Westwood Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 12121 Santa Monica Boulevard, Los Angeles, California 90025
- CMS Provider Number
- 055060
- Inspections on file
- 68
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westwood Post Acute Care during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, DM2, and HTN, who had moderate cognitive impairment and required staff assistance with ADLs, requested transfer to a facility in another city to be closer to family. Over several months, the resident and responsible party reported not being informed about the transfer process, not receiving a list of potential facilities, and not being able to speak with the ADM, while also receiving conflicting explanations about why the transfer could not occur. The SS director acknowledged the family’s ongoing request and that at least one potential receiving facility would not accept the resident’s insurance, but the facility did not assist with necessary insurance changes or document timely referrals or transfer planning, despite a care plan that called for discussing placement options and reviewing insurance verification as needed, resulting in an unreasonable delay in the resident’s requested transfer.
Surveyors found expired tomatoes and undated wilted celery in the refrigerator, indicating that food items were not removed as required by facility policy. The dietary supervisor confirmed that all food should be labeled and disposed of after the use by date, but this procedure was not followed.
Surveyors identified deficiencies in the dietary department, including unclean kitchen equipment, improper storage of partially cooked food, and failure to label and date potentially hazardous foods. Staff did not consistently follow menus or recipes, and required annual competency evaluations and performance reviews for dietary staff were missing.
A bedbound, visually impaired resident with Alzheimer's disease did not have a call light within reach and was unaware of its purpose, as confirmed by staff interviews and observation. The call light was found out of reach, and staff acknowledged the importance of accessibility and education for newly admitted residents per facility policy.
A resident with a full-code POLST was found unresponsive and pulseless in a wheelchair on the patio. Instead of starting CPR immediately as required by AHA guidelines and facility policy, staff moved the resident to his room before initiating resuscitation. Multiple staff and a physician confirmed that CPR was not started at the scene, resulting in a delay before emergency measures began. Paramedics later pronounced the resident dead after unsuccessful resuscitation.
A resident with multiple medical conditions was discharged to an ALF without proper coordination or communication regarding their gastrostomy tube, medication supply, or home health services. The facility did not regularly re-evaluate the discharge plan, failed to involve the resident's representative in the process, and did not notify the receiving ALF of the resident's g-tube. As a result, the resident arrived at the ALF unprepared, lacking necessary medication and home health arrangements, and the ALF had to arrange for additional medical care post-discharge.
The facility did not develop a care plan for a resident with a gastrostomy tube, omitting necessary interventions and monitoring, and also failed to initiate a discharge care plan for another resident with cognitive and physical impairments. These omissions were confirmed by the DON and were not in accordance with facility policy.
A resident with Parkinson's disease, muscle weakness, and other physical impairments was unable to use the standard call light due to insufficient hand strength, leaving them unable to call staff for assistance. The issue was confirmed by a CNA, who noted the resident's inability to press the call light button and suggested a more accessible option.
A resident with multiple health conditions and severe cognitive impairment experienced a decline in a pressure ulcer after staff failed to timely implement a care plan intervention for a Low Air Loss (LAL) mattress, despite physician orders and facility policy requiring pressure reduction devices for residents at risk of skin breakdown.
A resident with severe cognitive impairment and multiple chronic conditions had incomplete and missing documentation of ADLs over several days. The DON confirmed that the lack of documentation was due to CNAs not having access to iPads, which had been stolen and not replaced, resulting in shared computer use and missed entries.
A medication error occurred when an LVN attempted to administer Empagliflozin (Jardiance) to a resident despite a physician's hold order and left the medication unattended at the bedside for a family member to give. The resident, who had diabetes and other chronic conditions, had the medication on hold per physician and family request, and the error was acknowledged by nursing staff as a failure to follow standard medication administration procedures.
Twelve residents requiring feeding assistance were labeled as 'feeders' by staff, who maintained a list with this term to assign care duties. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, routinely used this terminology in both verbal and written communications, despite facility policy requiring respectful and dignified treatment. The residents affected had significant medical and cognitive needs, and the practice was acknowledged as standard among staff.
The facility did not ensure that advance directives were present and up-to-date in the clinical records for three residents with various medical conditions and cognitive statuses. During record reviews and interviews, an LVN confirmed the absence of these documents, which could cause confusion about residents' healthcare wishes in emergencies, contrary to facility policy.
An independent liaison, not affiliated with the facility or hospice, accessed and retained a resident's medical records without consent or proper authorization. The liaison did not meet with the resident or obtain consent, and used information from the records to arrange a discharge to hospice care. The resident had a terminal prognosis and intact decision-making capacity. Facility policy required limiting access to PHI, but this was not followed, resulting in a HIPAA violation.
A resident with diabetes, hyperlipidemia, stroke history, and hypertension was found to be cognitively intact but unaware of the reason for her insulin therapy. Review of her medical record showed no documentation that DM education was provided, despite facility policy requiring such documentation after new diagnoses. Both the RN Supervisor and DON confirmed the absence of required education documentation.
A resident with multiple medical conditions was found with topical medications and powder at the bedside, despite not being approved for self-administration according to facility assessment and policy. An LVN confirmed that medications should not be left at the bedside for residents not cleared for self-administration, and the DON stated that proper assessment and physician orders are required before allowing self-administration.
A resident did not have access to hot water for personal hygiene, and the cold water faucet in their room splashed water onto the resident and the floor. The TV was loose and tilted, and the window blinds were broken and improperly attached, creating an unsafe and uncomfortable environment. Facility staff confirmed these issues and identified the need for repairs.
A resident with a history of stroke, generalized weakness, diabetes, cognitive impairment, and dependence on staff for daily living did not have a baseline care plan developed as required by facility policy. The absence of this care plan, particularly for gastrostomy tube management, was confirmed by interviews with nursing leadership and was identified during record review.
A resident with cognitive impairment and multiple hospitalizations for g-tube dislodgement did not have an IDT meeting conducted as required by facility policy. Despite repeated changes in condition, there was no documentation that the resident or their representative were involved in care planning or decision-making, as confirmed by interviews with the ADON and DON.
A resident's room was found to have a loose, tilting TV and broken, bent blinds that were not properly attached, creating potential accident hazards. The resident, who was cognitively intact and independent, reported these issues, which were confirmed by observation and staff interviews. Facility policy requires rooms to be safe and well-maintained, but these hazards were not addressed at the time of the survey.
A resident with cognitive impairment and multiple medical conditions did not receive prescribed enteral nutrition when the feeding tube connection device was found on the floor and not attached to the gastrostomy tube, despite the feeding pump running. An LVN confirmed the improper connection, and the DON noted this could result in the resident not receiving necessary nutrition, contrary to facility policy.
A resident's protected health information was accessed and retained by an independent liaison who was not affiliated with the facility or hospice company. The liaison obtained the resident's medical records without consent and used the information to arrange a discharge to home hospice, without confirming the resident's wishes or involving the family in advance. Facility leadership confirmed the liaison was not authorized to access or use the resident's records, resulting in a violation of HIPAA privacy standards.
Two residents were not offered or administered the pneumococcal vaccine at admission as required by facility policy, and there was no documentation of consent or declination forms until a later date. This occurred despite both residents being cognitively intact and the facility's stated process for screening and documenting vaccination status.
Two residents were not properly offered or documented for COVID-19 vaccination as required by facility policy. Both residents, who were cognitively intact and had multiple medical conditions, lacked evidence of a consent or declination form for the vaccine in their records, despite the facility's process requiring this documentation upon admission.
A resident with type 1 diabetes did not receive insulin as ordered when blood sugar was critically high, and staff failed to consistently monitor and document blood sugar levels before administering insulin. Insulin was sometimes given without a current blood sugar reading, and required physician notifications for abnormal results were missed. These actions and omissions resulted in inadequate diabetic management and confusion among staff regarding appropriate interventions.
The facility failed to ensure staff were seated while feeding two residents, compromising their dignity and comfort. Observations showed CNAs standing over residents with severe cognitive impairments, contrary to facility policy. Interviews confirmed staff awareness of the requirement to sit, but one CNA cited a lack of available chairs as a reason for standing.
A resident with atrial fibrillation, muscle weakness, and polyneuropathy experienced delays in having their call light answered, despite the facility's policy requiring prompt responses. The resident reported that staff sometimes turned off call lights without returning to assist. During an observation, the call light remained on for over 10 minutes while staff were present in the hallway and nursing station, and an alarm was sounding. A nurse confirmed the expectation for prompt responses but could not explain the delay.
A resident with hemiplegia and CHF experienced a fall resulting in a forehead bump and headache. The facility failed to develop a comprehensive care plan with goals and interventions following the incident, as required by their Fall Management Program policy. This deficiency was confirmed by the Medical Record Director during a record review and interview.
A resident with a history of hemiplegia and CHF was found unresponsive and pronounced dead by paramedics. The facility failed to follow its policy requiring a physician's declaration of death and proper documentation, resulting in missing progress notes and a death certificate in the resident's medical records.
The facility failed to provide adequate respiratory care for two residents by not ensuring a physician's order for oxygen therapy and not changing nasal cannula tubing and humidifiers as per policy. One resident was using an oxygen concentrator without a physician's order, and both residents had unlabeled and unchanged equipment, contrary to facility policy.
Two residents experienced misappropriation of belongings due to the facility's failure to follow its theft and loss policy. One resident lost clothes after a scabies outbreak, and another lost clothes and neck pillows, with no inventory or labeling in place. Staff interviews confirmed the lack of initiated reports and adherence to procedures.
A resident with a history of falls and assessed as high risk was left unattended in a wheelchair, resulting in an unwitnessed fall and a laceration requiring sutures. Staff interviews revealed that both the charge nurse and a CNA were on break or attending to personal tasks at the time, and the facility's fall management policy requiring frequent observation was not followed.
The facility failed to implement effective infection control measures, leading to potential infection spread among residents. Three residents with severe cognitive impairments were not assessed for skin rashes, placed on contact precautions, or had their physicians notified about ineffective treatments. Observations revealed red, raised, scaly rashes and burrowing, indicating possible scabies. The facility's infection control policy was not followed, contributing to the deficiency.
A resident with a G Tube experienced multiple dislodgements due to the facility's failure to consistently use an abdominal binder, as outlined in the care plan. Additionally, there was a delay in transferring the resident to the hospital after the G Tube malfunctioned, risking malnutrition and dehydration. The facility also lacked adequate training and policies on bowel impaction and abdominal assessments, contributing to the resident's fecal impaction and associated complications.
A resident reported her personal walker missing upon readmission to the facility, but no grievance form was initiated, and there was no documentation of her report. Despite staff being aware of the issue, the facility failed to follow its grievance and theft and loss policies, resulting in a violation of the resident's rights.
A resident with a history of stomach cancer and severe pain was not administered Norco as ordered by the physician, resulting in unmanaged pain. Despite the resident's reports of severe pain and the facility's policy requiring pain management, the medication was not given during night shifts, and no interventions were documented. Interviews with the ADON and DON confirmed the oversight.
A resident with hypertension, diabetes, and dementia, who was on hospice care, passed away without proper documentation in their medical record. The facility did not follow its policy on documenting the death, as confirmed by the DON.
A facility failed to educate a visitor on the use of PPE for a resident under droplet precautions due to COVID-19 exposure. The resident, with a history of hemiplegia, COPD, and diabetes, was in a room with droplet precaution signage, but the visitor was not informed about PPE requirements. Staff interviews confirmed the need for visitor education on PPE, as outlined in the facility's COVID-19 management policy.
A resident at risk for unplanned weight loss experienced significant weight loss due to the facility's failure to implement dietary recommendations. Despite a Registered Dietician's advice to provide ice cream with meals and snacks, these were not followed, resulting in a 3% body weight loss in one week. The Director of Nursing highlighted the importance of adhering to dietary plans to prevent such outcomes.
A resident with prostate cancer did not receive the prescribed medication Darolutamide due to its high cost and lack of insurance coverage. The facility failed to notify the physician or oncologist, resulting in a breakdown of communication and adherence to medication administration policies. Staff interviews revealed assumptions and lack of documentation regarding the missing medication.
A resident with severe cognitive impairment and a history of abdominal issues was not properly monitored or reported to a physician when symptoms of abdominal distention and inconsistent bowel movements were observed. Despite staff noticing these changes, the required notification to the physician was not made, leading to the resident being found unresponsive and later pronounced dead. The facility's policy on Change of Condition Notification was not followed, contributing to the deficiency.
A resident with a history of falls and psychosis experienced multiple falls and injuries due to the facility's failure to provide a full-time 1:1 sitter as outlined in their care plan. Despite being assessed as high risk for falls, the resident fell on several occasions, resulting in injuries such as a dislocated finger, a fractured ulna, and a hematoma. The facility did not consistently implement care plan interventions, and staff acknowledged the ineffectiveness of these measures in preventing the falls.
The facility failed to maintain a safe and functional area in the staff's breakroom, where multiple dead roaches were found under the sink. The Maintenance Supervisor acknowledged the issue, and the Administrator confirmed that the Maintenance and Housekeeping staff would clean the breakroom and remove the dead roaches. The facility's policies indicated that the facility should be free of pests and maintained in a clean and sanitary condition.
The facility failed to promote dignity and respect for two residents by not conducting a personal property inventory upon admission for one resident and allowing staff to speak in a language not understood by another resident in their presence. This led to missing belongings and feelings of exclusion and anger.
The facility failed to ensure comfortable sound levels at night, affecting three residents' ability to sleep undisturbed. Residents reported high noise levels, particularly from staff activities, which were confirmed by staff interviews. The facility's policies emphasize maintaining comfortable noise levels, but these were not followed.
The facility failed to conduct timely PASRR for two residents, leading to potential inappropriate care. One resident's PASRR was incomplete, and another's was delayed by several months. The facility's policies were not followed, compromising the care provided.
The facility failed to store and label food in accordance with professional standards and facility policy, placing residents at risk for foodborne illnesses. Observations revealed expired and unlabeled food items in the kitchen and the refrigerator used for residents' outside food. The Dietary Supervisor and Maintenance Assistant acknowledged the issues and the potential health risks.
The facility failed to obtain a physician's order for a resident to go out on pass, despite the resident's threats and previous doctor's order for a one-day pass. This non-compliance with facility policy potentially impacted the resident's psychosocial well-being and self-esteem.
The facility failed to ensure a comprehensive PASRR assessment for a resident with major depressive disorder, anxiety disorder, and PTSD. The PASRR level 1 screening had a blank question regarding suspected mental illness, which could lead to inadequate care. Only one RN had access to the PASRR system, and the facility's policy mandates that incomplete PASRRs must be completed the same day.
The facility failed to accurately document a resident's psychiatric/mood disorder on the MDS, omitting an anxiety disorder diagnosis. This discrepancy was identified during a review with the DON, who acknowledged the importance of accurate documentation for proper care planning. The omission had the potential to negatively impact the resident's care plan and delivery of necessary services.
Failure to Assist Resident With Requested Transfer and Insurance Coordination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding transfer to another skilled nursing facility closer to family. A resident with diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and essential primary hypertension, and with documented moderate cognitive impairment and dependence on staff for several ADLs, expressed a desire to transfer to a facility in Bakersfield to be closer to his sons. The resident reported wanting this for some time and stated he was not informed about the transfer process and was unaware of what was happening, indicating reliance on his responsible party to handle the transfer. The responsible party stated that it had been almost three months since the resident’s desire and request to transfer were communicated to the facility, but they were not provided with a list of available facilities in Bakersfield and did not receive consistent information about why the transfer could not occur. The responsible party further reported not being able to speak with the administrator despite requests and not receiving assistance from the facility in changing the resident’s insurance so that Bakersfield facilities could accept the resident. The social services director confirmed that the family had requested a transfer to Bakersfield for at least one to three months and acknowledged that a contacted Bakersfield facility did not accept the resident’s insurance, stating that changing insurance was the responsibility of the resident or responsible party. Progress notes showed that social services spoke with an admissions director at a Bakersfield facility and learned they did not take the resident’s insurance, but records did not show referrals or transfer plans prior to the complaint investigation date. The resident’s discharge care plan, which included interventions to discuss placement options as requested and review insurance verification and authorization as needed, did not reflect that these interventions were implemented before the complaint, resulting in an unreasonable delay and impediment to the resident’s requested transfer.
Failure to Remove Expired Food from Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to remove expired food items from the refrigerator in accordance with their policy. Specifically, a bin of tomatoes with a use by date that had passed and a bin of wilted celery with no date were found during an inspection. The facility's produce storage guidelines require that fresh vegetables be checked for ripeness, labeled, dated, and rotated so that the oldest produce is used first, and that expired items be disposed of. During an interview, the dietary supervisor confirmed that all deliveries are labeled upon receipt and should be discarded after the use by date, but this was not followed in practice.
Deficiencies in Food Safety Practices and Staff Competency in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food and nutrition service. The kitchen stove top was found with dried food and debris, and the refrigerator contained unlabeled and undated slices of cheese, a large container of egg salad, and a large container of tuna. During the inspection, a dietary cook was found storing partially cooked chicken and zucchini in the oven at 250 degrees, claiming it was not being cooked but stored. The cook did not follow the prescribed menu or recipe for meal preparation. The cook became visibly angry during the inspection, slamming hot pans and oven doors, which led the surveyor to exit the kitchen for safety concerns. The dietary supervisor confirmed that recipes and menus are to be followed unless changes are approved, and the dietician emphasized the importance of labeling and dating potentially hazardous foods. Further review of employee records revealed that annual competencies and performance evaluations were missing for multiple dietary staff members, including cooks and aides. The Director of Staff Development acknowledged that these evaluations are required to ensure staff competency and safe food preparation. Facility policies reviewed indicated that standardized recipes and menu adherence are mandatory, and that staff competency checks should be performed upon hire, annually, and as needed. The lack of adherence to these policies and procedures contributed to the observed deficiencies in food safety and staff competency.
Failure to Ensure Call Light Accessibility and Resident Education
Penalty
Summary
A deficiency occurred when a bedbound resident with blindness, muscle weakness, dysphagia, and Alzheimer's disease did not have access to a call light while in bed. During observation, the call light was not visible or within reach of the resident, and the resident stated they were unaware of what a call light was, indicating they had not been educated on its use. The call light was later found on a nightstand under a pillow, out of the resident's reach by more than an arm's length. Staff interviews confirmed that the call light should have been accessible and that education on its use is required upon admission. The CNA admitted to forgetting to check the call light's placement, and the LVN and DSD both acknowledged the importance of call light accessibility and resident education, especially for newly admitted, visually impaired, and primarily Spanish-speaking residents. Facility policy requires that residents be instructed on the use of the call system upon admission.
Failure to Immediately Initiate CPR for Unresponsive Resident
Penalty
Summary
Facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with American Heart Association (AHA) guidelines for a resident who was found unresponsive in the patio. The resident had a valid Physician Orders for Life-Sustaining Treatment (POLST) indicating a desire for full resuscitation and no advance directive limiting care. Upon discovery, the resident was unresponsive, with no vital signs appreciated, and was seated in a wheelchair. Instead of starting CPR at the location where the resident was found, staff moved the resident from the patio to his room before initiating CPR. Multiple staff members, including a Registered Nurse Supervisor (RNS), were involved in transferring the resident back to bed, which required six to seven people. Interviews with staff and another resident confirmed that CPR was not started on the patio, despite the resident being unresponsive and pulseless. The facility's policy and AHA guidelines both require immediate initiation of CPR when a person is found unresponsive and not breathing normally, but this was not followed in this instance. The delay in starting CPR was further corroborated by interviews with staff, a resident witness, and the facility's medical doctor, who all stated that CPR should have been started immediately at the site where the resident was found. The medical doctor also confirmed that the patio floor was an appropriate surface for CPR. Paramedics arrived after the resident had been moved to his room and found the resident pulseless and unresponsive, with CPR in progress. The resident was pronounced dead by paramedics after resuscitation efforts were unsuccessful.
Failure to Coordinate Discharge Planning and Communication for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure proper discharge planning and coordination for a resident with complex medical needs. The resident, who had a history of hemiplegia, hemiparesis, cerebral infarction, primary thrombophilia, depression, aphasia, seborrheic dermatitis, dysphagia, gastrostomy, hyperlipidemia, glaucoma, and coronary artery disease, was discharged to an assisted living facility (ALF) without adequate communication or preparation. The discharge process did not include regular re-evaluation of the discharge plan, nor was there effective coordination with the resident's representative. The resident's legal guardian participated in initial goal setting, but the overall discharge goal remained unclear, and no referrals were made to local contact agencies as required. During the discharge process, the facility did not ensure that the ALF was notified of the resident's gastrostomy tube, nor did it provide the resident with a supply of hydroxyzine, a medication prescribed for itching. The ALF and care coordinator reported a lack of communication from the facility's Director of Social Services (DSS), resulting in the ALF being unaware of the resident's g-tube and the need for home health services. The resident arrived at the ALF with the g-tube still in place, no home health services arranged, and without all necessary medications. The ALF had to arrange for the removal of the g-tube at a hospital and struggled to set up home health due to insurance issues. Interviews and record reviews revealed that the DSS did not follow up with the resident, family, or ALF after discharge, and did not provide necessary documentation or coordination for the resident's ongoing care needs. The facility's policies required discharge planning to begin at admission, regular updates to the care plan, and communication with all parties involved, but these steps were not consistently followed. The lack of follow-up and incomplete discharge preparation led to significant gaps in the resident's transition to the ALF.
Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents with specific needs. For one male resident with multiple diagnoses including hemiplegia, dysphagia, and a gastrostomy, the care plan did not address the presence or management of the gastrostomy tube, despite documentation in the Minimum Data Set and physician orders indicating its use for water administration. The care plan only referenced dietary restrictions and dysphagia, omitting any interventions or monitoring related to the gastrostomy tube. The Director of Nursing confirmed that a care plan for the gastrostomy tube was missing, even though it was required. For a female resident with diagnoses including monoplegia, dysphagia, and cognitive impairment, the facility did not initiate a discharge care plan upon admission, as required by facility policy. The Director of Nursing acknowledged that discharge planning should begin at admission and be updated as needed, but there was no evidence of a discharge care plan being developed for this resident. The facility's policy mandates that a comprehensive care plan, including discharge planning, be developed within seven days of the comprehensive assessment, but this was not followed.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had access to a call light that could be used independently. The resident, who had diagnoses including Parkinson's disease, abnormal posture, muscle wasting, generalized osteoarthritis, and muscle weakness, was cognitively intact but required maximal to total assistance for most activities of daily living. During observation and interview, the resident was unable to locate or use the call light due to insufficient hand strength to press the button, and expressed difficulty in calling for help. A CNA confirmed that the resident was unable to press the call light button and suggested an alternative device for easier use. This deficiency resulted from the facility's inaction in providing a call light system that accommodated the resident's physical limitations, thereby preventing the resident from being able to summon staff assistance when needed.
Failure to Timely Implement Pressure Ulcer Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including diabetes mellitus, abnormal posture, muscle weakness, osteoarthritis, heart failure, hypertension, and dementia, was dependent on staff for most activities of daily living and had severe cognitive impairment. The care plan, dated 2/6/25, specified the use of a Low Air Loss (LAL) mattress to prevent further decline in the resident's pressure ulcer condition. However, despite physician orders for the LAL mattress on multiple dates, the mattress was not installed until several days after a noted decline in the resident's pressure ulcer status. The delay in providing the LAL mattress was attributed to concerns from the resident's family about the risk of falls due to the increased bed height. The Director of Nursing confirmed that the mattress was not put in place until after the resident's condition had worsened. Facility policy required the provision of appropriate mattresses to residents at risk for skin breakdown, but this was not followed in a timely manner for this resident, resulting in a decline in the pressure ulcer.
Incomplete ADL Documentation Due to Lack of CNA Access to Electronic Devices
Penalty
Summary
The facility failed to ensure that medical record documentation of activities of daily living (ADLs) was accurate and complete for one of five sampled residents. The resident in question had multiple diagnoses, including diabetes mellitus, abnormal posture, muscle weakness, generalized osteoarthritis, heart failure, hypertension, and dementia, and was assessed as having severe cognitive impairment. According to the Minimum Data Set (MDS), the resident required significant assistance with most ADLs and had a history of rejecting care on several occasions during the assessment period. A review of the resident's ADL records over a ten-day period revealed multiple instances of missing documentation for essential care tasks such as eating, bed mobility, personal hygiene, toilet hygiene, and oral hygiene across various shifts. During an interview and record review, the Director of Nursing (DON) confirmed the missing documentation and attributed the issue to the theft of iPads used by CNAs for documentation, which had not been replaced. As a result, CNAs had to share computers with nurses, leading to delays and omissions in documentation due to limited access.
Medication Error Due to Failure to Follow Hold Order and Unattended Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow a physician's order to hold the medication Empagliflozin (Jardiance) for a resident with diabetes, hypertension, and atherosclerotic heart disease. The medication was on hold per physician order and family request, as documented in the resident's medical record and medication administration record. Despite the hold order, the LVN attempted to administer the medication during a morning shift and left the medication unattended at the resident's bedside at the request of a family member, intending for the family to administer it after oral care. The LVN acknowledged during an interview that leaving the medication with the family and attempting to administer a medication that was on hold was not standard nursing practice. The registered nurse supervisor confirmed that the medication was on hold and later discontinued, and that the error was discussed with the LVN and the family. The assistant director of nursing also stated that medication administration should be witnessed by licensed staff and that all medication orders, including holds and discontinuations, are clearly visible in the medication administration record. Facility policy and procedure require that medications be administered only as ordered by a physician or licensed independent practitioner, and define a medication error as administering a medication that is not currently prescribed. The LVN's actions in attempting to administer and leaving a held medication unattended constituted a failure to comply with these requirements, resulting in a medication error for the resident.
Residents Labeled as 'Feeders' in Staff Assignments
Penalty
Summary
The facility failed to treat twelve residents who required feeding assistance with respect and dignity by referring to them as "feeders" and maintaining a list labeled as such for staff assignment purposes. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, consistently used the term "feeders" to identify and assign residents needing feeding assistance. This terminology was used in staff communications, written lists, and verbal exchanges, and was acknowledged by multiple staff members during interviews. The list of "feeders" was used to distribute workload among staff, and the term was used both in conversation and in written documentation. The residents involved had significant medical needs, including diagnoses such as diabetes Type 2, muscle weakness, Parkinson's disease, quadriplegia, schizophrenia, hypertension, and anxiety disorder. Most of these residents had severely impaired cognition and required substantial or maximal assistance with all activities of daily living, including eating. Some residents had intact cognition but still required extensive assistance. The use of the term "feeders" was applied regardless of cognitive status, and staff described entire rooms as being "feeders" and discussed their care in these terms. Facility policy required that residents be treated with dignity and respect, including being addressed by their name of choice and prohibiting demeaning practices. However, staff interviews and record reviews confirmed that the practice of labeling and referring to residents as "feeders" was routine and accepted among staff, despite the policy. The report notes that this practice caused or had the potential to cause depression among the affected residents.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to maintain accurate and current copies of advance directives in the clinical records for three out of four sampled residents. During record reviews and interviews, it was found that the medical charts for these residents did not contain their advance directives, despite facility policy requiring such documentation. Licensed vocational nursing staff confirmed the absence of these documents in the residents' charts, acknowledging that this could lead to confusion regarding the residents' wishes in the event of a medical emergency. The residents involved had varying medical conditions, including muscle weakness, rheumatoid arthritis, hypertension, atrial fibrillation, and diabetes, with cognitive statuses ranging from intact to moderately impaired. The Minimum Data Set assessments indicated differing levels of assistance required for activities of daily living. The facility's policy states that residents have the right to formulate advance directives and that these should be included in their records, but this was not followed for the residents in question.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
A deficiency occurred when an independent liaison, who was not an employee of the facility or the hospice company, obtained and retained medical records for a resident without proper authorization or consent. The liaison stated she did not meet with the resident or the resident's sister prior to arranging the discharge and did not receive the resident's consent to access or review the medical records. The liaison acquired the records from the hospice company and used information from them to facilitate the resident's discharge, despite not having a medical background or a direct relationship with the facility or hospice. The resident involved had a history of paraplegia, essential hypertension, and recurrent urinary tract infections with sepsis, and was readmitted to the facility with a terminal prognosis. The resident's medical records indicated intact cognition and the capacity to make medical decisions. The discharge summary and care plan noted the resident's terminal condition and the plan for a safe transition home, but there was no documentation that the physician spoke to the resident's family about the terminal prognosis. The discharge planning review form was also found to be incomplete. Facility policy required that access to protected health information (PHI) be limited to the minimum necessary and that the entire medical record should not be disclosed unless specifically justified, particularly for non-treatment purposes. The liaison's access and retention of the resident's medical records, without proper consent or justification, constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA) and the facility's own policies regarding the disclosure of PHI.
Failure to Document and Provide Diabetes Education to Resident
Penalty
Summary
Facility staff failed to accurately and completely document diabetes mellitus (DM) education in the medical record for one resident. The resident, who had a history of DM, hyperlipidemia, cerebral vascular accident without residuals, and hypertension, was found to be cognitively intact and required staff assistance with activities of daily living. During an interview, the resident stated she did not know why she was taking insulin, indicating a lack of understanding about her diagnosis and treatment. A review of the resident's chart with the Registered Nurse Supervisor revealed no documented evidence that education regarding the DM diagnosis was provided to the resident or her representative. The facility's process requires that new diagnoses be discussed in an interdisciplinary team meeting with the resident or representative, with documentation in the progress notes. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that documentation of education was missing, and facility policy requires that each discipline document relevant information in the resident's progress notes.
Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed and approved for self-administration of medications. The resident, who had diagnoses of hypertension, generalized weakness, and diabetes mellitus, was admitted to the facility and had a self-administration assessment indicating a need for assistance with ointments and topical medications. The assessment specifically stated that the resident was not approved for self-administration or for keeping medications at the bedside. Despite this, during an observation, the resident was found with two creams and a powder medication at the bedside, which the resident identified as prednisolone cream, Vitamin A&D ointment, and athlete's foot powder. A Licensed Vocational Nurse confirmed that these medications should not have been left at the bedside, as the resident was not approved for self-administration and all medications should be administered by licensed staff and securely stored. The Director of Nursing stated that the facility's process requires an assessment and a physician's order for self-administration, and that medications should not be left with residents who are not approved, to prevent potential medication errors. The facility's policy also requires IDT and physician determination before allowing self-administration, which was not followed in this case.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for one resident, as evidenced by the lack of access to hot water for grooming and personal hygiene, and a malfunctioning cold water faucet that splashed water onto the resident and the floor. The resident reported that the hot water in the room did not function properly, taking over ten minutes to become warm and then only dribbling out, while the cold water came out at an odd angle and caused splashing. Additionally, the television in the room was loose, tilted to the side, and appeared unstable, and the window blinds were broken, bent, and not properly attached, creating the appearance that they might fall at any time. Observations confirmed the resident's room was clean and free of unusual odors, but the TV was loosely affixed and tilted, and the blinds were in disrepair with broken slats and a bent top. The bathroom faucet did not provide hot water, and the cold water splashed outside the sink. The facility's maintenance supervisor acknowledged these issues, attributing the hot water problem to a possible pipe clog and noting the need for repairs to the faucet, TV bracket, and blinds. Facility policies require the maintenance department to keep the building and equipment safe and operable at all times and to provide residents with a safe, clean, comfortable, and homelike environment.
Failure to Develop Baseline Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a baseline care plan in accordance with its own policy and procedures for one resident. Record review showed that the resident was admitted and later readmitted with diagnoses including stroke, generalized weakness, and diabetes mellitus. The resident's Minimum Data Set indicated cognitive impairment and dependence on staff for activities of daily living. Despite these needs, there was no baseline care plan developed to address the resident's specific conditions, including the management of a gastrostomy tube (g-tube). Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the absence of a care plan could result in staff not having unified or appropriate interventions for the resident, particularly regarding the risk of g-tube dislodgement. The facility's policy required a comprehensive, person-centered care plan to be developed for each resident to meet their health, safety, psychosocial, behavioral, and environmental needs, but this was not done for the resident in question.
Failure to Conduct Interdisciplinary Team Meeting After Change in Condition
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting for one of three sampled residents, as required by facility policy. Specifically, a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus was admitted and later readmitted to the facility. The resident was noted to have cognitive impairment and was dependent on staff for activities of daily living. From January 2025 onward, the resident experienced multiple hospitalizations due to gastrostomy tube (g-tube) dislodgements. However, there was no documented evidence that an IDT meeting was conducted to address these incidents, despite the facility's policy requiring such meetings upon admission, quarterly, annually, and as needed, particularly at changes of condition. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that IDT meetings should have been held to involve the resident's representative and develop a comprehensive care plan, especially after repeated g-tube dislodgements and hospitalizations. The facility's policy on comprehensive person-centered care planning also specifies that the IDT team must include the resident and their representative. The lack of documented IDT meetings meant that the resident and their representative were not involved in care planning or decision-making regarding the resident's care needs during these significant events.
Failure to Maintain Resident Room Free from Accident Hazards
Penalty
Summary
A deficiency was identified when a resident's room was found to have accident hazards and did not provide a safe, comfortable, and homelike environment. The resident, who was cognitively intact and primarily independent with diagnoses including hypertension and muscle weakness, reported that the television in the room was loose, tilting to the right, and appeared as though it might fall. Additionally, the blinds in the room were broken, bent, and not properly attached, creating the appearance that they could fall at any time. These issues were confirmed during an observation of the room, where the TV was seen to be loosely affixed and the blinds were in disrepair. Interviews with facility staff, including the Maintenance Supervisor, confirmed that the TV had a loose screw and the blinds were damaged, both of which had not yet been addressed at the time of the initial observation. The facility's policies and procedures require that the maintenance department keep the building and equipment safe and operable at all times, and that resident rooms provide a safe, clean, comfortable, and homelike environment. The failure to maintain the resident's room in good repair and free from hazards constituted a deficiency.
Failure to Properly Administer and Connect Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus, who was dependent on staff for activities of daily living and had cognitive impairment, did not receive appropriate care related to their enteral feeding. The resident had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube twice daily at a specified rate. During observation, the feeding tube connection device was found on the floor, disconnected from the resident's gastrostomy tube, while the feeding pump continued to run. Upon further investigation, a Licensed Vocational Nurse confirmed that the feeding tube was not properly connected, which could result in the resident not receiving their prescribed nutrition. The Director of Nursing also acknowledged that the tube feeding set should be a closed unit to prevent infection and that failure to connect the feeding could lead to nutritional deficits. Facility policy required enteral feedings to be administered per physician order and connected to the resident, which was not followed in this instance.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for one resident. An independent liaison, who was not an employee of the facility, hospice company, or corporation, obtained and retained the resident's medical records without the resident's consent. The liaison accessed these records through the hospice company and used the information to arrange for the resident's discharge to home hospice services, despite not having a medical background or prior contact with the resident or their family. The resident in question had a diagnosis of complete paraplegia and essential hypertension, with medical records indicating intact cognition and the capacity to make medical decisions. The resident required significant assistance with activities of daily living. The liaison did not confirm the resident's wishes or obtain consent before accessing and using the resident's protected health information (PHI) for discharge planning. The family was informed by the liaison, who identified herself as a case manager for the corporate office, that the resident needed to be discharged the next day, without prior notice or direct communication from facility staff. Facility leadership, including the Vice President of Operations, confirmed that the liaison was not affiliated with the facility or corporation and had no authorization to access or use the resident's medical records. The facility's failure to control access to PHI resulted in a violation of HIPAA privacy standards, as the liaison was able to obtain, review, and act upon the resident's medical information without proper authorization or consent.
Failure to Offer and Document Pneumococcal Vaccination per Policy
Penalty
Summary
The facility failed to ensure that pneumococcal (PNA) vaccines were offered and/or administered to two of five sampled residents in accordance with facility policy. For both residents, who were cognitively intact and required varying levels of assistance with activities of daily living, there was no documented evidence that a consent or declination form for the PNA vaccine was obtained at the time of admission. Instead, the consents were obtained at a later date, well after their respective admissions. The facility's process, as described by the Infection Prevention (IP) Nurse, involves screening residents upon admission for vaccination status using resident or representative interviews and checking immunization registries, followed by obtaining consent or declination forms based on current vaccination status. Record reviews confirmed that for both residents, the required documentation regarding the offer or administration of the PNA vaccine was missing at admission, contrary to the facility's policy and CDC recommendations. The facility policy, reviewed previously, specified that pneumococcal immunization should be offered according to CDC guidelines, but this was not followed for the two residents identified in the report.
Failure to Document and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination was offered and/or administered to two of five sampled residents in accordance with its policy and procedures. For one resident, the admission record showed they were admitted and readmitted with diagnoses including spinal stenosis, muscle spasm, and GERD. The Minimum Data Set (MDS) indicated the resident was cognitively intact and required assistance with activities of daily living. Upon review of the electronic chart and interview with the Infection Prevention (IP) Nurse, it was found that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident at the time of admission, as required by facility policy. Similarly, another resident was admitted with diagnoses of anemia, generalized weakness, and diabetes mellitus, and was also found to be cognitively intact and moderately dependent on staff for activities of daily living. Record review and interview with the IP Nurse revealed that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident either. The facility's policy, reviewed on 12/18/2020, required that residents be screened for vaccination status and that appropriate documentation be obtained, but this was not followed for the two residents identified.
Failure to Administer Insulin and Monitor Blood Sugar per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with type 1 diabetes mellitus did not receive appropriate insulin administration and blood sugar (BS) monitoring according to physician orders and facility policy. On one occasion, the resident's BS was found to be 541 mg/dL, but the prescribed dose of Humalog KwikPen insulin was not administered, and the physician was not notified as required. Additionally, there were multiple instances where the licensed vocational nurse (LVN) failed to check the resident's BS prior to administering insulin, and in one case, administered insulin based on a BS reading taken several hours earlier without rechecking the current level. The facility's policy required BS checks and physician notification for readings above 350 mg/dL, but these steps were not consistently followed. The resident's medical records indicated a history of type 1 diabetes and essential hypertension, with orders for both scheduled and sliding scale insulin. Documentation showed that the resident experienced a severe hypoglycemic event, with a BS of 25 mg/dL, resulting in unresponsiveness and transfer to the hospital. Despite this event, subsequent insulin administration and BS monitoring remained inconsistent. The LVN involved stated that fear of another hypoglycemic episode influenced the decision not to administer insulin when the BS was high, but this was not communicated to the physician in a timely manner. There were also discrepancies in the documentation of BS checks and insulin administration, with some doses given without recent BS readings and some high BS readings not followed by the required interventions. Interviews with staff and review of facility policies confirmed that the required protocols for diabetic care, including timely BS monitoring, insulin administration, and physician notification, were not adhered to. The director of nursing acknowledged that the nurse should have rechecked the BS before administering insulin and should have notified the physician of significant changes. The facility's policies emphasized the importance of monitoring and documentation, but these were not consistently implemented, leading to confusion among staff and inadequate care for the resident.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care that promoted or enhanced the dignity and respect of residents by not ensuring staff were seated while feeding residents. This deficiency was observed in two residents who required assistance with feeding due to severe cognitive impairments and other medical conditions such as dysphagia and dementia. During observations, Certified Nursing Assistants (CNAs) were seen standing over the residents while feeding them, causing the residents to raise their necks and look up at the staff, which is contrary to the facility's policy that staff should be seated to ensure comfort and dignity for the residents. Interviews with the CNAs and a Licensed Vocational Nurse (LVN) confirmed that the staff were aware of the requirement to sit while feeding residents to maintain their dignity and comfort. However, one CNA did not sit due to the unavailability of a chair, and another CNA initially stood before sitting down after being reminded. The facility's policies, including the Restorative Dining Program and Feeding the Resident, clearly state that staff should sit while assisting or feeding residents, and residents should be properly positioned to facilitate eating.
Failure to Promptly Answer Resident's Call Light
Penalty
Summary
The facility failed to ensure that a resident's call light was answered promptly, which is a device used to notify the nurse that the resident needs assistance. This deficiency was observed for one of the sampled residents, who was admitted with diagnoses including atrial fibrillation, muscle weakness, and polyneuropathy. The resident's cognitive skills for daily decisions were intact, and they required moderate assistance from staff for activities of daily living. During an observation and interview, the resident expressed that staff took a while to answer call lights and sometimes turned them off without returning to assist. On the day of the observation, the resident pressed the call light for help, and it remained on for more than 10 minutes while staff were observed walking in the hallway and present in the nursing station. An alarm sound was heard in the nursing station, indicating that the call light was active. A Licensed Vocational Nurse confirmed that call lights should be answered right away and that any staff could respond to them. However, the nurse was unable to explain why the call light had not been answered promptly. The facility's policy and procedure indicated that call alerts should be answered promptly and courteously, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident following a fall incident with injury. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, and congestive heart failure, experienced a fall on 12/5/2024, resulting in a bump on the forehead and a headache. Despite the incident, there was no care plan developed with goals and interventions to address the fall, as confirmed by a review of the resident's electronic and paper health records. The facility's policy on Fall Management Program, which requires interventions to be documented in the resident's plan of care, was not followed. This deficiency was identified during a record review and interview with the Medical Record Director, who confirmed the absence of a care plan for the resident after the fall incident. The lack of a comprehensive care plan following the fall had the potential to negatively impact the resident's health and safety, as well as the quality of care and services received.
Failure to Document Resident's Death According to Policy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not implementing the facility's policy and procedure titled 'Death of a Resident' when the resident passed away. The resident, who had a history of hemiplegia, hemiparesis, and congestive heart failure, was found unresponsive by a Certified Nursing Assistant. Paramedics pronounced the resident dead, but there was no physician's progress note or record of death filed in the resident's medical records. The facility's policy required that only a licensed physician could declare a resident dead and that all documentation related to the resident's death should be maintained in the medical record. However, the Medical Record Director confirmed that there were no physician's progress notes or death certificate on file for the resident. This oversight resulted in an incomplete assessment and documentation as required by the facility's policy and procedure upon the resident's death.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents by not ensuring a physician's order was in place for oxygen therapy for one resident and not changing the nasal cannula tubing and humidifier as per facility policy for both residents. Resident 4, who was admitted with diagnoses including atrial fibrillation and muscle weakness, was observed using an oxygen concentrator without a physician's order for supplemental oxygen therapy. Additionally, the nasal cannula tubing and humidifier for Resident 4 were not labeled with a date and the humidifier was empty, indicating a failure to follow the facility's policy of changing and labeling these items weekly. Resident 2, admitted with conditions such as type II diabetes mellitus and heart failure, also experienced deficiencies in respiratory care. The nasal cannula tubing and humidifier for Resident 2 were not labeled with a date and had not been changed since admission, contrary to the facility's policy. The humidifier was observed to be more than halfway empty, and no bubbling was noted, suggesting it was not functioning properly. Licensed Vocational Nurses confirmed these observations and acknowledged the lack of adherence to the facility's policy, which requires weekly changes and labeling of the equipment.
Failure to Protect Residents' Belongings
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their personal belongings. Resident 1, who was admitted with a left femur fracture, bipolar disorder, and depression, reported missing clothes after a scabies outbreak led to her clothes being laundered and stored in the basement. Despite a list being made of her clothes, the items were not returned, and she was given clothes from the donation stock instead. Interviews with staff confirmed that a theft and loss report was not initiated, contrary to the facility's policy. Resident 2, admitted with hemiplegia and hemiparesis following a cerebral infarction, reported missing clothes and neck pillows that were sent to the laundry. The facility failed to maintain an inventory of Resident 2's belongings upon admission, and her clothes were not labeled, making it difficult to identify them. The Assistant Director of Nursing confirmed the absence of an inventory list and acknowledged the need for labeling residents' clothes. The facility's policy on theft and loss requires the initiation of a report and investigation when personal property is reported missing. However, this procedure was not followed for either resident, resulting in the unresolved loss of their belongings. The policy also mandates the documentation of residents' belongings upon admission and the labeling of clothes, which was not adhered to in these cases.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident, identified as Resident 1, who was at high risk for falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls, with a fall risk evaluation score of 12, indicating a high risk for potential falls. The resident's care plan included interventions to anticipate and meet the resident's needs and to provide a safe environment. Despite these measures, on the evening of November 8, 2024, Resident 1 suffered an unwitnessed fall from a wheelchair, resulting in a laceration on the left eyebrow that required three sutures. The incident occurred when Resident 1 was left unattended in a wheelchair across from their room. Interviews with staff revealed that both the charge nurse and a certified nursing assistant were on break or attending to personal tasks at the time of the fall. The resident was found on the floor in a prone position by the doorway, with a skin tear and minimal bleeding. The facility's policy on fall management, which requires more frequent observation for residents with multiple falls, was not adhered to, contributing to the incident. The report highlights that the facility's failure to provide adequate supervision and a safe environment for Resident 1, who was known to be at high risk for falls, directly led to the resident's fall and subsequent injury. Interviews with staff and the review of the facility's policies indicate a lack of adherence to established protocols for monitoring high-risk residents, which resulted in the deficiency noted in the report.
Failure to Implement Effective Infection Control Measures
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of infection among residents, visitors, and the community. Three residents were affected by this deficiency, as the facility did not assess their skin rashes, place them on contact precautions, or notify a physician about ineffective treatments. Resident 1 was observed with red, raised scaly rashes on her lower legs and had severe cognitive impairment, requiring assistance with daily activities. Resident 3, who had diabetes and other health issues, was seen with red, raised, scaly rashes and burrowing on his body, indicating a possible scabies infestation. Resident 4, also with severe cognitive impairment, had similar rashes and was observed scratching continuously. The facility's Director of Nursing (DON) admitted that the staff had not reassessed Resident 3's condition after suspecting an allergic reaction, leading to a delay in effective treatment. The DON also confirmed that the nursing staff failed to identify Resident 4's rash, resulting in a delay in care and worsening of the condition. The facility's policy on scabies prevention and management was not followed, as residents with undiagnosed rashes were not placed on contact isolation, and there was no confirmation of scabies diagnosis through skin scrapings. The dermatologist's notes for Residents 3 and 4 indicated the presence of erythematous eczematous patches, linear burrows, and scabietic nodules, suggesting a scabies infestation. Despite these findings, the facility did not take appropriate measures to prevent the spread of infection. The lack of timely assessment, communication with physicians, and adherence to infection control policies contributed to the deficiency, putting the health and safety of residents and others at risk.
Failure to Prevent G Tube Dislodgement and Timely Hospital Transfer
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident with a Gastrostomy Tube (G Tube) by not ensuring the use of an abdominal binder to prevent frequent dislodgement of the tube. Despite a care plan being initiated to use an abdominal binder, it was not consistently applied, leading to multiple dislodgements and unnecessary transfers to a General Acute Care Hospital (GACH). Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), confirmed the oversight and acknowledged that the use of an abdominal binder could have prevented these incidents. Additionally, the facility did not transfer the resident to the hospital in a timely manner after the G Tube was dislodged. There was a significant delay between the identification of the G Tube malfunction and the actual transfer to the hospital, which could have resulted in malnutrition and dehydration for the resident who relied on the G Tube for nutrition and hydration. The ADON admitted that the physician should have been notified sooner, and the Medical Doctor (MD) emphasized the importance of timely hospital transfers to prevent health deterioration. The facility also lacked adequate training and policies regarding bowel impaction and abdominal assessments. The Director of Nursing (DON) admitted that abdominal assessments were conducted quarterly instead of the recommended three to four times a week, and there was no policy on constipation management. This lack of policy and training potentially contributed to the resident's fecal impaction and associated complications, as evidenced by the resident's repeated hospital visits for abdominal pain and bowel issues.
Failure to Address Resident Grievance Regarding Missing Walker
Penalty
Summary
The facility failed to promptly address a grievance reported by a resident, identified as Resident 6, regarding a missing personal walker. Resident 6, who was admitted with conditions including hemiplegia and major depressive disorder, reported that upon readmission from the hospital, her walker, which contained personal documents and blank checks, was missing. Despite informing the nursing staff, no grievance form was initiated or completed, and there were no nursing or social services notes documenting the resident's report of the missing walker. Interviews with facility staff revealed a lack of action in addressing the grievance. The Licensed Vocational Nurse (LVN) acknowledged being informed by Resident 6 about the missing walker. The Social Services Director (SSD) was aware of the report but had not initiated a theft and loss report, as she was waiting for confirmation from the rehabilitation department regarding the walker. The SSD also stated that a grievance form was not completed, and she did not document the resident's report. The Director of Nursing (DON) indicated that any theft and loss report should be investigated promptly and that a grievance and theft and loss report should have been initiated upon the resident's report. The facility's policies and procedures for grievances and theft and loss were not followed. The grievance policy required that any grievance or complaint be documented and investigated without fear of reprisal. The theft and loss policy mandated immediate investigation and documentation of missing property reports. However, these procedures were not adhered to, as evidenced by the lack of documentation and investigation into Resident 6's missing walker, resulting in a violation of the resident's right to have grievances addressed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to effectively manage a resident's pain by not adhering to the physician's orders for pain management. Resident 2, who was admitted with a diagnosis of malignant neoplasm of the stomach, muscle weakness, and dysphagia, was prescribed Norco to be administered every six hours as needed for moderate to severe pain. Despite the physician's orders and the resident's intact cognitive skills, the facility did not administer the medication as required. The resident reported experiencing severe pain, rated at 8/10, and stated that the nurses were not administering the pain medication on time, which hindered his rehabilitation therapy. The medication administration records (MAR) for September showed that the resident's pain was assessed at a level of 8/10 on two occasions, but no interventions were documented, and Norco was not administered during the night shifts on those dates. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the licensed nurse should have provided interventions according to the physician's order when the resident reported severe pain. The facility's policy on pain management required the administration of pain medication as ordered and documentation of the resident's pain level and response to interventions, which was not followed in this case.
Failure to Document Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not implementing the facility's policy and procedures titled 'Death of a Resident.' This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including hypertension, diabetes mellitus, and dementia. The resident was on hospice care and passed away at 9:48 a.m. on the specified date. Upon review of the resident's medical records, it was found that there were no nurse's notes documenting the resident's death. The Director of Nursing confirmed the absence of documentation and acknowledged that there should have been a complete record of what transpired on the day of the resident's death. The facility's policy required that all documentation related to the resident's death, including the official pronouncement of death and communications with the family and relevant agencies, be maintained in the medical record, which was not adhered to in this case.
Failure to Educate Visitor on PPE Use for COVID-19 Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not providing education about transmission-based precautions and not offering personal protective equipment (PPE) to a visitor of a resident who was under droplet precautions due to exposure to COVID-19. The resident, who had a history of hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and type II diabetes mellitus, was observed in a room with droplet precaution signage. However, the resident's family member was seen inside the room without wearing any PPE and stated that they were not informed about the need for PPE or the reasons for its use. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that visitors should be educated on the importance of wearing PPE when visiting residents under isolation precautions. The facility's policy and procedures for managing COVID-19, which were reviewed prior to the incident, also indicated that visitors must wear a facemask and adhere to other precautionary measures. The failure to implement these measures had the potential to spread infection to residents, visitors, and the community.
Failure to Implement Dietary Recommendations Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to update and implement a menu to meet the nutritional needs of a resident identified as being at risk for unplanned weight loss. The resident, who had diagnoses including prostate cancer, encephalopathy, and bile duct obstruction, was admitted to the facility and had a physician's order for a Registered Dietician (RD) consult. Despite the RD's recommendations to provide ice cream with meals and snacks to improve the resident's appetite, these recommendations were not carried out. As a result, the resident experienced significant weight loss of 5 pounds, which was 3% of his body weight in one week. The resident's weight loss was noted during a weight variance meeting, and it was acknowledged by the RD that the recommendations were not implemented. The Director of Nursing (DON) expressed concern about the resident not eating and emphasized the importance of following dietary recommendations to prevent significant weight loss. The facility's policy and procedures on evaluating weight and nutritional status were reviewed, indicating the need to maintain acceptable nutritional parameters through proper assessment and intervention, which were not adhered to in this case.
Failure to Administer Critical Cancer Medication
Penalty
Summary
The facility failed to implement its own policies and procedures by not ensuring the accurate administration of the medication Darolutamide for a resident with prostate cancer. The resident was admitted with diagnoses including prostate cancer, encephalopathy, and obstruction of the bile duct. A physician's order was in place for Darolutamide to be administered twice daily, but the medication was not delivered or administered due to its high cost and lack of insurance coverage. There was no documented evidence that the physician was notified of the missing medication. Interviews with staff revealed a lack of communication and documentation regarding the missing medication. A Licensed Vocational Nurse (LVN) admitted to informing the attending physician but could not provide evidence of this communication. The oncologist was not notified, and another LVN assumed the first LVN had contacted the physician based on overheard conversations. The Pharmacy Consultant emphasized the importance of taking the medication daily to slow disease progression, and the Director of Nursing acknowledged the failure to provide the necessary medication. The facility's policy on medication administration was not followed, as confirmed by the Director of Nursing and the Administrator. The Administrator admitted that the facility should have ensured the availability of all medications upon the resident's admission. The attending physician was unaware of the situation, highlighting a breakdown in communication and adherence to the facility's procedures.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a licensed nurse notified the physician about a change of condition (COC) for a resident, which is a significant deficiency. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, exhibited symptoms of abdominal distention and inconsistent bowel movements. Despite these symptoms being reported by a Certified Nursing Assistant (CNA) to a Licensed Vocational Nurse (LVN), the LVN did not notify the physician or initiate a COC form, which was required by the facility's policy. The resident had a history of abdominal distention due to alcohol-induced chronic pancreatitis, and the facility's care plan required changes in bowel and bladder status to be reported to a medical doctor. On the day of the incident, the resident was found unresponsive during dinner service, and despite efforts to perform CPR, the resident was pronounced dead shortly after. Interviews with staff revealed that the resident had refused to eat and had not had a bowel movement, which were signs that should have prompted immediate medical attention. The Director of Nursing (DON) acknowledged that the resident's assessments should have included daily abdominal girth measurements to detect changes. The facility's policy on Change of Condition Notification required prompt communication with the resident's physician and family in the event of significant changes in the resident's condition. The failure to adhere to this policy potentially contributed to the resident's decline and subsequent death.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and preventive measures for a resident assessed as high risk for falls, resulting in multiple falls and injuries. The resident, admitted with a history of repeated falls and unspecified psychosis, was identified as high risk for falls in their care plan. Despite this, the facility did not provide a full-time 1:1 sitter as outlined in the care plan, leading to the resident experiencing falls on several occasions, including incidents on January 25, April 11, April 28, and May 7, 2024. These falls resulted in injuries such as a dislocated finger, a fractured ulna, and a hematoma on the forehead. The care plan for the resident included interventions such as maintaining a safe environment, frequent visual checks, and providing a 1:1 sitter as necessary. However, the facility did not consistently implement these interventions, particularly the provision of a 1:1 sitter, which was only arranged after the resident's fall on May 7, 2024. The facility's failure to evaluate the effectiveness of the care plan interventions after the resident's initial fall on January 25, 2024, and to consider alternative interventions, contributed to the resident's subsequent falls and injuries. Interviews with facility staff, including a CNA and the Director of Nursing, revealed that the resident was not provided with a full-time sitter before the most recent fall on May 7, 2024. The staff acknowledged that the care plan interventions were ineffective in preventing the resident's falls. The facility's policy and procedures for sitters and fall prevention were not adequately followed, resulting in the resident's repeated falls and injuries.
Failure to Maintain Clean and Pest-Free Staff Breakroom
Penalty
Summary
The facility failed to maintain a safe and functional area to prevent the infestation of roaches and provide a clean environment in the staff's breakroom. During an observation and interview with the Maintenance Supervisor, multiple dead roaches were found under the sink in the staff's breakroom on the lower level. The ground was dirty, and the floors were dusty with dead roaches and baits under the sink. The Maintenance Supervisor acknowledged that the roaches had been dead for a long time and had not been cleaned. The Administrator confirmed that the Maintenance and Housekeeping staff would clean the breakroom and remove the dead roaches. The facility's policies and procedures for pest control and housekeeping, reviewed on 1/26/2024, indicated that the facility should be free of pests and maintained in a clean and sanitary condition to promote health and safety.
Failure to Promote Dignity and Respect for Residents
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not conducting a personal property inventory upon admission for one resident and allowing staff to speak in a language not understood by another resident in their presence. Resident 200, who was admitted with several medical conditions including supra ventricular tachycardia, muscle weakness, cognitive communication deficit, and end-stage renal disease, reported missing belongings and dentures. The facility did not complete a personal property inventory upon Resident 200's admission, leading to confusion and distress for the resident. The Social Worker later attempted to rectify the situation by reviewing the belongings list with Resident 200, but discrepancies remained, particularly regarding the amount of cash and the delay in providing dentures, which affected the resident's ability to eat properly. Interviews with facility staff confirmed the failure to follow proper procedures for documenting and securing residents' belongings upon admission, as outlined in the facility's policy and procedures. The Assistant Director of Nursing acknowledged that failing to complete a resident's belongings list upon admission was a significant oversight that could lead to the loss of irreplaceable valuables and make the facility liable for any missing items. Resident 21, who was admitted with cellulitis and chronic kidney disease, complained that staff spoke in a language not understood by the resident in their presence. This made Resident 21 feel excluded and angry, as they believed the staff might be talking about them. The Assistant Director of Nursing confirmed that the facility's policy required staff to speak only in English in the presence of residents unless communicating with a resident who does not speak English. The facility's policy aimed to maintain the dignity and well-being of residents by ensuring clear and inclusive communication.
Failure to Ensure Comfortable Sound Levels at Night
Penalty
Summary
The facility failed to ensure comfortable sound levels at night for three residents, compromising their ability to sleep undisturbed. Resident 52, who has medical diagnoses including atrial fibrillation, subdural hemorrhage, and hypertension, reported high noise levels at night, requiring them to close the door to sleep. Resident 246, diagnosed with generalized muscle weakness, schizophrenia, and hypertension, also complained about high noise levels both during the day and night. Resident 83, with bipolar disorder, depression, and generalized muscle weakness, stated that the night shift was very loud, making it difficult to sleep due to staff opening closet doors loudly and causing window shutters to make noise due to a breeze. Interviews with staff confirmed the issue, with a Certified Nursing Assistant stating that lights should be off and noise minimized during the night shift to allow residents to sleep. The Director of Nursing also acknowledged that noise levels should be minimal, especially at the nursing station, to ensure residents can sleep. The facility's policies and procedures emphasize providing a safe, clean, comfortable, and homelike environment with comfortable noise levels, but these were not adhered to, leading to the deficiency.
Failure to Conduct Timely PASRR for Residents
Penalty
Summary
The facility failed to conduct Pre-Admission Screening Resident Review (PASRR) for two residents, leading to potential inappropriate care and services. Resident 33 was admitted with diagnoses including major depressive disorder, anxiety disorder, and PTSD. A review of Resident 33's PASRR level 1 screening revealed that question 27, which pertains to suspected mental illness, was left blank. The Assistant Director of Nursing (ADON) acknowledged that the incomplete PASRR could result in the resident not receiving the appropriate level of care for their behavioral needs. The facility's policy mandates that any incomplete PASRRs be completed the same day, but this was not adhered to in Resident 33's case. The Administrator also noted that only one staff member, a Registered Nurse, had access to the PASRR system, which contributed to the oversight. The facility's policy emphasizes the importance of PASRR in ensuring comprehensive and person-centered care for residents with mental health needs. Resident 60 was admitted with diagnoses including unspecified psychosis, dementia, and cognitive communication deficit. A review of Resident 60's PASRR indicated that it was not initiated until several months after admission. The ADON confirmed that the delayed PASRR could lead to inappropriate care, potentially resulting in harm to the resident. The facility's policy requires that PASRRs be completed by midnight on the date of admission, but this was not followed for Resident 60. The care plan for Resident 60 highlighted the need to address concerns about confusion and the disease process, but the lack of a timely PASRR compromised the ability to provide appropriate care. The facility's failure to adhere to its own policies and procedures for PASRR completion was evident in both cases, leading to deficiencies in the care provided to these residents.
Failure to Properly Store and Label Food
Penalty
Summary
The facility failed to store and label food in accordance with professional standards and facility policy, which placed residents at risk for foodborne illnesses. During an initial tour of the kitchen, seven food items in the refrigerator were found with past expiration dates, and eight food items on the shelves had no expiration dates. The Dietary Supervisor (DS) acknowledged that it was the kitchen staff's responsibility to check for expired foods and discard them, and admitted that residents could get sick if they consumed expired foods. Additionally, the DS stated that she would remind the kitchen staff every morning to check for expired foods and discard them. Further observations revealed that the refrigerator used for residents' food brought from outside contained 15 food items that were not labeled or dated. The DS admitted that the refrigerator in the staff lounge was the only one used for storing residents' outside food and that she did not know how the staff identified which food belonged to the residents. The Maintenance Assistant (MA) confirmed that he was responsible for cleaning the refrigerator in the staff lounge every Thursday and acknowledged that consuming expired food could make residents or staff sick. A review of the facility's policies indicated that food brought in by visitors should be clearly labeled with the resident's name and date received, and stored in a designated refrigerator, which was not being followed.
Failure to Obtain Physician's Order for Resident's Out on Pass
Penalty
Summary
The facility failed to protect the rights of Resident 60 by not obtaining a physician's order for the resident to go out on pass. Despite Resident 60 having a doctor's order issued on 12/16/23 for a one-day pass, the facility did not secure a continuous order for subsequent passes. Resident 60, who has intact cognition and requires supervision and moderate assistance for mobility, complained about being denied the ability to go out on pass, which was corroborated by the resident's out on pass sign sheet showing multiple instances of leaving the facility without a current physician's order. Interviews with the Registered Nurse and the Director of Nursing revealed that the staff allowed Resident 60 to go out on pass without a physician's order due to the resident's threats to blow up the facility if not permitted to leave. The facility's policy requires a physician's order for a resident to go out on pass, which was not adhered to in this case. This failure to follow protocol potentially impacted Resident 60's psychosocial well-being and self-esteem.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure a comprehensive assessment for pre-admission screening Resident Review (PASRR) for one of the sampled residents, Resident 33. The resident was admitted with medical diagnoses including major depressive disorder, anxiety disorder, and PTSD. A review of Resident 33's PASRR level 1 screening revealed that question 27, which pertains to suspected mental illness, was left blank. This incomplete assessment was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the blank question could lead to inadequate care for the resident's behavioral needs. The ADON stated that the PASRR is crucial for determining the mental capacity of the resident and ensuring their needs are met appropriately. The facility's policy mandates that any incomplete PASRRs must be completed the same day, but this was not adhered to in this case. During an interview with the Administrator (ADM), it was revealed that only one Registered Nurse had access to the PASRR system, and efforts were being made to grant access to more staff members. The facility's policy on PASRR, revised in 2018, emphasizes the importance of screening all applicants for mental illness and intellectual disability before admission. Additionally, the facility's policy on medical record completion, revised in 2012, states that no blank spaces should be left on forms. The failure to complete the PASRR accurately for Resident 33 had the potential to negatively affect the provision of necessary care and services for the resident.
Inaccurate MDS Documentation for Psychiatric/Mood Disorder
Penalty
Summary
The facility failed to ensure accurate documentation on the Minimum Data Set (MDS) for Resident 12, specifically regarding the resident's psychiatric/mood disorder. Resident 12 was admitted with diagnoses including anxiety disorder, dementia, and hypertension. However, the MDS dated [DATE] did not reflect the anxiety disorder diagnosis, indicating that Resident 12 did not have a psychiatric/mood disorder. This discrepancy was identified during a review and interview with the Director of Nursing (DON), who acknowledged that the MDS was missing the anxiety disorder diagnosis and emphasized the importance of accurate documentation for proper care planning. The facility's policy and procedures on Completion & Correction and Comprehensive Person-Centered Care planning were reviewed, highlighting the requirement for complete and accurate medical records. The failure to document Resident 12's anxiety disorder on the MDS had the potential to negatively impact the resident's plan of care and the delivery of necessary services. The DON confirmed that the omission could lead to inadequate care for the resident, as the care plan would not fully address the resident's psychiatric needs.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
