Vineland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 10830 Oxnard Street, North Hollywood, California 91606
- CMS Provider Number
- 555011
- Inspections on file
- 35
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Vineland Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple neurologic diagnoses, and total dependence for ADLs was identified as a fall risk and had a physician order for a tab alarm, but the facility did not develop a care plan addressing the alarm’s use, monitoring, or related interventions. A CNA reported leaving the dependent, non-alert resident in a wheelchair with a family member while obtaining hygiene supplies, with the tab alarm device left on the bed and not attached to the resident, so no alarm sounded. When the CNA returned, the resident was found on the floor after sliding from the wheelchair and reporting elbow pain. IDT notes and staff interviews confirmed there was no tab alarm care plan, and staff cited lack of education and incorrect implementation of the alarm, despite facility policies requiring alarms to be used per the care plan and comprehensive care plans with measurable objectives and timeframes.
A resident with severe cognitive impairment, Parkinson’s disease, dementia, and total dependence for ADLs had a physician order for a tab alarm and was assessed as a fall risk, but no specific care plan was developed for the alarm. A CNA left the resident in a wheelchair to obtain hygiene supplies, leaving the tab alarm on the bed with the magnet still attached, so it did not sound when the resident moved. While the CNA and family member were out of the room, the resident slid from the wheelchair to the floor and sustained an acute fracture, and staff later acknowledged the alarm had not been correctly implemented and was not included in the care plan.
A resident with COPD, type 2 DM with neuropathy, and HTN had multiple scheduled oral medications, including daily bupropion, clopidogrel, docusate, Jardiance, losartan, and TID Lyrica. On the survey day, an LVN prepared the resident’s morning medications and noted the ordered docusate capsule was not available in the cart. The LVN administered the remaining scheduled morning medications more than two hours after their scheduled time and later stated that the medications were the resident’s 9 a.m. doses, acknowledging they were late. Review of the MAR showed docusate documented as given at the scheduled time even though the LVN reported it had not yet been received or administered. The DON confirmed that medications were not given within the facility’s 1-hour window, physician orders were not followed, and the MAR was signed before actual administration, contrary to facility policy.
A resident with severe cognitive impairment and epilepsy was not readmitted to the facility after a hospital stay, despite being ready for discharge and facility policy supporting the right to return. The decision to deny readmission was made by the Administrator and DON, even though the facility was equipped to care for the resident and there was no policy-based reason for refusal. The resident was eventually readmitted after several days, resulting in a violation of the resident's right to readmission.
A facility failed to maintain a sanitary environment, leading to an infection control deficiency. A shared bathroom used by a resident with a complex medical history was found with overflowing trash and unflushed waste. Staff interviews confirmed the need for immediate cleaning to prevent infection spread, but the facility's policy on routine bathroom cleaning was not followed.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, affecting seven residents. Observations showed temperatures ranging from 65.1 to 70.3 degrees Fahrenheit. Staff interviews and facility policy emphasized the importance of maintaining appropriate temperatures for resident comfort and safety.
A resident in an LTC facility was physically and verbally abused by another resident, resulting in multiple injuries. The incident occurred when one resident struck another, pushed a bedside table causing a fall, and yelled profanities. The altercation was witnessed by an LPN, who documented the event and noted the injuries sustained by the victim. The facility's policy classified the incident as abuse.
The facility failed to maintain a homelike environment, as observed in missing lamp covers in two residents' rooms, peeling paint in two shower rooms, and a torn floor mat in a resident's room. The Maintenance Supervisor and DON acknowledged these issues, which could affect residents' safety and comfort.
The facility failed to obtain physician's orders and informed consent for the use of bed rails and bed placement against the wall for three residents, potentially leading to entrapment. Observations revealed that residents had beds placed against walls with side rails up, without proper documentation. The facility's policies require informed consent and physician's orders for such restraints, which were not followed in these cases.
The facility failed to provide in-service training on physical restraints, risking inappropriate use. A resident with limited mobility was observed with side rails up, unable to adjust them, while another resident's bed was against the wall for wheelchair space. The facility's policy considers such setups as restraints, but no training was provided to staff.
The facility did not post the actual hours worked by nursing staff in a visible and prominent place daily. Observations and interviews revealed that the information was located inside the nursing station and next to the staff clock-in area, making it inaccessible to residents and visitors. The facility's policy required daily posting of staffing information, including the facility name, current date, total number, and actual hours worked by RNs, LPNs, CNAs, and the resident census.
A facility failed to reassess a resident's ability to self-administer medication upon re-admission and quarterly, as required by the care plan. The resident, with type two diabetes and a colostomy, was initially assessed as capable of self-administration, but no further assessments were conducted. Interviews with the MDSN and DON confirmed the oversight, highlighting the importance of timely reassessments to prevent medication errors. The facility's policy requires reassessment under certain conditions, which were not followed in this case.
A facility failed to maintain the privacy of a resident's medical records when an LVN left the EHR open and unattended on a medication cart. The resident, who had severe cognitive impairment, was at risk of having their confidential information accessed by unauthorized individuals. The LVN admitted the oversight, and the DON highlighted the importance of protecting resident information, as per the facility's policy.
The facility failed to develop comprehensive care plans for two residents regarding bed placement against the wall, posing a risk for entrapment. Both residents had significant medical conditions and required assistance, yet lacked care plans to guide staff on necessary interventions. This oversight could lead to inconsistent care delivery.
A resident with dementia and other health issues was discharged without a documented referral to a home health agency, as required by the facility's discharge planning policy. The Social Services Director did not document the referral process or ensure the resident's post-discharge care needs were met, relying on the board and care to handle the referral. This oversight was contrary to the facility's policy, which mandates documentation of all assessments and services provided.
A resident with an indwelling catheter had their urinary drainage bag improperly positioned flat on the floor, contrary to facility policy. This practice, observed by staff, posed a risk of contamination and infection. The resident, who required assistance with personal hygiene, had a history of UTIs and sepsis. Staff interviews confirmed the correct procedure was not followed, highlighting a deficiency in catheter care.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, missing required monitoring on two occasions. The DON confirmed the oversight, which was against the facility's policy requiring documentation of the dialysis access site status after treatment.
A facility failed to monitor side effects of psychotropic medications and signs of bleeding for a resident with dementia and Parkinson's, and did not specify aspirin dosage for another resident with hemiplegia and a recent MI. The lack of documentation and dosage specification violated facility policies, potentially delaying care and risking incorrect medication administration.
A facility failed to implement Enhanced Barrier Precautions for a resident with a gastrostomy tube. LVN and CNA did not wear isolation gowns during medication administration and repositioning, contrary to facility policy. The oversight was acknowledged by staff, and the DON confirmed the lack of infection control.
The facility did not make state inspection results readily accessible to residents and their representatives, as required. Observations revealed that the results were stored in a closed cabinet at the nurse's station, requiring individuals to request access from staff. Interviews with an RN and the DON confirmed this practice, which contradicted the facility's policy of having the survey binder available in the main lobby.
The facility did not meet the required 80 square feet per resident in multiple resident bedrooms, affecting 18 out of 20 rooms. Despite this, observations showed residents had adequate space, and staff could provide care safely. The facility requested a waiver, asserting that the room size did not impact residents' health and safety.
Failure to Care Plan and Implement Ordered Tab Alarm Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan for the ordered use of a tab alarm for a resident at high risk for falls. The resident was originally admitted with metabolic encephalopathy, Parkinson’s disease, difficulty in walking, dementia, and Alzheimer’s disease. An MDS assessment showed the resident had severe cognitive impairment and was fully dependent on staff for toileting, dressing, and personal hygiene. A fall risk assessment identified the resident as being at risk for falls, and on 2/18/2026 the physician ordered the use of a tab alarm for this resident. However, there was no corresponding care plan created that outlined individualized interventions, measurable objectives, or timeframes for the use and monitoring of the tab alarm. On the date of the fall, a CNA reported that the resident was not alert, was fully dependent on staff, and required two-person assistance for transfers between bed and wheelchair. The CNA stated that the resident had a tab alarm intended to alert staff when the resident moved, and that the same alarm was used in both bed and wheelchair. The CNA described leaving the resident in a wheelchair with a family member present while the CNA left the room to obtain hygiene supplies. At that time, the tab alarm device was on the bed and not connected to the resident, and its magnet remained attached, so no alarm sounded. When the CNA returned, the resident was found on the floor, having slid from the wheelchair, and later reported left elbow pain. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor after the CNA stepped out, and that the family member walked out of the room with the tab alarm off. Facility staff, including an LVN, acknowledged that they could not definitively identify who removed the alarm, and that there had been a failure in the system related to lack of staff education on tab alarm use, lack of family knowledge, and incorrect implementation of the alarm. Review of the comprehensive care plan confirmed there was no specific care plan for the tab alarm despite the physician’s order. Facility policies on resident alarms and comprehensive care plans required that alarms be used and monitored in accordance with the resident’s care plan and that each resident have a comprehensive care plan with measurable objectives and timeframes, but these requirements were not met for this resident.
Failure to Care Plan and Properly Implement Tab Alarm Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and safety devices were properly care planned and implemented for a resident at high risk for falls. The resident was originally admitted with metabolic encephalopathy, Parkinson’s disease, difficulty in walking, dementia, and Alzheimer’s disease. An MDS assessment showed the resident had severe cognitive impairment and was fully dependent on staff for toileting, dressing, and personal hygiene. The physician ordered a tab alarm for the resident, and a fall risk assessment identified the resident as being at risk for falls. On the day of the incident, a CNA reported that the resident was not alert, was fully dependent on staff, and required two-person assistance for transfers between bed and wheelchair. The CNA stated that the resident had a tab alarm that should sound when the resident moves or when the magnet is displaced, and that the same alarm was used in both bed and wheelchair. The CNA explained that when a family member asked about providing personal hygiene care, the CNA left the room to obtain supplies, leaving the resident in a wheelchair and the tab alarm on the bed with the magnet still connected to the alarm unit. Because the alarm was not attached to the resident and the magnet remained in place, no alarm sounded when the resident moved. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor while the CNA was out of the room and the family member had walked out of the room with the tab alarm off. When the CNA returned, the resident was found lying on the floor and reported left elbow pain; the resident was later transferred to a higher level of care and diagnosed with an acute fracture. Review of the comprehensive care plan showed there was no specific care plan for the use of the tab alarm, despite the physician’s order. Facility staff acknowledged that there was no care plan for the alarm and that this resulted in no defined interventions for nurses to follow, and that the tab alarm was not implemented correctly at the time of the fall, contrary to the facility’s policies on resident alarms and comprehensive care plans.
Late and Inaccurate Medication Administration for a Resident
Penalty
Summary
Surveyors identified a deficiency in medication administration for Resident 4 related to failure to follow physician orders, late administration of scheduled medications, and inaccurate documentation on the Medication Administration Record (MAR). Resident 4 was admitted with diagnoses including COPD, type 2 diabetes with neuropathy, and essential hypertension, and had intact cognition per the MDS. Physician orders included daily bupropion, clopidogrel, docusate sodium, Jardiance, losartan, and three-times-daily Lyrica for polyneuropathy. On the survey date, an LVN prepared Resident 4’s scheduled 9 a.m. medications outside the resident’s room and identified that the ordered docusate sodium 250 mg capsule was not available in the medication cart. At 11:33 a.m., the LVN administered the prepared medications (bupropion, clopidogrel, Jardiance, losartan, and Lyrica) to Resident 4, confirming these were the resident’s scheduled 9 a.m. medications. The LVN stated that Lyrica was ordered three times daily at 9 a.m., 1 p.m., and 5 p.m., and acknowledged that the 9 a.m. medications were administered late. The LVN also reported that Resident 4’s systolic blood pressure was elevated at 162. Record review of the MAR for the month showed that the docusate sodium 250 mg capsule was documented as given at 9 a.m. on the same day, despite the LVN stating that the medication had not been received and would be administered once the supply arrived. The LVN acknowledged that medications should be documented as given only after administration and that documenting prior to administration could mislead other nurses. The DON confirmed that facility policy required medications to be administered within one hour before or after the scheduled time and that the MAR only reflected scheduled times, not actual administration times. The DON stated that Resident 4’s medications were administered late, physician orders were not followed, and the MAR was signed before the docusate was actually administered, contrary to the facility’s medication administration policy.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following a discharge to a General Acute Care Hospital (GACH), despite the resident being ready for discharge from the hospital and the facility's own policies supporting the right to readmission. The resident, who had diagnoses including epilepsy and muscle weakness and was assessed as severely impaired in thought process and requiring maximal assistance with activities of daily living, was admitted to the facility in September and discharged to the hospital in December. When the hospital determined the resident was ready for discharge, the facility's Social Service Worker, Administrator, and Director of Nursing all communicated that the resident would not be accepted back, even though the facility's policies required readmission after hospitalization and there was no indication that the resident was ineligible for return. Interviews with facility staff confirmed that the decision not to readmit the resident was made by the Administrator and DON, and that the facility was equipped to care for the resident. The facility's policies, reviewed with the DON, explicitly stated the right to readmission after hospitalization, regardless of payment source, and did not provide any justification for denying the resident's return. The resident was ultimately readmitted several days later, but the delay constituted a violation of the resident's right to readmission as outlined in facility policy.
Infection Control Deficiency Due to Unclean Shared Bathroom
Penalty
Summary
The facility failed to enforce its own policy related to maintaining a safe and sanitary environment, resulting in a deficiency in infection control. During an observation, a shared bathroom used by a resident was found with overflowing toilet paper in the trash and stool and urine in the toilet bowl. This situation was confirmed by interviews with the resident, a Certified Nurse Assistant (CNA), the Infection Preventionist (IP), and the Director of Nurses (DON). The CNA acknowledged the need for immediate cleaning and sanitization, while the IP and DON recognized the potential risk for infection spread due to the shared use of the bathroom by multiple residents. The resident involved had a complex medical history, including Parkinson's disease, metabolic encephalopathy, acute pancreatitis, urinary tract infection, dementia, hypertension, asthma, and Alzheimer's disease. The resident was severely cognitively impaired and required moderate assistance with activities of daily living. The facility's policy, titled 'Routine Bathroom Cleaning,' dated December 19, 2022, mandates maintaining a clean and sanitary environment to prevent cross-contamination and transmission of healthcare-associated infections. However, the policy was not adhered to, as evidenced by the unclean state of the shared bathroom.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit, affecting seven residents. Observations conducted on December 19, 2024, revealed that room temperatures ranged from 65.1 to 70.3 degrees Fahrenheit, all below the minimum required temperature. The Maintenance Director confirmed these readings during a series of observations conducted between 11:45 a.m. and 11:55 a.m. Interviews with facility staff, including the Maintenance Director, Administrator, and Director of Nursing, highlighted the importance of maintaining appropriate room temperatures for resident comfort and safety. The facility's policy, last reviewed on April 17, 2024, also emphasized the need to maintain comfortable and safe temperature levels in resident areas. Despite this, the facility did not adhere to its policy, resulting in room temperatures that could compromise resident comfort and safety.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. On the morning of November 17, 2024, Resident 2 struck Resident 1, pushed a bedside table towards him, causing Resident 1 to fall to the floor, and yelled profanities at him. This incident resulted in Resident 1 sustaining multiple injuries, including abrasions on his left forearm, lower back, and left posterior leg, as well as bruises and discoloration on his right thigh. The altercation was witnessed by LVN 1, who responded to Resident 1's call for help and observed Resident 2 attempting to strike Resident 1 while yelling profanities. Resident 1 was admitted to the facility with diagnoses including metabolic encephalopathy, bipolar disorder, and muscle weakness. He required substantial assistance with daily activities such as toileting, showering, and dressing. On the day of the incident, Resident 1 was found on the floor by LVN 1, who noted his injuries and documented the event in the Change in Condition Evaluation and Progress Notes. Despite the physician's order to transfer Resident 1 to a hospital for further evaluation, he refused the transfer. Resident 2, who was admitted with diagnoses including encephalopathy and schizophrenia, was also involved in the incident. He admitted to being physically aggressive towards Resident 1 but could not provide a reason for his actions. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating that the incident was considered a resident-to-resident altercation and classified as abuse. The Director of Nursing confirmed the incident as abuse based on the facility's policy, highlighting the failure to protect Resident 1 from harm.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In the case of two residents, their room was found to have overhead lamps with missing covers, which the Maintenance Supervisor acknowledged but was unaware of when they went missing. The Director of Nursing confirmed that the absence of lamp covers could result in inappropriate lighting, detracting from a homelike setting. This oversight indicates a lapse in maintaining the residents' right to a comfortable and safe environment. Additionally, the facility did not maintain the shower rooms adequately, as observed with peeling paint on the floors of two shower rooms. The Maintenance Supervisor noted that the peeling was likely due to the use of disinfectants, which could lead to potential mold growth. The Director of Nursing acknowledged the risk of mold exposure to residents and suggested that the issue might require professional intervention to address the peeling and potential mold. Furthermore, a resident's floor mat was found to be in poor condition, with a tear that could pose a tripping hazard. The MDS Coordinator identified the issue during an observation, and the Director of Nursing confirmed the need for immediate replacement to prevent accidents. These deficiencies collectively highlight the facility's failure to uphold its policy of providing a safe, clean, and homelike environment for its residents.
Failure to Obtain Consent and Orders for Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the lack of physician's orders and informed consent for the use of bed rails and the placement of beds against the wall for three residents. Resident 25 was observed with quarter rails on both sides of the head of the bed and the bed placed against the wall without a physician's order or informed consent. The Infection Preventionist confirmed the absence of these documents and acknowledged that the use of bed rails and the bed's placement could be considered restraints, potentially leading to entrapment. Similarly, Resident 21's bed was placed against the wall with quarter bed rails, also lacking a physician's order and informed consent. The Director of Nursing confirmed that informed consent should be obtained to discuss the risks and benefits of such arrangements, especially for residents who are not cognitively intact. The facility's policy indicated that physical restraints, including bed rails and bed placement against the wall, should only be used when medically necessary and with proper documentation. Resident 33, who lacked the capacity to make decisions, was found with the bed against the wall and side rails up, without informed consent or a physician's order. The Director of Nursing stated that informed consent should be obtained from the resident's family representative, given the resident's cognitive impairment. The facility's policies emphasized the need for informed consent and physician's orders for the use of physical restraints, highlighting the facility's responsibility to evaluate the appropriateness of such requests and inform residents or their representatives of the associated risks and benefits.
Deficiency in Restraint Use Training
Penalty
Summary
The facility failed to provide in-service training regarding the use of physical restraints, which placed residents at risk for inappropriate restraint use. This deficiency was identified during interviews and record reviews. The facility's policy on competency evaluation requires that each employee meets appropriate competencies and skills for their job, but the Director of Staff Development (DSD) could not locate any competencies or in-services related to physical restraints. Resident 33 was admitted with multiple diagnoses, including COPD and generalized muscle weakness, and was observed with bilateral side rails up on their bed, which they were unable to lower. The resident's Minimum Data Set (MDS) indicated they required assistance for mobility and had limited ability to understand and communicate. The MDS Nurse confirmed the resident's bed was positioned against the wall with side rails up, which the resident could not adjust. Resident 14, who had the capacity to understand and make decisions, was observed with their bed against the wall to allow space for wheelchair maneuvering. The resident confirmed the bed's position, and a Certified Nursing Assistant (CNA) corroborated this setup. The facility's policy on a restraint-free environment states that bed positioning against a wall can be considered a form of restraint, and the facility is responsible for evaluating the appropriateness of such arrangements. However, the lack of in-service training on restraints suggests a gap in staff competency regarding restraint use.
Failure to Post Nursing Staff Hours Visibly
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff responsible for resident care in a visible and prominent place daily. During a tour of the facility, it was observed that the staffing information was not posted in a visible area. Interviews with the Staff Developer (DSD) and the Director of Nursing (DON) revealed that the staffing information was located inside the nursing station and next to where the staff clock in, respectively. Both acknowledged that the information was not visible to residents and visitors. The facility's policy and procedure required the posting of staffing information, including the facility name, current date, total number, and actual hours worked by Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, and the resident census, on a daily basis.
Failure to Reassess Resident's Medication Self-Administration Ability
Penalty
Summary
The facility failed to reassess a resident's ability to self-administer medication upon re-admission and quarterly, as specified in the resident's care plan. The resident, who was originally admitted with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and a colostomy, was found capable of self-administration in an assessment dated over a year prior. However, no subsequent assessments were conducted after the resident's re-admission, despite the care plan's requirement for reassessment at specified intervals and upon significant changes in condition. Interviews with the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) confirmed the oversight, acknowledging the importance of timely reassessments to prevent potential medication errors. The facility's policy mandates reassessment by the interdisciplinary team under certain conditions, such as significant changes in the resident's status or medication errors, but these were not adhered to in this case. This lapse in following the care plan and facility policy had the potential to lead to medication errors during self-administration by the resident.
Failure to Maintain Privacy of Resident's Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN) left the electronic health record (EHR) of a resident open, unattended, and out of sight. This incident involved a resident who was admitted with diagnoses including dementia and generalized muscle weakness, and who had severe cognitive impairment as indicated in their Minimum Data Set (MDS). The LVN left the computer on top of the medication cart with the resident's electronic chart open while stepping away to assist a resident's family member. During an interview, the LVN acknowledged the mistake, stating that he should have locked the screen to prevent unauthorized access to the resident's confidential information. The Director of Nursing (DON) emphasized the importance of safeguarding medical information to prevent unauthorized access. The facility's policy on safeguarding resident identifiable information, last reviewed in April 2024, clearly states that medical records should not be left in open areas where unauthorized persons could access them.
Failure to Develop Comprehensive Care Plans for Bed Placement
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which was identified during a review of the physical restraints care area. Resident 21, who was admitted with diagnoses including Parkinson's disease and generalized muscle weakness, did not have a care plan addressing the placement of their bed against the wall. Observations and interviews confirmed that the bed was placed in a manner that could pose a risk for entrapment, yet no care plan was in place to guide staff on interventions to mitigate this risk. Similarly, Resident 33, who was admitted with chronic obstructive pulmonary disease and generalized muscle weakness, also lacked a care plan for their bed placement against the wall. The resident required assistance with mobility and was unable to move the side rails down, which increased the potential for entrapment. Despite these risks, there was no care plan developed to address the bed's position and the use of side rails. The facility's policy and procedure on comprehensive care plans, which mandates the development of person-centered care plans with measurable objectives and timeframes, was not followed. This oversight had the potential to result in inconsistent implementation of care plans, leading to delays or lack of care and services for the residents involved.
Failure to Document Home Health Referral for Discharged Resident
Penalty
Summary
The facility failed to address the needs of a resident, identified as Resident 48, for a home health agency referral prior to discharge. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, type II diabetes mellitus, and repeated falls, required assistance with activities of daily living due to moderate cognitive impairment and functional limitations. Despite the discharge order indicating the need for home health services, the Social Services Director (SSD) did not document the referral process or ensure that the resident's needs for post-discharge care were met, relying instead on the board and care to make the referral. The facility's policy on discharge planning required the SSD to assist residents in choosing an appropriate post-acute care provider, including home health agencies, and to document all assessments and services provided. However, the SSD failed to document conversations with the resident's family regarding the home health referral, which was necessary to ensure continuity of care and prevent rehospitalization. The Director of Nursing emphasized the importance of documentation to prove that staff made the referral, highlighting a lapse in following the facility's policy and procedure for documentation in the medical record.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not maintain proper positioning of the urinary drainage bag for a resident with an indwelling catheter. The resident's urinary drainage bag was observed lying flat on the floor, which is against the facility's policy and procedure for catheter care. This practice has the potential to expose the drainage bag to contaminants, increasing the risk of infection. The resident in question had been admitted with an indwelling urethral catheter, a history of urinary tract infections, and sepsis. Despite the resident's cognitive impairment, the Minimum Data Set indicated that the resident required assistance with personal hygiene and had an indwelling catheter appliance. Observations and interviews with facility staff, including a CNA and the DON, confirmed that the drainage bag should not be placed on the floor due to the risk of contamination. The facility's policy emphasized the importance of positioning the catheter bag below the bladder level and away from the floor to prevent infection.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and documentation for a resident receiving hemodialysis. Resident 18, who was dependent on renal dialysis due to end-stage renal disease, was not assessed after dialysis treatment on two occasions, specifically on 10/18/2024 and 10/21/2024 during the 11 p.m. to 7 a.m. shift. The Director of Nursing confirmed that the licensed nurse did not document the required dialysis access site monitoring during these shifts, which should have been done every shift as per the physician's orders. This lack of documentation could potentially lead to missed complications at the dialysis access site. The facility's policy and procedure for hemodialysis, last reviewed on 4/17/2024, required nurses to monitor and document the status of the resident's access site upon return from dialysis treatment to check for bleeding or other complications. Additionally, the facility's documentation policy mandated that all assessments, observations, and services provided be recorded in the resident's medical record. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Failure in Monitoring and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for Resident 21 by not monitoring side effects related to the use of psychotropic medications and signs of bleeding on a specified date. Resident 21, who was admitted with diagnoses including Parkinson's disease, dementia, and a fracture, was prescribed quetiapine fumarate for dementia-related behaviors and aspirin for stroke prophylaxis. Despite orders to monitor for side effects and behaviors every shift, documentation was missing, indicating that the monitoring may not have been performed. This lack of documentation was confirmed during an interview with RN 2, who acknowledged the importance of monitoring to prevent missed behaviors or adverse effects. Additionally, the facility failed to specify the dosage of aspirin for Resident 15, who was admitted with conditions such as hemiplegia and a recent myocardial infarction. The physician's order for aspirin administration via gastrostomy tube did not include the dosage, which was observed during medication preparation and administration by LVN 1. The DON confirmed that the omission of the dosage was a violation of medication rights, which include ensuring the correct medication, route, dose, patient, and time. The facility's policies and procedures, last reviewed in April 2024, require documentation of all assessments and services provided, as well as ongoing evaluation of psychotropic medication effects. The failure to adhere to these policies resulted in potential delays in care and the risk of administering incorrect medication doses, as highlighted by the deficiencies observed in the care of Residents 21 and 15.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN 2 and CNA 1 during the care of Resident 19. Resident 19, who was admitted with a gastrostomy tube and other medical conditions, required Enhanced Barrier Precautions (EBP) to prevent the spread of infections. Despite clear signage and care plan instructions, LVN 2 did not wear an isolation gown while administering medications through the gastrostomy tube, and both LVN 2 and CNA 1 failed to don isolation gowns while repositioning the resident in bed. These actions were contrary to the facility's policy, which mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. Interviews with LVN 2 and CNA 1 revealed an acknowledgment of the oversight, as both staff members admitted they should have worn isolation gowns to prevent potential cross-contamination and infection. The Director of Nursing confirmed that the failure to wear gowns during these activities exposed the resident to microorganisms and demonstrated a lack of infection control. The facility's policy on Enhanced Barrier Precautions, last reviewed in April 2024, specifies the necessity of personal protective equipment during high-contact activities, underscoring the deficiency in adhering to established infection control protocols.
Deficiency in Accessibility of State Inspection Results
Penalty
Summary
The facility failed to uphold residents' rights to access the results of state inspections by not posting these results in a prominent and accessible location. During observations conducted over several days, it was noted that the state inspection results were not visible in easily accessible areas within the facility. Instead, a notice on the consumer information board directed individuals to request the survey results from the nurse's station, where they were kept inside closed cabinets. This setup required residents and their representatives to ask staff members to view the results, which is contrary to the requirement for the results to be readily accessible without needing to make a request. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the inspection results were stored in the nursing station, an area not accessible to residents and visitors. Both staff members acknowledged that while the results could be requested at any time, they were not displayed in a manner that allowed for easy access. The facility's policy and procedure indicated that the survey binder should be located in the main lobby for review by interested parties, highlighting a discrepancy between the policy and the actual practice observed during the survey.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' bedrooms met the required space of 80 square feet per resident in multiple resident bedrooms. This deficiency was observed in 18 out of 20 rooms, where the square footage per resident was only 74.25 square feet in rooms with two beds and 75 square feet in rooms with four beds. Despite the deficiency, observations indicated that residents had adequate space to move freely, and nursing staff had sufficient room to provide care safely. During a Resident Council meeting, several residents expressed that they did not experience any issues with the space in their rooms, and the facility staff were able to provide care safely. The facility's Client Accommodations Analysis and a document titled RE: Requirement 483.70(d)(3) confirmed the insufficient square footage per resident. The facility had requested an ongoing waiver for rooms with less than the required square footage, asserting that the room size did not adversely affect residents' health and safety or impede their ability to attain their highest practicable well-being. The Director of Nursing also stated that there was enough space to provide care for the residents. The facility's policy indicated that resident bedrooms should measure at least 80 square feet per resident in multiple resident bedrooms, and the facility should request variances if the room sizes are in accordance with residents' special needs and do not adversely affect their health and safety.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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