Western Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2190 W Adams Blvd, Los Angeles, California 90018
- CMS Provider Number
- 555069
- Inspections on file
- 37
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Western Convalescent Hospital during CMS and state inspections, most recent first.
Three dependent residents with significant cognitive and physical impairments were observed with poor oral hygiene, including thick secretions and dry, cracked lips. Staff interviews and record reviews confirmed that required oral care interventions, such as use of oral care kits and regular moisturizing, were not consistently provided as outlined in care plans and facility policy.
The facility failed to implement OT recommendations for hand splints and obtain physician orders for two residents with hand contractures, and did not reassess another resident's mobility needs after readmission and changes in condition. These actions were not in accordance with facility policy and led to residents not receiving appropriate interventions to maintain or improve range of motion.
A resident with significant cognitive and physical impairments sustained an unexplained right thumb fracture that was identified by nursing staff and confirmed by x-ray. Despite facility policy and federal regulations requiring immediate reporting of such injuries as potential abuse, the incident was not reported to CDPH within the mandated timeframe, and the results of the internal investigation were not sent to the state agency.
A resident with multiple medical conditions did not receive a complete dose of IV antibiotic as ordered, as the medication was not fully infused and the IV site was found dislodged and not properly maintained. Nursing staff did not ensure the IV was administered completely or monitor the site according to facility policy.
A resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered by the physician, despite care plan instructions and facility policy requiring administration as prescribed and regular monitoring. Staff confirmed the discrepancy between the order and the oxygen delivered.
A resident with complex medical needs did not have complete and accurate documentation in their clinical record regarding the application and tolerance of prescribed splint services. Although physician orders required daily use of hand and knee splints, staff failed to document the resident's inability to tolerate these devices on certain days, and the records inaccurately indicated that the services were provided. Facility policy required objective and accurate documentation, which was not met in this case.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. Key sections of the POLST, including those for CPR, medical interventions, nutrition, and required signatures, were left blank, and the form was not signed by the resident's legal decision maker. Staff interviews confirmed the form's incompleteness and acknowledged that it should have been fully filled out according to facility policy.
A resident with severe cognitive impairment and complex medical needs was transferred to a hospital, but staff failed to document the transfer, including the resident's clinical condition and vital signs. The Clinical Manager confirmed the medical record was incomplete, and facility policy requiring thorough documentation was not followed.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Although a baseline care plan was in place, facility staff confirmed that the required interdisciplinary comprehensive care plan addressing wound care was not completed, contrary to facility policy.
A resident with multiple Stage 4 and unstageable pressure ulcers, who was totally dependent on staff and had impaired cognition, did not receive weekly reassessment and documentation of their wounds as required. The treatment nurse failed to complete scheduled evaluations, and facility policies did not mandate weekly reassessment, resulting in inadequate monitoring of the resident's pressure ulcers.
A resident with multiple complex diagnoses and total dependence on staff for ADLs did not have a comprehensive, person-centered care plan. The care plan lacked specific interventions, such as the need for two-person assistance, and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not individualized to ensure the resident's needs were met.
A resident with severe mobility and cognitive impairments, dependent on staff for all ADLs, was not provided the required two-person assist during care activities. Despite the care plan and facility policy specifying the need for two-person assistance to prevent accidents and injuries, a CNA performed care alone, and the DON confirmed this was not in accordance with the resident's care plan.
The facility failed to implement its infection control program, as a Laundry Aide did not perform hand hygiene or change gloves and gown after handling dirty linens, risking cross-contamination. Additionally, a resident's opened strawberry jam was not refrigerated as required, posing a risk of foodborne illness. The facility lacked a refrigerator for personal food items, contrary to its policy discouraging outside food due to safety concerns.
The facility failed to obtain and document informed consent for psychotropic medications for two residents. One resident received lorazepam and sertraline without proper consent, and another was prescribed duloxetine without documented consent. The Director of Nursing and Assistant Director of Nursing confirmed these oversights, which violated the facility's policy requiring informed consent before treatment.
The facility failed to ensure that room windows were able to close properly, resulting in cold conditions for three residents. Observations revealed that the windows were open and unable to be closed, with one window cracked and others taped. Residents reported the issue, and the Maintenance Aide acknowledged it but required an outside company for replacement. The Administrator confirmed a request for replacement was made, but the facility's policy on maintaining comfortable temperatures was not met.
A facility failed to monitor a resident's weight weekly as ordered, missing several scheduled weigh-ins, which could have impacted the resident's health. Additionally, another resident's orthostatic blood pressure was inaccurately measured, with identical readings recorded for lying and sitting positions, suggesting procedural errors. These deficiencies indicate non-compliance with the facility's policies on weight and blood pressure monitoring.
A facility failed to set a low air loss mattress correctly for a resident with a Stage 4 pressure ulcer, risking ineffective wound healing. Additionally, another resident at risk for pressure injuries was found without physician-ordered Prevalon boots, increasing the risk of skin breakdown. These deficiencies indicate non-compliance with care plans and physician orders.
The facility failed to provide appropriate ROM care for several residents, including not adhering to physician orders for splint application and duration, and missing RNA treatments. Residents did not receive timely annual JMAs, and splints were applied without orders, risking further decline in joint mobility. Staff interviews highlighted the importance of following orders to prevent worsening contractures.
The facility failed to provide adequate RNA staffing, affecting 81 residents with physician's orders for RNA treatments. Staffing records showed inconsistencies, with RNAs often reassigned to CNA duties due to CNA shortages. This led to difficulties in fulfilling RNA responsibilities, risking residents' range of motion and mobility. The Director of Nursing highlighted the importance of sufficient RNA staffing to prevent contractures and maintain joint mobility.
Two LVNs at the facility demonstrated inadequate competency in assessing orthostatic hypotension, as they misunderstood the procedure for taking blood pressure readings in different positions. This deficiency could lead to delays in care and potential resident injury. The DSD clarified the correct procedure, emphasizing the need for proper training to ensure quality care.
A facility failed to monitor a resident's blood pressure when administering amlodipine, as required by the care plan and physician's order. The resident's care plan indicated a risk for elevated blood pressure and falls due to antihypertensive medications, necessitating monitoring of vital signs. However, the MAR lacked documented blood pressure readings during the administration period, which was confirmed by the DON. This failure to document vital signs as per facility policy increased the risk of adverse effects.
A facility failed to ensure a resident was not prescribed Seroquel without an appropriate diagnosis, as the resident's records did not support a mental illness diagnosis. Additionally, the facility did not define or monitor behaviors related to lorazepam use for another resident, failing to document the resident's response to the medication. The Director of Nursing acknowledged these deficiencies, which contravened the facility's policy on psychotropic medication management.
A facility exceeded the acceptable medication error rate with two errors affecting two residents. One resident received an incorrect strength of cranberry supplement, while another was given a tablet instead of a liquid multivitamin. The errors were due to a failure to follow physician orders and proper medication labeling, as admitted by the LVN involved.
A resident did not receive the correct laboratory tests as ordered by the physician to monitor thyroid function due to Seroquel use. The care plan indicated a risk for dehydration, and a thyroid panel was recommended by the pharmacist. However, only a thyroid peroxidase and thyroglobulin antibody test was performed, not the complete thyroid panel. RN 2 confirmed the discrepancy, noting the tests conducted were not equivalent to the ordered thyroid panel.
The facility failed to follow the standardized recipes for residents on a soft and bite-size diet, serving whole bread instead of appropriately sized pieces. The menu did not reflect the new IDDSI standards, leading to inconsistencies with physician diet orders. This discrepancy was confirmed by dietary staff and posed potential risks to residents.
The facility failed to ensure sanitary food preparation practices, as a can opener blade in the kitchen was found dirty and worn, potentially harboring harmful bacteria. The Dietary Supervisor confirmed the residue and was unsure of the last cleaning. This deficiency risked cross-contamination for 47 out of 109 residents receiving food from the facility.
The facility lacks a comprehensive policy for storing and reheating food brought by family and visitors, as confirmed by interviews with staff including the Dietary Supervisor, charge nurse, and DON. The current policy discourages outside food due to safety concerns but does not provide procedures for safe storage, leading to potential foodborne illness risks.
A resident was found with all four bed rails raised without a proper order or informed consent, contrary to facility policy. The resident did not request the bed rails and had no recent history of falls. The facility's policy requires an assessment, consent, and order for bed rail use, which were not present in this case, potentially restricting the resident's movement and posing a risk of injury.
A facility failed to document a resident's diabetes mellitus (DM) diagnosis on the Minimum Data Set (MDS), despite a physician's order for Metformin. The MDS Coordinator acknowledged the omission, which is crucial for accurate care planning.
A resident's room was found to have an unsafe setup of extension cords, posing a fire and fall risk. Personal chargers were plugged into an extension cord lying on the ground and connected to another cord under the bed. Staff acknowledged the hazard, and the facility's policy prohibits such use of extension cords.
A resident experienced falls and injuries due to the facility's failure to adhere to medication hold parameters for amlodipine, which was administered 81 times despite the resident's systolic blood pressure being below the prescribed threshold. The resident's care plan noted a risk of falls related to antihypertensive medication, but no specific interventions were implemented. The DON acknowledged the oversight, linking the medication errors to the resident's falls.
The facility failed to implement infection control measures for two residents. A resident's foley catheter bag was found on the floor, and LVNs did not wear PPE or perform hand hygiene during wound care, despite Enhanced Barrier Precautions. Another resident received wound care without proper hand hygiene between glove changes. These actions were against the facility's infection control policies.
The facility failed to maintain a safe, clean, and homelike environment for two residents, leading to unsanitary conditions. Observations revealed dry brown spots on ceilings, peeling paint, and dirt in rooms of residents with significant medical needs. Staff interviews confirmed awareness of these issues, but maintenance and cleaning were not adequately performed, contrary to facility policies.
A resident with cognitive and functional deficits was found with stained bed sheets that were not changed by the CNA after providing a bed bath. The facility's policy requires daily linen changes, especially when soiled, to maintain a clean environment and prevent infection. Staff interviews confirmed the importance of this practice to uphold the resident's right to a clean living space.
A resident with severe cognitive impairment and multiple health conditions was found to have a skin discoloration on the wrist, indicative of potential abuse. The facility failed to report this allegation to the CDPH within the required two-hour timeframe, resulting in a delayed investigation and placing the resident at risk for further abuse.
A resident with severe cognitive impairment and multiple diagnoses did not receive timely toileting hygiene due to combative behavior. A CNA stopped providing care, resulting in a 30-minute delay until the resident's family member assisted. The DON noted the lack of documentation and emphasized the importance of timely care to prevent skin breakdown.
The facility failed to implement proper infection control practices, as oxygen nasal cannulas for two residents were improperly stored, hanging uncovered on GT feeding poles, contrary to policy. Additionally, two other residents had unclean gastrostomy tube sites, with one showing dried serous sanguineous spots and redness, and another with dried brownish spots on the dressing. Staff interviews confirmed these practices were against facility policies, posing a risk of infection.
A resident with a history of cerebral infarction exhibited slurred speech and other stroke symptoms, but the LVN did not notify the physician, leading to delayed medical care. The resident was later diagnosed with an acute subdural hematoma at a hospital. The facility's policy requires prompt physician notification for changes in condition, which was not followed.
A resident with a history of stroke experienced a change of condition, including altered consciousness and right arm weakness. An LVN failed to notify the physician or RN, delaying care. The DON stated these symptoms should have been reported immediately, as per facility policy.
A resident with hypotension was prescribed Midodrine with instructions to hold the medication if systolic blood pressure exceeded 110 mmHg. However, the medication was administered on three occasions despite the resident's blood pressure being above the threshold. Interviews with the LVN and DON confirmed the oversight, which was contrary to the facility's medication administration policy.
Failure to Provide Adequate Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene to three out of five sampled residents who were dependent on staff for activities of daily living. Observations revealed that these residents had visible signs of poor oral care, such as thick, white secretions, white crusty discharges, and dry, cracked lips. Interviews with staff and residents confirmed that oral care was not consistently provided as required by the residents' care plans and facility policies. Resident 2, who had diagnoses including hemiplegia, hemiparesis, diabetes, and hypertension, was observed with thick, white secretions in the mouth and reported that nurses did not provide daily oral care. Resident 3, with severe cognitive impairment and similar physical limitations, was found with white crusty discharges on the lips, and staff acknowledged that oral care was difficult but still necessary. Resident 4, also dependent on staff and with severe cognitive impairment, was observed with dry, crusty mucus on the lips, and staff noted that moisturizer was not always applied as part of oral care. Record reviews for all three residents showed that their care plans required daily and every shift oral care, including the use of oral care kits with Chlorhexidine Gluconate, brushing teeth twice daily, and moisturizing the lips. Despite these documented interventions, the observed conditions and staff interviews indicated that these measures were not consistently implemented, resulting in poor oral hygiene for the affected residents.
Failure to Implement Therapy Recommendations and Reassess Mobility Needs
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for hand splints and to obtain physician orders for two residents with significant or developing hand contractures. One resident, who was non-ambulatory and dependent on staff for all activities of daily living, had severe loss of passive range of motion in both hands. Despite an OT evaluation recommending hand rolls for both hands to reduce pain and maintain joint mobility, the resident was not assessed for hand splints, and no physician order was obtained until after the surveyor's visit. Observations confirmed the resident's hands were contracted in a fist position, and the OT acknowledged that the absence of hand splints could worsen the contractures. Another resident with muscle weakness and a history of respiratory failure was also identified as being at risk for contracture development. The OT evaluation recommended resting hand splints for both hands, but the OT did not follow up to obtain a physician order, and the resident had not worn splints for over a month. The resident was observed with contracted fingers and reported not receiving restorative nursing assistance for finger exercises. The facility's policy required the therapist to order splints and ensure physician orders were in place, but this was not followed. Additionally, the facility did not implement its policy for screening and reassessment after a change in condition or readmission for another resident with a history of traumatic brain injury and severe contractures. After readmission, the resident was ordered to receive hand and knee splints, but the rehabilitation department did not formally assess the resident prior to resuming these services. When the resident was unable to tolerate the splints, no new recommendations were made, and the required reassessment was not completed. The facility's policy specified that a PT or OT should complete a joint mobility screening after readmission or a change in condition, but this was not done.
Failure to Timely Report Unexplained Fracture as Possible Abuse
Penalty
Summary
The facility failed to report a resident's right thumb fracture to the California Department of Public Health (CDPH) within the required two-hour timeframe, as mandated by federal regulations. The resident, who had a history of tracheostomy, gastrostomy, ventilator dependence, and dementia, was found to have redness and swelling on the right thumb, which was later confirmed by x-ray to be an acute nondisplaced fracture. The resident was highly dependent, unable to communicate, and lacked decision-making capacity. The injury was not witnessed by staff, and there was no explanation provided by the resident due to their condition. Despite the facility's policy requiring immediate reporting of suspected abuse or unexplained injuries, the Administrator, who also served as the abuse coordinator, did not report the incident to CDPH, citing the absence of hospitalization or surgical intervention. The Registered Nurse involved recognized that the injury could be a result of abuse or mishandling, as it was unexplained and severe. The facility also failed to send the results of the abuse investigation to the State Survey Agency, contrary to their own policies and regulatory requirements.
Failure to Ensure Complete IV Antibiotic Administration and Secure IV Site
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus did not receive intravenous (IV) antibiotic medication as ordered. The physician's order and care plan required the administration of Ertapenem Sodium 1 gram IV every 24 hours for a UTI, with the expectation that the IV site would be maintained and free of complications. However, during observation, it was found that the IV antibiotic bag, which should have been completely infused by 6:30 a.m., still had 40 cc remaining at 11:15 a.m., indicating the medication was not fully administered. The Assistant Director of Nursing confirmed that the medication should have been completely infused and that failure to do so would not treat the infection. Further observation revealed that the resident's saline lock needle tip was dislodged and lying on the skin, rather than being properly inserted into the vein. The registered nurse acknowledged that a patent saline lock should be in the vein to administer IV medications. Review of facility policy confirmed that nurses are required to monitor the IV site frequently for complications and ensure proper administration. These failures resulted in the resident not receiving the complete dose of antibiotic medication and the IV site not being securely maintained.
Failure to Administer Oxygen as Ordered
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), respiratory failure, urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus was admitted and readmitted to the facility. The resident's care plan specified the use of oxygen therapy, with a goal to remain free from adverse effects and interventions to provide oxygen as ordered, monitor oxygen saturation, and check the rate of oxygen flow every shift. The physician's order directed that oxygen be administered at 2 liters per minute (L/min) via nasal cannula, with titration up to 3 L/min if oxygen saturation fell below 92%. Despite these orders, observations on two separate occasions found the resident receiving oxygen at 3 L/min via nasal cannula, without documentation that the oxygen saturation was below 92% to warrant the increased flow. A registered nurse confirmed that the physician's order was for 2 L/min and acknowledged the risk of over-oxygenation. The facility's policy on medication reconciliation emphasized the importance of accurate medication dosages upon admission or readmission, but the resident was not administered oxygen according to the prescribed amount.
Incomplete and Inaccurate Documentation of Resident Services
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained complete and accurate documentation of services not received, as required by its own policy and procedure on charting and documentation. Specifically, a resident with a history of traumatic brain injury, tracheostomy, ventilator dependence, and gastrostomy had physician orders for Restorative Nursing Assistant (RNA) program interventions, including the application of bilateral resting hand splints and bilateral knee extension splints. Documentation indicated that the resident received and tolerated these splints for specified periods; however, interviews and record reviews revealed that the resident was unable to tolerate the splints during certain dates, and this was not accurately documented in the medical record. RNA staff acknowledged that they did not write progress notes to reflect the resident's inability to tolerate the splints, despite being aware of the issue and notifying the Director of Rehabilitative Services (DOR) during an RNA meeting. The DOR confirmed that documentation should have accurately reflected the services provided and the resident's tolerance, and that oversight of RNA services and documentation accuracy was their responsibility. The facility's policy required objective, complete, and accurate documentation of treatments and resident tolerance, which was not followed in this instance.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
The facility failed to complete the Physician Orders for Life-Sustaining Treatments (POLST) for one resident who was admitted with multiple serious medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was documented as lacking capacity to make decisions and was assessed as having severely impaired cognitive skills, being totally dependent on staff for daily care. Despite this, the resident's POLST form was found to be incomplete, with critical sections such as Cardiopulmonary Resuscitation, Medical Interventions, Artificially Administered Nutrition, and Information and Signatures left unchecked. The form was also not signed by the resident's legally recognized decision maker, but only by the provider. During interviews, staff confirmed that the POLST was incomplete and acknowledged that all sections should be filled out as it is a legal document reflecting the resident's care preferences in emergencies. The facility's policy required that the provider speak with the resident or their legal representative to ensure the POLST accurately reflected the resident's wishes before signing. However, this process was not followed, and the responsibility for ensuring the POLST was complete was not met by the social worker and licensed nursing staff, as stated by the Director of Nursing.
Failure to Document Resident Hospital Transfer
Penalty
Summary
The facility failed to document the transfer of a resident to a general acute care hospital in the resident's medical records. The resident, who had chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube, was noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities. The physician had placed a telephone order for the transfer, but there was no documentation by facility staff regarding the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. During a review, the Clinical Manager confirmed that the medical records were incomplete and not accurate, specifically lacking documentation of the transfer event. Facility policies required complete and accurate documentation of all services provided and any changes in the resident's condition, but these were not followed in this instance. The absence of documentation was identified through interviews and record reviews, highlighting a failure to maintain systematic and accessible medical records as per facility policy.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple pressure ulcers, despite the resident's complex medical history and high level of dependency. Upon admission, the resident was diagnosed with several stage 4 and unstageable pressure ulcers, a urinary tract infection, and had a gastrostomy tube in place. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. Although a baseline care plan was created at admission, no comprehensive care plan was developed more than two months later to address the resident's pressure ulcers. Interviews with facility staff confirmed that the comprehensive care plan, which should have been developed by the interdisciplinary team within 14 days of admission, was not completed. The Clinical Manager acknowledged the absence of a comprehensive care plan for the resident's wounds, and the Director of Nursing confirmed that the baseline care plan was only valid for 14 days. Facility policy required comprehensive care plans for skin alterations and pressure ulcers, with realistic, measurable goals and time frames for re-evaluation, but this was not followed in the resident's case.
Failure to Perform Weekly Pressure Ulcer Reassessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers and had severely impaired cognitive skills, was dependent on staff for all activities of daily living. The baseline care plan identified impaired skin integrity and required treatment as ordered, with monitoring for signs of infection. However, the weekly reassessment and documentation of the resident's pressure ulcers, including type, location, measurement, and description, were not completed as required. Specifically, the treatment nurse did not reassess or document the pressure ulcers on a scheduled weekly basis, as confirmed during an interview and record review. The facility's treatment nurse job description required maintaining and updating a pressure ulcer profile weekly, but did not specify reviewing and revising the care plan for accurate wound care guidance. Additionally, the facility's policy on pressure ulcers did not require scheduled weekly reassessment to determine progression. This lack of consistent and thorough reassessment and documentation increased the risk of the resident's pressure ulcers worsening or receiving inappropriate or delayed treatment, as the status and progression of the wounds were not adequately monitored.
Failure to Develop Comprehensive, Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident with significant care needs. The resident had multiple diagnoses, including a disorder of bone density, contractures at multiple sites, functional quadriplegia, and respiratory failure. Documentation showed the resident was totally dependent on staff for activities of daily living (ADLs) such as showering, dressing, oral hygiene, and personal hygiene, and lacked the capacity to understand or make decisions. Despite these needs, the care plan interventions were generic and did not specify critical details, such as the requirement for two-person assistance during care, nor did they provide measurable objectives or timetables tailored to the resident's condition. During interviews and record reviews, the DON acknowledged that the care plan was not person-centered and did not ensure the resident's needs were being met. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not reflected in the resident's care plan. The lack of specificity and individualized planning placed the resident at risk for injuries and unmet needs.
Failure to Provide Required Two-Person Assist During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living (ADLs) due to conditions such as functional quadriplegia, contractures, and cognitive impairment, was not provided the required two-person assist during care. The resident's care plan specifically indicated the need for two-person assistance with transfers, repositioning, and daily care due to their high risk for falls and injuries, as well as their inability to participate in or understand care activities. Despite this, a Certified Nursing Assistant (CNA) reported performing the resident's ADL care alone, including cleaning and turning, without assistance from another staff member. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and acknowledged that failing to follow this intervention placed the resident at risk for further injuries. Facility policy emphasized the importance of safety, supervision, and targeted interventions to reduce individual risks, including communicating and assigning responsibility for specific interventions. The failure to provide the required two-person assist as outlined in the care plan and facility policy constituted the deficiency.
Infection Control and Food Safety Deficiencies
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by two key deficiencies. Firstly, a Laundry Aide (LA) was observed handling both dirty and clean linens without performing necessary hand hygiene or changing contaminated gloves and gown. This occurred after the LA sorted dirty linen and then proceeded to handle clean linen, which could lead to cross-contamination and infection. The Infection Prevention Nurse (IPN) confirmed that the LA should have changed her gown and gloves after handling the dirty linen to prevent the transfer of contaminants such as urine and feces to clean linen. The facility's policy and procedure on laundry processes also indicated that staff should wash hands after handling soiled linens to prevent cross-contamination. Secondly, the facility failed to refrigerate an opened food item as required, which involved a resident who had a bottle of strawberry jam on their bedside table. The label on the jam indicated it should be refrigerated after opening, but the facility did not have a refrigerator for storing residents' personal food items. A Licensed Vocational Nurse (LVN) observed the jam and acknowledged that not refrigerating it could lead to foodborne illnesses. The facility's policy discouraged food from outside sources due to food safety and infection control concerns. The resident involved had diagnoses including hyperlipidemia and hypertension, and was capable of understanding and making decisions, with no limitations to their extremities as per their assessment records.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications to two residents. Resident 83 was administered lorazepam and sertraline without proper informed consent. The clinical records showed that lorazepam was given for anxiety over a period of 14 days, and sertraline was administered for depression. However, there was no documentation that Resident 83 or her responsible party received education regarding the risks and benefits of lorazepam before its administration. Informed consent for sertraline was obtained only after the medication had been initiated and subsequently discontinued. The Director of Nursing (DON) acknowledged the failure to obtain informed consent for Resident 83's medications, stating that this oversight increased the risk that the resident or her representative might not have been able to exercise their right to opt out of treatment. The facility's policy on psychotropic medications and informed consent requires that residents or their representatives be informed of the risks and alternatives before treatment, which was not adhered to in this case. Similarly, Resident 46 was prescribed duloxetine for peripheral neuropathy without documented informed consent. The resident's Minimum Data Set indicated the ability to express ideas and understand others, yet there was no consent form in the resident's chart. Both the RN and the Assistant Director of Nursing (ADON) confirmed the absence of informed consent documentation, which is required by the facility's policy before initiating treatment.
Failure to Ensure Windows Close Properly
Penalty
Summary
The facility failed to ensure that room windows were able to close properly in the rooms of three residents, resulting in the rooms being cold. During an initial tour, it was observed that the windows in the rooms of Residents 23, 55, and 102 were open and unable to be closed. Resident 102's window had a crack, and the windows in the rooms of Residents 23 and 55 were taped on three sides. Interviews with the residents revealed that they were aware of the issue and had to dress warmly to stay comfortable. Resident 102 reported the issue to a Certified Nursing Assistant, and a Maintenance Aide checked the window but was unable to fix it. The Maintenance Aide acknowledged the problem and stated that he had requested the windows to be replaced, but he was not qualified to do the replacement himself. The Administrator confirmed that a request for window replacement had been made and was awaiting a work order from the management company. The facility's policy on providing a homelike environment with comfortable temperatures was not adhered to, as the residents experienced cold conditions due to the inability to close the windows.
Deficiencies in Weight Monitoring and Blood Pressure Measurement
Penalty
Summary
The facility failed to ensure that a resident received weekly weight monitoring as ordered by the physician. The resident, who was admitted with conditions including hypotension, diabetes, and asthma, was dependent on staff for daily activities. The physician had ordered weekly weights for four weeks to manage the resident's weight, but the weights were only recorded on two occasions, missing the scheduled dates. This lack of monitoring meant that staff were unaware of any potential weight loss, which could have impacted the resident's health and dietary needs. Another deficiency involved the inaccurate measurement of orthostatic blood pressure for a resident with hypertension, muscle weakness, and bipolar disorder. The physician's order required monitoring for orthostatic hypotension, with specific instructions to notify the doctor if there was a significant drop in blood pressure readings between lying and sitting positions. However, the recorded blood pressures were identical for both positions, suggesting that the procedure was not followed correctly. The Director of Staff Development noted that the use of a manual blood pressure cuff might have led to rounding errors, preventing accurate assessment of the resident's condition. The facility's policies on weight assessment and blood pressure measurement were not adhered to, leading to these deficiencies. The policy required residents to be weighed at specified intervals and for blood pressure changes to be noted accurately. The failure to follow these procedures resulted in inadequate monitoring of the residents' health conditions, potentially delaying necessary interventions.
Improper Use of Pressure Relieving Devices
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set correctly for a resident with a Stage 4 pressure ulcer. The resident, who was small-framed and weighed less than 400 pounds, had a mattress set at 400 pounds, which was inappropriate for their weight. This incorrect setting could result in the mattress being too firm or too soft, thereby not promoting wound healing effectively. Interviews with the LVN, Wound Care Nurse, and DON confirmed that the incorrect setting would not be beneficial and could lead to slower healing or worsening of the pressure ulcer. Another deficiency was identified with a resident who was at risk for developing pressure injuries. The resident had a physician's order for Prevalon boots to offload pressure from the heels and prevent skin breakdown. However, during an observation, the resident was found without the boots, and the LVN present could not explain their intended use. The Director of Staff Development confirmed that the absence of the boots put the resident at risk for skin breakdown. These deficiencies highlight the facility's failure to adhere to care plans and physician orders, which are critical for managing and preventing pressure ulcers. The facility's policies on pressure injury prevention and wound care emphasize the importance of using appropriate supportive devices, yet these were not followed, placing residents at risk for further complications.
Deficiencies in ROM Care and RNA Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for six out of ten sampled residents. The deficiencies included not adhering to physician orders for the application and duration of splints, as well as failing to complete restorative nursing aide (RNA) treatments as prescribed. For instance, Resident 15 was observed wearing a right resting hand splint and a right elbow splint for longer than the physician-ordered four hours, which was confirmed by documentation showing the splints were applied for six hours on multiple occasions. Additionally, RNA treatments for Resident 15 were not completed on several specified dates. Resident 2 also did not receive RNA treatments as ordered, with documentation indicating missed sessions for PROM exercises and splint applications. Furthermore, Resident 2 did not receive timely annual Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM, with the last assessments being significantly outdated. Similar issues were noted for Resident 8, who did not receive timely annual JMAs, and Resident 24, who had ankle splints applied without a physician's order. Resident 24 also missed annual OT JMS, which are crucial for tracking and comparing joint ROM to identify any decline. Residents 17 and 67 experienced similar deficiencies, with RNA treatments not being completed as ordered. Resident 17's documentation showed missed RNA services for the application of hand rolls and elbow splints, while Resident 67's RNA task form indicated inconsistent application of a right PRAFO. Interviews with staff, including the Director of Nursing and the Director of Rehabilitation, highlighted the importance of following physician orders and completing RNA treatments to prevent worsening contractures and maintain joint mobility. The facility's policies and procedures emphasized the need for timely and appropriate RNA services, which were not adhered to in these cases.
Inadequate RNA Staffing Leads to Potential Decline in Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) treatments. This deficiency was identified through observation, interviews, and record reviews, revealing that 81 residents with physician's orders for RNA services were at risk of experiencing a decline in range of motion, mobility, and activities of daily living function. The facility's staffing records for February and March 2025 showed inconsistencies in RNA staffing, with some days having no RNA staff available, leading to the reassignment of RNAs to Certified Nursing Assistant (CNA) duties. Interviews with RNA staff and the Director of Staff Development confirmed that RNAs were often reassigned to CNA duties due to a shortage of CNA staff, making it difficult for them to fulfill their RNA responsibilities. The Director of Nursing emphasized the importance of sufficient RNA staffing to ensure residents received their necessary treatments to prevent contractures and maintain joint mobility. The facility's policy on staffing indicated a commitment to providing sufficient nursing staff to meet residents' needs, but the observed staffing levels did not align with this policy.
Inadequate Competency in Assessing Orthostatic Hypotension
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVNs) possessed the necessary competencies to properly assess orthostatic hypotension in residents. During interviews, LVN 4 demonstrated a misunderstanding of the procedure by stating that if a resident's blood pressure in the lying position did not indicate hypotension, there was no need to take a sitting blood pressure reading. LVN 6 also showed a lack of understanding by indicating that blood pressure readings could be taken at the resident's convenience without a specific timeframe, contrary to the standard procedure. This misunderstanding of the procedure for assessing orthostatic hypotension could lead to a delay in care and services, potentially resulting in falls or injury to residents. The Director of Staff Development (DSD) clarified the correct procedure, which involves taking the resident's blood pressure in the lying position, then having the resident sit and waiting about five minutes before taking another reading. A change of 20 mmHg in the systolic or 10 mmHg in the diastolic value would indicate orthostatic hypotension, necessitating notification of the doctor for further orders. The facility's job description for LVNs requires them to ensure physicians' orders are followed and quality care is provided, highlighting the importance of proper training and understanding of procedures to prevent deficiencies in care.
Failure to Monitor Blood Pressure for Amlodipine Administration
Penalty
Summary
The facility failed to monitor the blood pressure of Resident 83 in relation to the administration of amlodipine, a medication used to treat high blood pressure, between March 23, 2024, and March 31, 2024. The resident's care plan, revised on March 27, 2024, indicated a risk for elevated blood pressure and required monitoring of pulse rate and blood pressure as ordered. Additionally, the care plan noted a risk of falls or injury related to antihypertensive medications, necessitating an assessment for possible adverse effects. Despite these directives, the Medication Administration Record (MAR) for March 2024 showed no documented blood pressure readings corresponding to the administration of amlodipine during the specified period. The Director of Nursing (DON) confirmed that the facility did not consistently document blood pressure readings in the MAR, which was necessary to adhere to the hold parameters specified in the physician's order for amlodipine. The facility's policy and procedure required obtaining and recording vital signs prior to medication administration, and the documentation of medication administration policy mandated the inclusion of specific medication parameters, such as blood pressure. The lack of documentation in the MAR made it impossible to determine if the medication was administered within the prescribed parameters, increasing the risk of adverse effects for the resident.
Failure to Appropriately Prescribe and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was not prescribed Seroquel without an appropriate diagnosis. The resident was admitted with conditions such as hypotension, diabetes, and asthma, but there was no indication of a mental illness in their medical records. Despite this, an order was placed for Seroquel to be administered for psychosis, a diagnosis not supported by the resident's history or assessments. The facility's policy requires that psychotropic medications be prescribed only when necessary to treat a specific, documented condition, which was not adhered to in this case. Additionally, the facility did not adequately define and monitor behaviors related to the use of lorazepam for another resident. This resident, diagnosed with vascular dementia and anxiety, was prescribed lorazepam as needed for moderate anxiety. However, the facility failed to document or monitor the resident's behaviors during the administration of the medication, as required by their care plan and facility policy. The lack of monitoring meant that the effectiveness of the medication and the resident's response to it were not assessed. The Director of Nursing acknowledged the failure to monitor and define behaviors related to the use of lorazepam, which is crucial for assessing the medication's effectiveness and ensuring the resident's condition is adequately treated. The facility's policy emphasizes the importance of involving residents and their representatives in medication management and ensuring adequate monitoring for efficacy, which was not followed in these instances.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06% due to two medication errors out of 33 opportunities. The errors affected two residents during medication administration. Resident 4 was prescribed a cranberry supplement at 425 mg but was administered a 450 mg dose. This discrepancy was observed when the Licensed Vocational Nurse (LVN 4) prepared and administered the incorrect dosage by crushing the tablet and mixing it with applesauce for the resident to consume. The error was acknowledged by LVN 4, who admitted to not clarifying the order with the physician to adjust for the available product strength. Resident 83 was prescribed a liquid formulation of multivitamins but was given a crushed tablet form instead. LVN 4 prepared and administered the incorrect formulation by mixing the crushed tablet with applesauce. During an interview, LVN 4 admitted to mistakenly believing the tablet and liquid formulations were interchangeable, not realizing the differences in formulation and strength. The facility's policy and procedure for medication administration emphasize adherence to physician orders and proper medication labeling, which were not followed in these instances.
Failure to Conduct Ordered Thyroid Panel for Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct laboratory tests as ordered by the physician, which was necessary to monitor the resident's thyroid function due to the use of Seroquel, a medication for bipolar disorder. The resident's care plan indicated a risk for dehydration due to medication use, and the consultant pharmacist recommended a thyroid panel to assess thyroid function. However, the laboratory results showed that only a thyroid peroxidase and thyroglobulin antibody test was performed, rather than the complete thyroid panel that was ordered. During an interview, RN 2 confirmed that the thyroid panel was ordered but not conducted, and explained that the tests performed were not equivalent to a thyroid panel, which includes triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH). This oversight could prevent the physician from identifying potential thyroid issues in the resident. The facility's policy required staff to process and arrange for tests as ordered by the physician, but this was not followed in this instance.
Failure to Follow Soft and Bite-Size Diet Menu
Penalty
Summary
The facility failed to ensure that the standardized recipes for the lunch menu were followed, specifically for residents on a soft and bite-size diet. On March 18, 2025, eighteen residents who required a soft and bite-size diet received whole bread instead of bread cut into smaller pieces, as per their dietary needs. The facility's lunch menu did not include the texture-modified diet that was ordered for these residents, and the menu lacked a serving guide for the bread at each meal. This discrepancy was observed during a kitchen inspection and interviews with the dietary staff, who admitted that the menu was still following old standards and had not yet transitioned to the new IDDSI standards, which the physician diet orders were based on. The Registered Dietitians and the Speech and Language Therapist confirmed that the facility was in the process of transitioning to the new IDDSI menu, but the current menu did not reflect the updated diet orders. The facility's diet manual, dated 2020, did not include a description or plan for a soft and bite-size diet, leading to inconsistencies between the diet orders and the menu. The facility's policies indicated that menus should be prepared using standardized recipes and that diet orders should align with the approved diet manual, which was not the case. This failure had the potential to result in meal dissatisfaction, decreased nutritional intake, and increased choking risk for the affected residents.
Unsanitary Can Opener Blade in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation practices in the kitchen, as observed during a survey. A can opener blade was found to be dirty, with a dry brown sticky residue, and worn out, which could potentially harbor harmful bacteria. The Dietary Supervisor confirmed the presence of the residue and was unable to identify its nature, although they suggested it could be removed with washing. The supervisor also admitted to not knowing when the blade was last cleaned. The facility's policy and procedure on sanitizing equipment and surfaces, which was undated, required that all equipment, shelves, serving utensils, and surface areas be clean and in good condition. Additionally, the 2022 U.S. Food and Drug Administration Food Code specified that can opener blades should be kept sharp to prevent metal fragments from contaminating food and that can openers must be replaced if they become uncleanable. This deficiency had the potential to result in harmful bacteria growth and cross-contamination, affecting 47 out of 109 residents who received food from the facility.
Deficiency in Policy for Storing Food Brought by Visitors
Penalty
Summary
The facility's policy on food brought in by family and visitors did not adequately address the storage and reheating of such food to ensure safe and sanitary conditions. The Dietary Supervisor stated that families are encouraged not to bring food that requires storage, as there is no space available for storing leftovers. The policy indicates that any leftover food will be discarded. Interviews with various staff members, including a charge nurse and treatment nurse, confirmed the absence of a refrigerator for residents to store perishable food. The Director of Nursing (DON) and the Administrator both acknowledged that the facility lacks a policy and procedure for safely storing food brought in from outside. The facility's policy titled 'Food From Outside Sources' discourages bringing in outside food due to concerns about food safety, infection control, and maintaining therapeutic diet orders. The policy states that the facility is not liable for food safety and infection control issues related to outside food, and any leftovers will be discarded. Despite this, there is no procedure in place for handling situations where residents or their families wish to store food for later consumption, potentially leading to foodborne illness among residents.
Failure to Obtain Consent and Order for Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 99 was free from the use of physical restraints, specifically bed rails, without proper authorization and consent. During an observation, Resident 99 was found in bed with all four bed rails raised, which the resident did not request and did not recall any recent falls. The resident's Minimum Data Set indicated no limitations in range of motion, and the resident was capable of rolling left and right. However, there was no order for the use of bed rails, nor was there a signed informed consent for their use. The Assistant Director of Nursing confirmed that an assessment, consent, and order are required for the use of bed rails, which were absent in this case. The facility's policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. The policy also requires informing the resident or their representative about the risks and benefits of bed rails and obtaining informed consent before use. Despite these requirements, Resident 99's medical chart lacked the necessary documentation and orders for the use of bed rails, and the resident was found with all four side rails up, which is considered a restraint. This oversight had the potential to restrict the resident's movement and posed a risk of injury.
Failure to Document Diabetes Diagnosis on MDS
Penalty
Summary
The facility failed to ensure that a resident's diagnosis of diabetes mellitus (DM) was accurately entered on the Minimum Data Set (MDS), a critical assessment and care screening tool. The resident, who was admitted and readmitted with various diagnoses including polyneuropathy, hypertension, and fibromyalgia, was prescribed Metformin for DM as per a physician's order dated February 1, 2024. However, the MDS dated December 26, 2024, did not reflect the DM diagnosis, despite the resident's ability to express ideas and understand others. During an interview and record review on March 20, 2025, the MDS Coordinator acknowledged the absence of the DM diagnosis on the MDS, which is essential for accurate care planning. The facility's MDS Coordinator Job Description mandates the completion and auditing of all MDS entries for accuracy, yet this oversight occurred, potentially impacting the resident's care plan and the delivery of necessary services.
Unsafe Use of Extension Cords Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment for Resident 96 by allowing the use of an extension cord in a manner that posed a safety hazard. During an observation, it was noted that personal chargers were plugged into an extension cord that was lying on the ground next to the resident's bed and connected to another extension cord, which was also on the ground under the bed. This setup was identified as a potential fire and fall risk. Licensed Vocational Nurse (LVN) 3 acknowledged the hazard, stating that the extension cords should not be arranged in such a manner, as it posed a safety issue that could harm the resident. Further interviews with Maintenance Aide (MA) 1 and the Director of Nursing (DON) confirmed the unsafe nature of the extension cord setup. MA 1 indicated that the wrong type of extension cord was used and that it should not be plugged into another extension cord or placed on the ground. The DON also recognized the situation as a fall and fire hazard. The facility's policy on electrical safety, dated January 2011, specifies that extension cords should not be used as a substitute for adequate wiring and should be secured to prevent trips, falls, or overheating, and should only connect to one device.
Failure to Adhere to Medication Hold Parameters Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering amlodipine outside of the prescribed hold parameters. This occurred a total of 81 times over a period of several months, affecting a resident who was at risk for elevated blood pressure and falls due to the use of antihypertensive medications. The resident's care plan indicated a risk of falls and injury related to these medications, yet no specific interventions were in place to address this risk. The medication order specified that amlodipine should be held if the resident's systolic blood pressure was less than 120, but the medication was administered even when the blood pressure was below this threshold. As a result of this deficiency, the resident experienced two falls with injuries on specific dates, which were linked to the improper administration of the medication. The Director of Nursing acknowledged that the licensed staff failed to observe the hold parameters, potentially contributing to the resident's falls and injuries. The facility's policies and procedures for medication administration were not followed, as medications are required to be administered according to the physician's written orders. The facility's clinical protocol for hypertension also emphasized the importance of monitoring for complications such as dizziness and falls, which were not adequately addressed in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control measures for two residents. For Resident 2, the facility did not ensure that the foley catheter bag was kept off the floor, which is crucial to prevent urinary tract infections. Additionally, Licensed Vocational Nurses (LVNs) 1 and 2 did not wear the required Personal Protective Equipment (PPE) while providing wound care to Resident 2, who was on Enhanced Barrier Precautions due to the risk of transmitting Multidrug-Resistant Organisms. LVN 1 also failed to perform hand hygiene during wound care after cleaning stool and between glove changes. Resident 2 was admitted with diagnoses including a Stage 4 pressure ulcer, unspecified dementia, and cellulitis. The resident was totally dependent on staff for activities of daily living and had a physician's order for specific wound treatment. During an observation, the foley catheter bag was seen on the floor, and LVNs entered the room without donning isolation gowns, despite the presence of an Enhanced Barrier Precautions sign. LVN 1 cleaned stool and the wound without changing gloves or performing hand hygiene, which was confirmed as a breach of protocol by RN 1. For Resident 3, who was admitted with a Stage 4 pressure ulcer and other conditions, LVN 1 was observed performing wound care without performing hand hygiene between glove changes. This was acknowledged by LVN 1 and RN 1 as a failure to follow infection control practices. The facility's policies on hand hygiene, catheter care, and Enhanced Barrier Precautions were reviewed, indicating the importance of these measures in preventing the spread of infections.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to unsanitary living conditions. Resident 2, who was admitted with a Stage 4 pressure ulcer, unspecified dementia, and cellulitis, was found to be totally dependent on staff for activities of daily living. Observations in Resident 2's room revealed multiple dry brown spots on the ceiling, peeling paint, and black dirt in the corners of the walls and floor. Resident 4, who was diagnosed with COPD, hemiplegia, hemiparesis, and schizophrenia, was also totally dependent on staff for daily activities. Similar observations were made in Resident 4's room, with multiple dry brown spots on the ceiling. Interviews with facility staff, including a CNA and the Maintenance Supervisor, confirmed the presence of these deficiencies. The CNA acknowledged seeing the ceiling stains but was unsure of their origin, while the Maintenance Supervisor admitted to not noticing the stains during his rounds and acknowledged the need for maintenance and cleaning. The Registered Nurse emphasized the importance of daily room checks and maintenance to ensure a homelike environment. The facility's policies and procedures highlighted the need for a clean, sanitary, and orderly environment, which was not upheld in this instance.
Failure to Provide Clean Bed Sheets for a Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for one of the residents, identified as Resident 2, by not ensuring clean bed sheets were used. During an observation, it was noted that Resident 2's bed had brown dry spots on the bottom sheet, yellow stains on the top sheet, and a white blanket with brown spots. Despite these visible stains, the Certified Nurse Assistant (CNA) did not change the bottom sheet after providing a bed bath and covered the resident with the stained top sheet and blanket. The CNA acknowledged that the sheets were stained and stated that bed sheets are supposed to be changed daily if soiled or dirty. Resident 2, who was admitted to the facility with a gastrostomy tube and anoxic brain damage, was dependent on staff for activities of daily living (ADL) care due to cognitive and functional deficits. Interviews with other staff, including another CNA, a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the facility's policy requires bed sheets to be changed daily and as needed when soiled. The staff emphasized the importance of maintaining a clean environment to prevent infection and uphold the resident's right to a clean living space. The facility's policy and procedures also highlighted the need to provide a safe, clean, and comfortable environment with clean linen for residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe as per their policy. The resident, who was admitted with conditions such as hemiplegia, dysphagia, and severe cognitive impairment, was found to have a yellowish-green skin discoloration on the left wrist. This discoloration was first noticed by a family member on July 30, 2024, and reported to the facility on August 2, 2024. However, the facility did not document this report in the progress notes or create a Change of Condition (COC) assessment on the same day. The facility eventually faxed the Report of Suspected Dependent Adult/Elder Abuse to the CDPH on August 3, 2024, which was beyond the two-hour reporting requirement. Interviews with family members and staff revealed that the discoloration was indicative of potential abuse, and the delay in reporting was acknowledged by the Director of Nursing. The failure to report the incident in a timely manner resulted in a delayed investigation by the CDPH and placed the resident at risk for further abuse.
Failure to Provide Timely Toileting Hygiene
Penalty
Summary
The facility failed to provide timely toileting hygiene for a resident who was dependent on staff for assistance. The resident, who had severe cognitive impairment and was diagnosed with conditions such as hemiplegia, hemiparalysis, dysphagia, and osteoarthritis, was not changed for at least 30 minutes after becoming combative during toileting hygiene. A Certified Nurse Assistant (CNA) attempted to change the resident but stopped due to the resident's combative behavior. The resident's family member eventually assisted in changing the resident. The Director of Nursing (DON) confirmed there was no documentation of the resident refusing care and stated that the CNA should not have waited for the family member to assist. The facility's policy and procedures for perineal care emphasize the importance of cleanliness, comfort, and skin condition observation, and require notifying the charge nurse if a resident refuses care. The delay in providing care had the potential to cause skin breakdown, as acknowledged by both the CNA and the DON.
Infection Control Deficiencies in Oxygen and GT Site Management
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the improper storage of oxygen nasal cannulas for two residents. Both residents were observed with their oxygen concentrators turned on, but the nasal cannulas were not in use and were hanging uncovered on gastrostomy tube (GT) feeding poles. This practice was contrary to the facility's policy, which required that unused oxygen tubing be stored in a clean bag with the resident's name and room number to prevent contamination. Interviews with staff, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that the nasal cannulas should not have been left uncovered and in contact with surfaces, as this could lead to contamination and potential infection. Additionally, the facility failed to maintain cleanliness at the gastrostomy tube sites for two other residents. Observations revealed that one resident's GT site had no dressing and showed signs of dried serous sanguineous spots and redness, while another resident's GT dressing had dried brownish spots. The LVN acknowledged that the GT sites were dirty and should have been cleaned, emphasizing the risk of infection and skin breakdown if not properly maintained. The Director of Nursing (DON) stated that GT dressings should be changed daily or as needed when dirty, and licensed staff could change the dressings during rounds and medication passes. The facility's policy on gastrostomy/jejunostomy tube site care, dated March 2023, outlined the importance of promoting cleanliness and protecting the site from irritation, breakdown, and infection. It required cleaning the area surrounding the tube, assessing the stoma site for signs of infection, and reporting any signs of infection to the resident's physician. The failure to adhere to these policies and procedures resulted in deficiencies that had the potential to cause infections in the affected residents.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician of a change of condition for a resident who was observed with slurred speech, a potential symptom of a stroke. The resident, who had a history of cerebral infarction and other related conditions, was noted to have an altered level of consciousness and weakness on the right side. Despite these symptoms, the Licensed Vocational Nurse (LVN) did not notify the physician, as the resident was still responsive. The Director of Nursing (DON) later confirmed that the resident's slurred speech was a change of condition that should have been reported to the physician. The resident was eventually taken to a General Acute Care Hospital, where they were diagnosed with an acute subdural hematoma. Interviews with staff revealed that the resident exhibited signs of a stroke, such as slurred speech and a steady gaze, which were not reported to the physician in a timely manner. The facility's policy and procedures require that any change of condition be promptly reported to a physician, which was not followed in this case, resulting in delayed medical care for the resident.
Failure to Identify and Respond to Change of Condition
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the necessary competencies to identify and respond to a change of condition (COC) in a resident. The resident, who had a history of hemiplegia, hemiparesis, and other serious conditions following a stroke, experienced an altered level of consciousness and weakness in the right arm. Despite these symptoms, the LVN did not notify the physician or the Registered Nurse (RN) on duty, as required by the facility's policy. The LVN observed the resident with impaired speech and a steady gaze but did not recognize these as potential signs of a stroke, leading to a delay in care. Interviews with the RN and the Director of Nursing (DON) revealed that the LVN did not report the resident's slurred speech and other symptoms, which were not part of the resident's baseline condition. The DON emphasized that such symptoms should have been reported immediately to the physician for further assessment and possible hospital transfer. The facility's policy clearly stated that changes in a resident's condition, such as altered level of consciousness and confusion, should be documented and reported promptly, which the LVN failed to do, resulting in a potential risk of harm to the resident.
Failure to Follow Physician's Order for Midodrine Administration
Penalty
Summary
The facility failed to adhere to the physician's order regarding the administration of Midodrine, a medication used to treat low blood pressure, for a resident. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hypotension, had an order to receive Midodrine 10 mg via gastric tube every 8 hours, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 110 mmHg. However, the Medication Administration Record (MAR) for July 2024 showed that the medication was administered on three occasions when the resident's SBP was above the specified threshold: 115 mmHg on July 4th, 114 mmHg on July 5th, and 116 mmHg on July 6th. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the medication was not held as per the physician's order. The DON acknowledged that the failure to hold the medication could lead to increased blood pressure and potential complications. The facility's policy and procedure on medication administration, dated April 2008, emphasized that medications should be administered as prescribed and in accordance with good nursing principles, which was not followed in this instance.
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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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