tubes. Staff, including RNs and CNAs, acknowledged that the soiled gown hampers should not be in contact with PPE carts due to the risk of contamination, but the issue persisted across several rooms. Further deficiencies were noted in the facility's infection surveillance documentation. The onset dates of infections for two residents were inaccurately recorded on the Infection Prevention and Control Surveillance Log, with staff using the date antibiotics were started rather than the actual onset of infection symptoms. Additionally, pending culture results for several residents were not updated in the surveillance logs, and in one case, there was no documentation of follow-up for a canceled culture. The Director of Staff Development/Infection Preventionist (DSD/IP) and DON confirmed these documentation errors during interviews and acknowledged that the logs should have been completed accurately and updated in a timely manner. Hand hygiene practices were also found to be deficient. A CNA was observed failing to perform hand hygiene after delivering a food tray to a resident on EBP and before delivering a tray to another resident. The CNA admitted to forgetting to sanitize hands between tasks, and the DSD/IP confirmed that hand hygiene should have been performed according to facility policy. These failures in infection control practices, documentation, and hand hygiene were verified by facility leadership and staff during the survey.
Failure to Maintain Essential Equipment in Safe and Clean Condition
Penalty
Summary
Surveyors observed multiple failures in the maintenance and safe operation of essential equipment within the facility. During inspections, the medication refrigerator and a specimen refrigerator were both found with significant ice buildup in their freezer compartments. In the medication refrigerator, melting ice was dripping water onto medication packages and bags stored below, and there was no documentation or recollection from staff regarding when the refrigerator was last defrosted. Similarly, the specimen refrigerator also had ice buildup, and facility leadership could not explain the cause. Additionally, a blood pressure machine in the rehabilitation area was found to be held together with clear tape, and staff could not identify the brand or provide a reason for the tape other than to keep the device intact. Further review of the facility's glucometer quality control practices revealed discrepancies in documentation and calibration. The serial number recorded on the quality control record did not match the glucometer in use, and the control ranges documented did not align with those printed on the test strip bottle. Staff interviews confirmed that calibration was supposed to be performed nightly and documented, but the records were inconsistent and did not reflect the actual equipment or correct control ranges. In the kitchen, the ice machine was found to be unclean, with brown residue observed inside the bin. The facility's policy required monthly cleaning and documentation, but the Maintenance Supervisor stated the machine was cleaned only every six months and could not provide records of the last cleaning. The Maintenance Supervisor was also unaware of the brown buildup present in the machine. These findings were verified by multiple staff members during the inspection.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for three residents by not ensuring their call lights were within reach, as required by facility policy. Observations revealed that one resident, who was cognitively intact and dependent on staff for bed mobility and personal care, reported using the call light during the night due to leg pain but waited two to three hours for assistance. The resident eventually resorted to yelling for help when no one responded, and subsequent observation confirmed the call light was on the floor and not accessible. Another resident, also with decision-making capacity, was observed twice with the call light on the floor and out of reach, which was verified by a CNA who acknowledged the call light should be accessible for the resident to request help. A third resident, who had severe cognitive impairment but no physical limitations to upper or lower extremities, was observed with the call light hanging on the side of the bed and not within reach. This was confirmed by a restorative nursing assistant, who stated the resident could use the call light if it were accessible. Medical record reviews for all three residents confirmed their cognitive and physical statuses at the time of the incidents. The facility's policy requires staff to ensure call lights are within residents' reach before leaving the room, but this was not followed in these cases.
Failure to Administer Prescribed Medications Upon Admission
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with physician's orders for Synthroid (levothyroxine) and Ajovy (fremanezumab-vfrm) as documented in the acute care hospital's discharge report. During the admission process, these medication orders were omitted from the facility's electronic health record. The resident, who was cognitively intact and able to communicate medical needs, did not receive Synthroid for ten days after admission, and there was no evidence that Ajovy was administered. The omission was not identified or clarified with the physician, the resident, or family members during the initial medication reconciliation. Interviews with nursing staff revealed that the nurse responsible for entering the orders missed the Synthroid and did not enter Ajovy due to a lack of frequency information on the discharge report. There was no double-checking of the medication list to ensure all orders were transcribed, and no follow-up occurred to clarify missing information. The resident reported feeling weak several days after admission, but this was not associated with the missed medication by staff, and no monitoring or laboratory tests were initiated in response to the resident's symptoms.
Failure to Measure Arm Circumference for Residents with IV Catheters
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids by not measuring the upper arm circumference for two residents with intravenous catheter devices as required by facility policy. For one resident with a midline catheter in the right upper arm, the medical record did not show documentation of the arm circumference measurement upon admission, nor was it measured during the resident's stay. The care plan for this resident included monitoring for signs of infection and complications at the IV site, but the required measurement was omitted. During interviews, nursing staff confirmed that the arm circumference was not measured and that the orders for dressing changes referenced a PICC line instead of the correct midline catheter. Another resident with a PICC line in the right upper arm also did not have documentation of the arm circumference measurement upon admission, despite physician orders and care plan interventions specifying this requirement. The resident was receiving IV antibiotics through the PICC line, and the care plan addressed the risk for IV-related complications, including infection and swelling. Nursing staff verified that the measurement was not performed or documented, acknowledging that it should have been done to monitor for complications. Facility policy required that upper arm circumference be measured three inches (10 cm) above the insertion site upon admission for residents with midline or PICC lines. The failure to perform and document these measurements for both residents was confirmed through medical record review, staff interviews, and observation, and was acknowledged by facility leadership.
Improper Storage and Cleaning of Respiratory Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide safe and appropriate respiratory care for three residents who required respiratory equipment, including a nebulizer, CPAP, and oxygen via nasal cannula. For one resident, a nebulizer mask and tubing were found stored unbagged and undated inside a bedside table drawer, in direct contact with the drawer's base. The resident confirmed receiving nebulizer treatments twice daily. A nurse verified that the nebulizer equipment should have been properly bagged and dated, but it was not. Another resident's nasal cannula tubing was observed placed on top of the oxygen concentrator and not stored in a set-up bag when not in use, which was also confirmed by nursing staff as not meeting facility policy. Additionally, a third resident's CPAP mask was found on the nightstand without a set-up bag for storage when not in use. Review of the resident's care plan and facility policy indicated that the CPAP mask, tubing, and related equipment should be cleaned regularly, but there was no documented evidence of cleaning in the medical record. Nursing staff were unsure about cleaning procedures and stated there was no order for cleaning the CPAP equipment. These observations and interviews confirmed that the facility did not follow its own policies and procedures for the storage and cleaning of respiratory care equipment for these residents.
Failure to Ensure Nurse Competency in Glucometer Calibration
Penalty
Summary
A licensed vocational nurse (LVN) was observed performing a calibration of a glucometer and was unable to demonstrate competency in the procedure. The LVN did not follow the manufacturer's instructions, specifically failing to enter the control solution mode as indicated by the absence of the control solution bottle icon on the glucometer screen. The LVN performed control solution tests for both low and high controls, with the high control repeatedly producing out-of-range results. The LVN confirmed that he had not received annual skills checks on glucometer calibration since his initial training three years prior. Facility documentation showed that six residents required blood sugar checks using the glucometer in question. The Director of Staff Development/Infection Preventionist (DSD/IP) stated that glucometer calibration should be performed when a new device is used and provided evidence of a prior in-service training, which the LVN had attended. However, the LVN was unable to correctly perform the calibration during the survey, indicating a lack of ongoing competency verification.
Medication Error: Eye Drops Administered to Wrong Eye
Penalty
Summary
A registered nurse (RN) administered ciprofloxacin 0.3% antibiotic eye drops to the wrong eye of a resident who had a documented left eye infection. The medication administration record (MAR) and the medication label both indicated that the drops were to be instilled in the resident's left eye. During a medication pass observation, the RN was seen preparing and then administering the eye drop to the resident's right eye instead of the left as ordered. Upon review of the MAR and interview with the RN, it was confirmed that the order specified administration to the left eye for a left eye infection. The RN acknowledged the error after reviewing the order and the MAR. The resident also confirmed that the eye drop was given in the right eye and that the infection was in the left eye. This event constitutes a significant medication error as the medication was not administered as prescribed by the physician.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications and biologicals within the facility. Medications and supplements for one resident were found stored in a tote bag hanging from a medication cart, which was left unsupervised and unsecured in a hallway. The tote bag contained various opened bottles and loose, unidentified tablets, and the responsible RN acknowledged that there was no available space in the medication cart for these items. Additionally, the RN confirmed that all medications and supplements should be securely stored, but this was not done at the time of observation. Further observations revealed additional lapses in medication management. An Advair inhaler label was found to be faded and unreadable, and a leaking bottle of povidone iodine and a wound cleanser with brownish drops were found in a treatment cart. Expired Sanicloth wipes and Glucerna GT feeding formulas were also discovered in storage areas. In several instances, medications were left unattended or improperly stored, including a box of semaglutide left on a resident's bedside table, magnesium found on top of another resident's dresser, and albuterol inhaler not stored in its protective pouch. In some cases, residents had not been assessed or authorized to self-administer or keep medications at their bedside, and there were no corresponding physician orders. Additional findings included unidentified tablets and capsules found on the floor in front of the nursing station, with staff unable to identify the medications or their intended recipients. Facility policy reviews confirmed that medications are to be stored securely, labeled properly, and only accessible to authorized personnel. However, these policies were not consistently followed, as evidenced by the observed deficiencies in medication storage, labeling, and security throughout the facility.
Failure to Conduct Regular Bed Inspections and Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular bed inspections as part of its maintenance program to identify potential areas of entrapment for two residents. According to facility policy, maintenance staff are required to inspect all beds and related equipment, including bed frames, mattresses, and side rails, to identify risks such as entrapment. However, interviews with the Maintenance Supervisor revealed that monthly bed inspections were performed visually without documentation, and no entrapment assessments were conducted. The Maintenance Supervisor also stated that he did not have the necessary measuring device to assess entrapment zones and had not received or requested such a tool. For one resident, who was cognitively intact and used bilateral grab bars for bed mobility and repositioning, there was no documented evidence of an entrapment assessment being completed. The resident's medical record included a physician's order for the use of grab rails, but neither the maintenance staff nor nursing staff performed or documented the required entrapment assessment. The ADON confirmed that while an assessment related to the use of the device was completed, a specific entrapment assessment was not performed. Another resident, who had fluctuating mental clarity due to multiple comorbidities and medications and required extensive assistance for mobility, also used bilateral halo rails. Despite a physician's order and staff interviews confirming the use of these rails for mobility and repositioning, there was no evidence of a regular bed inspection or entrapment assessment. Staff interviews indicated a lack of awareness and training regarding the need for entrapment assessments, and no documentation or logs of such assessments were available.
Failure to Prevent Flies in Kitchen Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent the presence of flies in the kitchen. Observations and interviews confirmed that flies were present in the kitchen area, specifically near the dishwashing machine, where stagnant water was also noted. The Certified Dietary Manager (CDM) acknowledged the presence of flies and attributed it to the stagnant water in the dishwashing area. Review of pest control service reports indicated that flies had been observed in the kitchen and drains during previous inspections, and food debris was found under shelves, sinks, cooking areas, and coolers. Recommendations from the pest control provider included cleaning these areas to prevent pest activity. Facility documentation showed that 53 of 54 residents consumed food prepared in the kitchen, highlighting the potential for widespread exposure. The facility's pest control policy stated an ongoing program to keep the building free of insects and rodents, but the presence of flies and food debris indicated lapses in implementation. The Administrator and Director of Nursing (DON) were informed of and acknowledged these findings during interviews.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse as required by both the USDA Food Code and its own policies and procedures. During an observation, the outside dumpster was found overflowing with trash, which prevented the lid from fully closing. The Maintenance Supervisor confirmed that the dumpster is collected six times a week, except Sundays, and acknowledged that the dumpster should remain fully closed at all times. Both the Administrator and DON were informed of and acknowledged these findings during interviews. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Accurately Apply McGeer Criteria in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to properly implement its antibiotic stewardship program as required by its own policies and procedures. Specifically, the facility did not ensure that the McGeer criteria, which are used to determine true infections in long-term care settings, were accurately completed for a resident. Medical record review showed that only one of the required criteria for urinary tract infection (UTI) surveillance was fulfilled, yet the checklist indicated that the UTI criteria were met. Despite this, a physician's order was written to administer cephalexin for a UTI. The Director of Staff Development/Infection Preventionist (DSD/IP) confirmed that two criteria must be met for the McGeer criteria for UTI, but acknowledged that only one was checked and that she had forgotten to check the second box, even though she believed it was fulfilled. Interviews with both the DSD/IP and the Director of Nursing (DON) confirmed the findings that the McGeer criteria were not accurately documented or followed. The DSD/IP stated that her determination of a true infection was based on the boxes checked on the surveillance checklist, which in this case was incomplete. This failure to accurately apply and document the McGeer criteria had the potential to result in inappropriate antibiotic use and misidentification of true infections.
Incomplete and Inaccurate Medical Record Documentation for Resident Admission and Discharge
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete, specifically regarding the resident's admission, refusal of care, and discharge information. Review of facility policies indicated that documentation should include the date and time of assessment, the name and title of the staff performing the assessment, relevant assessment data, how the resident tolerated the assessment, any physician orders, and the signature and title of the person recording the data. However, the resident's medical record lacked documentation of the time of admission, the nurse who interacted with the resident, and details about which assessments and care were refused. Additionally, the Leaving Facility Against Medical Advice form contained an inaccurate date for when the responsible party was notified. Interviews with staff confirmed that the resident was admitted in the evening, refused all care and assessments, and left the facility against medical advice. The Director of Nursing acknowledged that the expected documentation regarding the resident's admission time, general health condition upon arrival, and refusals of care or services was missing from the record. The discrepancies and omissions in the documentation were verified during the closed record review.
Failure to Document Staff Interviews in Abuse Investigation
Penalty
Summary
The facility failed to document interviews with all relevant staff during an abuse investigation involving a resident, as required by their policy and procedure (P&P). The incident involved a resident who was reportedly choked by her roommate, as communicated by the resident's family member. The facility's P&P, revised in December 2022, mandates a thorough investigation of abuse allegations, including interviews with all staff members who had contact with the resident during the period of the alleged incident. However, the Administrator only documented the statements of an RN and a CNA, neglecting to document interviews with other staff members who may have had relevant information. The deficiency was identified during a review of the facility's records and interviews with the Director of Nursing (DON) and the Administrator. The DON confirmed that the investigation process should include interviews with the victim, perpetrator, neighboring residents, and relevant staff. Despite this, the Administrator admitted to speaking with several staff members but failing to document these interviews, citing a lack of awareness of the requirement to do so. This oversight in documentation had the potential to negatively impact the resident, as the investigation information was incomplete.
Failure to Use Hair and Beard Restraints in Kitchen
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as observed during a survey. Specifically, the dietary staff did not use hair and beard restraints as required by both the USDA Food Code 2022 and the facility's own policy. The Dietary Services Director was seen without a hair covering, and another staff member was observed without a beard covering while working in the kitchen. This oversight was confirmed by the Dietary Services Director, who acknowledged the requirement for hairnets but was unsure about the necessity of beard coverings. The facility's policy, dated 2018, mandates that kitchen staff wear hair coverings and beard restraints to prevent hair from contacting food and food-related surfaces. During an interview, the Administrator and Director of Nursing (DON) were informed of these findings. The Administrator confirmed that the kitchen staff should adhere to the policy by wearing the appropriate hair and beard coverings. This failure posed a risk of foodborne illnesses to the medically vulnerable resident population consuming food prepared in the kitchen.
Failure to Notify Resident or RP of New Medication Order
Penalty
Summary
The facility failed to ensure that a resident or their responsible party (RP) was informed of a new medication order. Specifically, Resident 1 was prescribed Levaquin, an antibiotic, for pneumonia, but neither the resident nor their RP was notified of this new medication order. This oversight was identified during an interview with Family Member 1, who reported that the RP was unaware of the medication until the resident began experiencing side effects, such as vomiting. A review of Resident 1's medical records confirmed the lack of documentation indicating that the resident or their RP was informed about the new prescription. The facility's policy and procedure (P&P) require prompt notification of changes in a resident's medical condition or treatment to the resident and their RP. However, the Assistant Director of Nursing (ADON) verified that there was no documentation in the medical record to show that the notification had occurred, highlighting a deficiency in communication and adherence to the facility's P&P.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to promptly notify a resident's physician following an unwitnessed fall, as required by its policies and procedures (P&P). The incident involved a resident who was cognitively intact, with a BIMS score of 13, and who experienced an unwitnessed fall at 0145 hours. The facility's P&P mandates that the resident's attending physician and responsible party be notified immediately after such incidents. However, the physician was not informed until 0700 hours, over five hours after the fall occurred. Interviews with facility staff, including an LVN and the ADON, confirmed the delay in notification. The LVN acknowledged completing the Change of Condition (COC) documentation and notifying the physician at 0700 hours, stating that physicians should be informed as quickly as possible to ensure appropriate interventions. The ADON also verified the delay and recognized that the notification was not prompt, as required by the facility's P&P. The DON was informed of these findings and acknowledged the deficiency.
Failure to Resubmit Level I PASARR for Residents
Penalty
Summary
The facility failed to submit a Level I Preadmission Screening and Resident Review (PASARR) for two residents who stayed in the facility for more than 30 days. According to the facility's policy, all new admissions and readmissions must be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process. Resident #3, admitted with a history of bipolar disorder and major depressive disorder, and Resident #107, admitted with major depressive disorder, did not have a new Level I screening submitted after the 31st day of their admission, as required by the State of California-Health and Human Services Agency Department of Health Care Services. Interviews with facility staff revealed a lack of awareness and oversight regarding the requirement to resubmit Level I PASARR screenings after 30 days. The Director of Nursing was unaware of any residents needing a new Level I PASARR, and the Assistant Director of Nursing, who was responsible for overseeing PASARR screenings, admitted that the letters for the residents were not reviewed, and the screenings were not resubmitted. The Social Service Director was also unaware of the requirement, and the Administrator expected the nursing staff to complete the PASARR screenings as required.
Failure to Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation for a resident prescribed a PRN psychotropic medication, specifically trazadone hydrochloride, for depression-related insomnia. The facility's policy mandates that PRN orders for psychotropic medications be limited to 14 days and that residents be monitored for adverse effects. However, the order for the resident did not include a stop date, and there was no evidence of monitoring for side effects as required by the facility's policy. Interviews with facility staff, including LVNs and the Director of Nursing, revealed a lack of adherence to the policy. LVN #3 admitted to an oversight in not including a stop date and failing to document monitoring for side effects. The Director of Nursing and the Nurse Practitioner both confirmed that PRN psychotropic medication orders should include a stop date and require monitoring for side effects. The Administrator expressed an expectation for staff to follow proper protocols, indicating a systemic issue in policy implementation.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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