Alcott Rehabilitation Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3551 West Olympic Blvd., Los Angeles, California 90019
- CMS Provider Number
- 056293
- Inspections on file
- 35
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Alcott Rehabilitation Hospital during CMS and state inspections, most recent first.
A resident with severe cognitive impairment received a haircut without prior consent from their responsible party, despite facility policy requiring such consent for residents unable to make decisions. Interviews confirmed that staff did not inform or obtain approval from the resident's representative before providing the personal care service.
Two residents dependent on staff for ADLs did not receive scheduled showers or timely feeding assistance. One resident missed multiple scheduled showers without documentation or notification to the responsible party, while another waited over 30 minutes for feeding after meal delivery due to staff workload. Facility policies requiring scheduled care and proper documentation were not followed.
During a COVID-19 outbreak, staff failed to follow infection control protocols, including not performing hand hygiene after resident contact and not wearing required N95 respirators. An EVSD did not sanitize hands after disposing of a cup for a resident, while a CNA and a dietary aide were observed wearing surgical masks instead of N95s, despite facility policy and public health guidance requiring N95 use during the outbreak.
The facility failed to implement adequate infection control measures during a COVID-19 outbreak. Staff did not consistently wear N95 masks or perform COVID-19 tests at the start of their shifts. Resident activities were not paused, and a non-COVID-19 positive resident was bathed in a shower room reserved for COVID-19 patients. Additionally, air purifiers were not placed in all hallways as required, increasing the risk of virus spread.
The facility failed to screen visitors for COVID-19 symptoms during an outbreak, as observed when a family member entered unmasked and unscreened. The visitor log lacked proper documentation, and no staff were designated to enforce screening, despite the outbreak involving two residents. The IP and DON confirmed the lapse in screening, contrary to facility policy.
A facility failed to maintain a resident's dignity during mealtime when a CNA stood over a resident with dementia and feeding difficulties, instead of sitting at eye level as required by policy. The DON confirmed that staff should be seated to protect resident dignity, aligning with the facility's policy on promoting respect during mealtimes.
A resident with severe cognitive impairment and depression had a care plan that included attending church services, which they no longer enjoyed. Facility staff confirmed the resident preferred spending time with family, but the care plan was not updated to reflect this change. Observations showed the resident was not assisted to attend church services, contrary to their care plan.
The facility failed to update care plans for two residents with pressure ulcers. One resident's care plan did not reflect current wound care treatment, while another's included outdated interventions for pressure injury prevention. Staff interviews confirmed the need for updated care plans to ensure continuity of care.
A resident at moderate risk for pressure ulcers did not receive necessary pressure-relieving devices or regular repositioning as per their care plan. Staff were unaware of the resident's needs, and there was no documentation of repositioning or pressure reduction, increasing the risk of pressure sores.
A resident with hemiplegia and contracture was not provided with the prescribed frequency of passive range of motion exercises and knee splint assistance as per their care plan. The facility's RNA program was not followed, leading to a deficiency in maintaining the resident's mobility.
The facility failed to label an opened vial of Novolin R with an open date, as required by the manufacturer. During an inspection of a medication cart, it was found that the vial was stored at room temperature without an open date, making it impossible to determine its expiration. An LVN confirmed the oversight, acknowledging the risk of administering expired insulin, which could lead to poor blood sugar control. Facility policies require medications to be stored and labeled according to manufacturer recommendations.
The facility lacked a policy for storing and reheating leftover food brought by residents' families or visitors, potentially leading to foodborne illnesses. Staff interviews revealed that the facility discouraged storing perishable food and had no refrigerator for residents' use. The policy required food to be consumed or discarded within two hours, with nonperishable items allowed in sealed containers in resident rooms, but lacked procedures for residents wanting to store food.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to the facility's failure to accurately assess fall risk and implement effective interventions. The care plan lacked specific monitoring frequencies, leading to inadequate supervision and repeated falls. Interviews revealed that the facility's policies on fall prevention were not effectively implemented, contributing to the resident's risk of harm.
The facility was found non-compliant with the regulation limiting resident rooms to a maximum of four occupants, as room [ROOM NUMBER] housed five residents. Despite staff assurances of adequate space for care, including the use of a Hoyer lift, the facility's policy requires rooms to provide at least 80 square feet per resident for comfort and privacy.
The facility failed to meet the required 80 square feet per resident in 24 out of 63 rooms. Measurements showed that rooms did not provide adequate space per resident, despite staff believing there was enough space for care. The facility's policy mandates at least 80 square feet per resident in multiple occupancy rooms, which was not achieved.
Failure to Obtain Consent from Resident Representative for Personal Care
Penalty
Summary
The facility failed to obtain consent from a resident's responsible party (RP) before providing a haircut to a resident who was unable to make decisions due to severely impaired cognitive skills. The resident, admitted with diagnoses including dementia, right femur fracture, lack of coordination, and dysphagia, was assessed as having no capacity to understand or make decisions and was dependent on staff for most activities of daily living. Despite this, the facility's hairdresser cut the resident's hair without prior consent from the RP. Interviews with the resident's RP, the Activities Director, and the Social Services Designee confirmed that consent was not obtained before the haircut was given. The facility's policy stated that the resident representative has the right to exercise the resident's rights to the extent delegated and that residents must be informed in advance of care to be furnished. The failure to obtain consent resulted in a violation of the resident representative's right to make decisions on behalf of the resident.
Failure to Provide Scheduled Showers and Timely Feeding Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for residents who were dependent on staff for showers and feeding. One resident, admitted with diagnoses including dementia, right femur fracture, lack of coordination, and dysphagia, was scheduled to receive showers every Monday and Thursday. However, the resident did not receive showers on three scheduled days, and there was no documentation explaining the missed showers. Staff interviews revealed that the resident was not given showers due to being resistive, and instead, a bed bath was provided. Despite this, there was no documentation that the resident's responsible party was notified of the missed showers, as required by facility policy. Another resident, also with dementia and dysphagia, was dependent on staff for feeding. During observation, this resident's breakfast tray was delivered and left on the bedside table for over 30 minutes before staff assisted with feeding. Staff interviews indicated that the CNA responsible for feeding had multiple residents to assist, resulting in delays. The restorative nursing assistant confirmed that food trays are delivered promptly but should not be left for extended periods, as the food can become cold. A review of facility policies confirmed that residents are to be assisted with bathing and feeding according to their care plans and schedules, and that documentation should reflect the care provided and any deviations. The facility's failure to provide scheduled showers, timely feeding assistance, and proper notification and documentation constituted deficiencies in meeting residents' ADL needs.
Failure to Follow Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices among staff during a COVID-19 outbreak. Specifically, the Environmental Services Director (EVSD) did not perform hand hygiene after disposing of a cup for a resident in a room, as observed by the Infection Preventionist (IP). The EVSD acknowledged that not sanitizing hands could contribute to the spread of infections, and the IP confirmed that this lapse could result in infection transmission. Additionally, two other staff members, a Certified Nursing Assistant (CNA 2) and a Dietary Aide (DA 1), were observed not wearing the required N95 respirator masks during the outbreak. DA 1 was seen wearing a surgical mask in the kitchen and only switched to an N95 mask upon noticing the presence of the Director of Nursing (DON) and a surveyor. CNA 2, who was responsible for screening employees and visitors at the facility entrance, was also observed wearing a surgical mask instead of an N95 respirator. Both the IP and DON confirmed that all staff were required to wear N95 masks during the outbreak, and failure to do so could contribute to the spread of COVID-19. A review of facility policies indicated that hand hygiene and the use of appropriate personal protective equipment (PPE), including N95 respirators during outbreaks, were required. The facility's records also showed that the EVSD, CNA 2, and DA 1 had declined COVID-19 vaccination. The observations and interviews confirmed that staff did not consistently follow established infection control protocols, including hand hygiene and use of N95 respirators, as required by facility policy and public health guidance during the outbreak.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection prevention and control policies during a COVID-19 outbreak, as observed by surveyors. Staff members were not consistently wearing N95 masks, which are essential for protection against airborne particles, during the outbreak. Instead, some staff, such as Certified Nursing Assistant 1, were observed wearing surgical masks and only switching to N95 masks when directly caring for COVID-19 positive residents. Additionally, staff members were not adhering to the requirement to perform COVID-19 tests at the beginning of their shifts, with some testing only twice a week or not at all. The facility also did not pause resident activities as required during the outbreak. An observation revealed 13 residents sitting close together in the activity/dining room, contrary to the guidelines to limit crowding in communal areas. Furthermore, the facility failed to use a dedicated shower room for COVID-19 positive residents, as evidenced by a non-COVID-19 positive resident being bathed in a shower room reserved for COVID-19 patients. This practice increased the risk of exposure and potential spread of the virus within the facility. Moreover, the facility did not place portable air purifiers with HEPA filters in all hallways, as recommended to reduce airborne contaminants. Only two air purifiers were observed, one in the west nursing station and another in the activity room, which was insufficient according to the local health department's guidelines. These deficiencies in infection control practices had the potential to facilitate the spread of COVID-19 among residents, staff, and visitors.
Failure to Screen Visitors During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement and maintain proper infection control procedures during a COVID-19 outbreak by not screening family members and visitors for signs and symptoms of the virus. Observations revealed that a family member entered the facility unmasked and without undergoing the required screening process. The visitor screening log, which was supposed to record visitors' COVID-19 test results and symptoms, was not properly filled out, and there was no designated staff to ensure compliance with the screening process. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that visitors were not being screened for COVID-19 symptoms, despite the ongoing outbreak in the facility. The IP acknowledged that the outbreak began with two residents testing positive, and no staff were affected at the time. The facility's policy required active screening of visitors, but this was not enforced, potentially allowing the virus to spread among residents and staff.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of a resident, identified as Resident 51, during a mealtime interaction. Resident 51, who was readmitted to the facility with diagnoses including dementia, lack of coordination, muscle weakness, and dysphagia, required partial to moderate assistance with eating. The Minimum Data Set (MDS) indicated that Resident 51 had severely impaired cognition and would hold food in their mouth after meals. During an observation, Certified Nursing Assistant (CNA) 3 was seen standing over Resident 51 while feeding them lunch, rather than sitting at eye level as required by the facility's policy. CNA 3 acknowledged during an interview that she was supposed to be sitting down while feeding Resident 51 to maintain eye contact and respect the resident's dignity. The Director of Nursing (DON) confirmed that staff should be seated at eye level with residents during feeding to protect their dignity and prevent them from feeling disrespected. The facility's policy on promoting and maintaining resident dignity during mealtimes, reviewed earlier in the year, emphasized the importance of treating residents with respect and dignity, and required staff to be seated while feeding residents whenever possible.
Failure to Update Resident's Person-Centered Care Plan
Penalty
Summary
The facility failed to update the person-centered care plan for a resident diagnosed with major depressive disorder, dementia, and muscle wasting. The resident, who had severe cognitive impairment and was totally dependent on staff for daily activities, had a care plan that included participation in activities of their choice, specifically attending church services. However, observations revealed that the resident was not assisted to attend church services, and staff indicated that the resident did not enjoy attending these services and preferred spending time with family. Interviews with facility staff, including a Rehabilitation Nursing Assistant and the Activities Director, confirmed that the resident no longer enjoyed attending church services and preferred family interactions. Despite this change in preference, the resident's care plan was not updated to reflect their current interests. The facility's policy on comprehensive care plans requires that care plans be consistent with resident rights and include measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Update Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to review, update, and revise the care plans for two residents, leading to deficiencies in their care. Resident 71, who was admitted with dementia and a Stage III sacral pressure ulcer, did not have an updated care plan reflecting the current wound care treatment. The physician's orders specified a daily treatment regimen, but the care plan was not revised to include these details. Observations and interviews with the treatment nurse and MDS coordinator confirmed that the care plan was not updated, which is crucial for ensuring continuity of care. Resident 75, diagnosed with Type II diabetes, major depressive disorder, and vascular dementia, was at moderate risk for developing pressure ulcers. The care plan for this resident included interventions for both a low air loss mattress and an alternating pressure pad, which was confusing and not reflective of the current treatment plan. Observations and interviews with nursing staff revealed that the resident only had an alternating pressure pad, and the care plan should have been revised to remove the unnecessary intervention for the low air loss mattress. The facility's policy on comprehensive care plans requires that they be person-centered and updated to reflect the resident's current medical, nursing, and psychosocial needs. However, the failure to update the care plans for Residents 71 and 75 resulted in a lack of clarity and potential gaps in the provision of necessary care and treatment. Interviews with the Director of Nursing and other staff highlighted the importance of resolving outdated interventions to ensure residents receive appropriate care.
Failure to Provide Pressure Ulcer Prevention for At-Risk Resident
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident assessed as being at moderate risk for developing pressure ulcers. The resident, who had a history of Type II diabetes, major depressive disorder, and vascular dementia, was not provided with necessary pressure-relieving devices such as pillows or heel protectors for the left and right heels, as outlined in their care plan. Additionally, the resident was not repositioned every two hours and as needed, which was a required intervention to prevent skin breakdown. Observations and interviews revealed that the staff, including a Certified Nurse Assistant and a Registered Nurse, were not aware of or did not follow the care plan interventions for the resident. The Director of Staff Developer confirmed that the resident was not included in the list of those needing repositioning every two hours, and there was no documentation of repositioning or pressure reduction from the heels for a specific period. This oversight placed the resident at increased risk for developing pressure sores, contrary to the facility's policy on pressure injury prevention and management.
Failure to Provide Prescribed Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate services for a resident, identified as Resident 84, who was at risk for decline in range of motion (ROM) and mobility. Resident 84, who had a history of hemiplegia, hemiparesis, contracture of the left knee, and osteoporosis, was enrolled in a Restorative Nursing Aide (RNA) program. The care plan required passive range of motion (PROM) exercises and knee extension splint assistance to be provided regularly. However, the documentation revealed that these services were not consistently delivered as per the care plan. Specifically, the resident received PROM and knee splint assistance fewer times than prescribed in both September and October 2024. During a review and interview with the Director of Nursing (DON), it was confirmed that the RNA program was not followed as documented. The DON acknowledged that the staff did not adhere to the prescribed frequency of RNA services, which was crucial for maintaining the resident's mobility and preventing further decline. The facility's policy on the Restorative Nursing Program emphasized the importance of maintaining or improving a resident's abilities, but the staff failed to implement the plan as required.
Failure to Label Opened Novolin R Vial
Penalty
Summary
The facility failed to ensure that an opened vial of Novolin R, a medication used to control blood sugar, was labeled with an open date as required by the manufacturer's specifications. During an observation of the West Medication Cart, it was found that the vial was stored at room temperature without an open date label. According to the manufacturer's product labeling, vials of Humulin R stored at room temperature should be used or discarded within 42 days. The absence of an open date made it impossible to determine the expiration date, increasing the risk of administering expired insulin. During an interview, the Licensed Vocational Nurse (LVN 1) confirmed that the Novolin R was opened but not labeled with an open date. LVN 1 acknowledged that without an open date, it was not possible to know how long the Novolin R had been stored at room temperature, which could lead to medical complications due to poor blood sugar control if expired insulin was administered. The facility's policy on medication storage and labeling requires that all medications be stored according to the manufacturer's recommendations and that multi-use vials include the date they were initially opened or accessed.
Lack of Policy for Storing Resident Food Brought by Visitors
Penalty
Summary
The facility failed to have a policy addressing the storage and reheating of leftover food brought in by residents' families or visitors, which could potentially lead to foodborne illnesses. Interviews with staff, including registered nurses and the Director of Staff Development (DSD), revealed that the facility's policy discouraged storing perishable food and encouraged families to bring only enough food for one meal, with leftovers to be discarded or taken home. However, there was no refrigerator available for residents to store food, and the facility did not have a clear policy or procedure for safely storing food if residents insisted on keeping leftovers. The Director of Nursing (DON) confirmed that the facility's policy required food to be consumed or discarded within two hours and did not allow for the storage of outside food. The policy allowed nonperishable food to be stored in resident rooms in sealed containers, but it was the responsibility of the resident or their representative to maintain these items. Despite these guidelines, there was no established procedure for handling situations where residents wanted to store food, indicating a gap in the facility's policy and procedures for ensuring safe and sanitary food storage and handling.
Failure to Prevent Falls for At-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards for Resident 306, who was at risk for falls due to a history of falling and severe cognitive impairment. The facility did not accurately assess the resident's fall risk, as the fall risk assessment was incorrectly completed, leading to an underestimation of the resident's fall risk. This incorrect assessment contributed to inadequate interventions and monitoring to prevent falls. Resident 306 experienced multiple falls, including incidents on 9/16/2024 and 9/17/2024, due to insufficient supervision and ineffective interventions. The care plan for the resident did not include specific and individualized interventions to address the resident's fall risk, and the facility staff failed to frequently check the resident when in the wheelchair, as recommended. The lack of specific frequency for monitoring in the care plan further contributed to the resident being left unsupervised, resulting in falls. Interviews with facility staff, including the DON, revealed that the interventions in place were not adequately tailored to the resident's needs, and there was no documentation of frequent checks as required. The facility's policies on fall prevention and comprehensive care plans were not effectively implemented, as the care plan did not reflect the resident's specific needs and risk factors, leading to repeated falls and potential harm to the resident.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility failed to comply with the requirement that resident rooms hold no more than four residents, as observed in room [ROOM NUMBER], which housed five residents. This deficiency was identified during an observation and interview conducted on 10/17/2024. A Certified Nursing Assistant (CNA 1) stated that there were no issues providing care in the room, even when using a Hoyer lift, as there was sufficient space. Similarly, Registered Nurse (RN 1) expressed that there was enough space to provide care and no complaints had been received from residents regarding room size. The facility's policy, revised on 3/27/2024, mandates that resident rooms must be designed for adequate nursing care, comfort, and privacy, with at least 80 square feet per resident in multiple resident bedrooms.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 24 out of 63 rooms met the required 80 square feet per resident in multiple occupancy rooms. During an observation, the Maintenance Supervisor measured the rooms and found that they did not meet the required space per resident. The rooms in question had varying square footage, with some rooms accommodating up to five beds, yet not providing the necessary space per resident as mandated by the facility's policy and procedures. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that they believed there was enough space in the rooms to provide care, including the use of equipment like a Hoyer lift. They also stated that there were no complaints from residents regarding room size, and if any complaints arose, residents could be moved to larger or single occupancy rooms if available. Despite these assertions, the facility's policy requires that resident rooms measure at least 80 square feet per resident in multiple occupancy rooms, which was not met in the observed rooms.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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