Alta Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 13075 Blackbird Street, Garden Grove, California 92843
- CMS Provider Number
- 555473
- Inspections on file
- 19
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Alta Gardens Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to coordinate contracted transportation for a resident on hemodialysis, resulting in the resident independently navigating public transit and walking back while weak and anxious, without the facility’s knowledge. Staff did not perform or document a change-of-condition assessment, notify the MD, or provide same-day psychosocial follow-up despite the resident reporting fear, crying, and anxiety, and PRN anxiolytics were not available until days later. The same resident’s midodrine was administered significantly late without MD notification. Another resident with a scalp lesion had a dermatology appointment rescheduled when transportation failed, with no evidence that all alternative transport options were exhausted beforehand. For two residents receiving dialysis, nurses did not document departure and return times for multiple outpatient treatments, contrary to facility P&P, leaving gaps in tracking residents’ whereabouts and clinical status around appointments.
The facility failed to protect a resident from physical abuse when two residents encountered each other in a hallway and one, who had severe cognitive impairment, became frustrated that the other resident in a wheelchair did not move quickly enough. The cognitively intact resident reported being struck in the face, and staff witnesses, including an RN and a Social Services Assistant, observed the aggressive resident yelling and then slapping the other resident’s head/face. Documentation noted redness on the affected resident’s face and forehead, and the incident was substantiated as physical abuse under the facility’s abuse prohibition policy.
The facility failed to provide necessary care and services for IV access maintenance for six residents, including inadequate documentation of PICC and midline catheter measurements, unlabeled dressings, and lack of care plans. These deficiencies could delay the identification of catheter-related complications.
The facility failed to follow dietary guidelines and menu plans, serving residents incorrect items such as yellow cake instead of carrot cake and vanilla pudding instead of chocolate ice cream. A resident on a renal diet did not receive the appropriate diet or double protein portion. The CDM acknowledged these issues, noting that the menu was not updated to reflect substitutions, and residents were not informed of changes.
A facility failed to implement the care plan intervention of placing floor mats on both sides of the bed for a resident with severe cognitive impairment and high fall risk. The mats were found leaning against the wall instead of on the floor, as confirmed by an LVN. The DON and Interim Administrator were informed of this oversight.
The facility failed to manage gastrostomy tubes (GT) appropriately for three residents. A resident's enteral feeding formula and water bag were not labeled correctly, and a CNA resumed GT feeding without verifying placement. Another resident's GT placement was not checked before medication administration, and an abdominal binder was not used as required. Additionally, a third resident's head of the bed was not elevated properly during feeding, increasing the risk of aspiration.
The facility failed to provide safe respiratory care for two residents. One resident did not receive oxygen as per the physician's order, leading to low oxygen saturation levels. Another resident's sterile water for humidification was not labeled with an opened date, violating facility policy. Staff acknowledged these deficiencies.
A resident who underwent orthopedic surgery did not receive appropriate pain management as per physician's orders. The facility failed to administer hydrocodone-acetaminophen for moderate pain and inconsistently provided non-pharmacological interventions before administering morphine. Interviews confirmed these deficiencies, highlighting a lack of adherence to the facility's pain management policy.
A resident requiring dialysis care did not receive appropriate services as the facility failed to hold hypertension medications on dialysis days, assess the AV shunt post-treatment, and document fluid intake. The facility also did not notify the physician of new recommendations or significant status changes, as confirmed by staff interviews and medical record reviews.
The facility failed to provide accurate pharmaceutical services for two residents, leading to potential medication errors. A resident's medications were ordered for oral administration instead of via GT, and a nurse did not administer a complete dose. Another resident's sodium chloride was unavailable, and its administration was undocumented. These lapses posed health risks due to potential complications or delays in interventions.
The facility failed to monitor two residents for signs of bleeding related to anticoagulant use. One resident was on enoxaparin, and another on apixaban, both without documented monitoring for adverse effects. Staff confirmed the lack of monitoring, and the Interim Administrator and DON acknowledged the findings.
The facility failed to monitor antipsychotic medication use for three residents, leading to potential adverse effects. One resident was not accurately monitored for orthostatic hypotension related to Seroquel, and their informed consent was incomplete. Another resident's informed consent for Risperdal lacked necessary details, and they were not monitored for orthostatic hypotension. A third resident was also not monitored for orthostatic hypotension as ordered. Staff acknowledged these deficiencies.
The facility's medication error rate was 11.54%, exceeding the acceptable threshold. Errors included a nurse failing to administer zinc due to unavailability, and two nurses administering polyethylene glycol 3350 without verifying residents' bowel movement history, contrary to physician orders. These oversights led to improper medication administration.
The facility failed to ensure kitchen staff had the necessary skills for safe operations in the Food and Nutrition Services Department. Dietary Aide 1 incorrectly demonstrated the procedure for testing sanitizing solution concentration, and both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. These failures could lead to foodborne illnesses among residents.
The facility failed to ensure food safety and sanitation in the kitchen by not labeling and dating food items in the freezer and improperly storing maintenance tools. Unlabeled and undated food items, such as veggie vegan patties, French toast, and hamburger buns, were found, violating the facility's policy. Additionally, brooms were improperly stored on the ground outside the kitchen, contrary to the USDA Food Code 2022. These issues posed a risk of foodborne illnesses to residents.
The facility failed to educate staff on safe food handling for food brought in by family members, leading to potential food safety risks. Staff, including CNAs and LVNs, were not trained on proper reheating practices, and there was no designated microwave for family use. The DSD admitted to not providing necessary education, and the Interim Administrator and DON acknowledged these deficiencies.
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool did not include all residents with infections, only those prescribed antibiotics. Additionally, staff did not consistently use proper PPE when caring for residents with infections, and medical equipment was not maintained in a sanitary condition. These failures posed a risk for the transmission of infections within the facility.
The facility failed to maintain complete advance directives in the medical records for two residents, risking their healthcare decisions not being honored. For one resident, only part of the directive was uploaded, missing key healthcare instructions. For another, no directive was found, and there was no documentation of attempts to obtain it. The DON and Interim Administrator acknowledged these deficiencies.
A facility failed to provide a resident or their representative with written information about the bed hold policy during a hospital transfer. Despite the facility's policy requiring notification at the time of transfer, there was no documentation in the medical records. Staff interviews confirmed the absence of the required notification, and the Interim Administrator and DON acknowledged the deficiency.
The facility failed to properly store garbage in one of six dumpsters, which was observed propped open on two consecutive days. This was against the FDA Food Code 2022, which mandates that outdoor refuse receptacles be covered with tight-fitting lids. The Maintenance Assistant confirmed the deficiency and acknowledged the importance of keeping lids closed for infection control.
The facility failed to remove expired medications from Medication Cart B, as observed during an inspection with an RN. Fourteen packets of Vitamin A & D ointment, expired since October 2023, were found in the cart. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed in this instance.
The facility failed to maintain infection control practices in the laundry room, risking disease transmission. Personal items, including food and drink, were found on laundry detergent boxes, and a fragrance mist spray was on the clean area counter. Staff confirmed these findings, acknowledging that such items should not be present to maintain infection prevention.
A resident at risk for falls did not have a floor mat as specified in their care plan, despite being identified as needing substantial assistance and having a history of falls. Staff familiar with the resident confirmed the absence of the floor mat, which was a required intervention to minimize injury risk.
Dialysis Transportation, Assessment, and Documentation Failures
Penalty
Summary
The deficiency involves multiple failures to coordinate and document transportation and clinical care for residents receiving dialysis and specialty appointments. For one resident with ESRD on hemodialysis, the facility’s transportation arrangements to and from the dialysis clinic were not properly coordinated. On one dialysis day, the contracted transportation left because the resident’s treatment was not yet complete, and the resident was not picked up from the clinic. The resident, who had muscle weakness, difficulty walking, and an ileostomy, reported walking to a nearby restaurant, emptying his ostomy bag, taking two public buses, stopping at a bank, and then walking the remaining distance back to the facility, including crossing major intersections. Staff interviews confirmed ongoing transportation issues for this resident, including prior occasions when transportation left the resident at the clinic and a family member had to pick him up. The facility also failed to assess, document, and notify the physician when this resident returned to the facility approximately seven to eight hours after dialysis. There was no documentation of the resident’s clinical condition, no change-of-condition assessment, no progress notes, and no monitoring despite the resident reporting fear, anxiety, and crying related to being followed by a man and involving the police while returning by public transit. Nursing staff acknowledged that the resident’s symptoms of being tired, weak, fearful, and crying constituted a change of condition and that the physician was not notified. The DON and DSD verified there was no assessment upon arrival, no physician notification of the incident, and no documentation of the resident’s status at the time of return. The facility further failed to provide timely psychosocial support and timely medication management for this resident. The resident’s PRN lorazepam for anxiety had been discontinued the day before the incident and was not available on the day the resident reported fear, anxiety, and crying; it was reordered the following day and first administered two days after the incident. There was no documented social services follow-up with the resident on the day of the incident, and the SSD confirmed she had not spoken with the resident until the following day. Additionally, the resident’s midodrine, ordered three times daily with meals for hypotension, was administered significantly late on one dialysis day, outside the facility’s one-hour window, and the physician was not notified of the late administration. Another resident experienced a failure in transportation coordination for a dermatology appointment. This resident had a documented brown scalp lesion and a dermatology consultation scheduled, which was rescheduled to a later date. Nursing notes showed the appointment was moved, and social services notes later documented that transportation did not arrive for the rescheduled appointment, requiring another rescheduling and arrangement of private transportation. Staff interviews indicated that alternative transportation options such as private ride-share and CNA accompaniment were available, but there was no evidence that all transportation methods were exhausted before rescheduling the earlier appointment, despite having time to arrange alternatives. The facility also failed to document departure and arrival times for two residents who regularly left the facility for outpatient dialysis. For one resident, progress notes for multiple dialysis dates lacked documentation of either departure time, arrival time, or both. For the second resident, treatment records showed multiple dialysis sessions, but corresponding progress notes were missing departure and/or arrival times on numerous dates. The DSD stated that nurses were responsible for documenting residents’ departure and arrival times in progress notes, and the DON confirmed that this documentation was missing for the identified dates.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse by another resident, in violation of its Abuse Prohibition Policy and Procedure. The policy, dated 2/23/21, prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. On the date of the incident, a cognitively intact resident (Resident 105), who used a wheelchair, was in the Station 2 hallway when another resident (Resident 3), who had severe cognitive impairment, attempted to pass. Resident 3 yelled for Resident 105 to get out of the way and, when Resident 105 did not move quickly enough, Resident 3 swung his hand and struck Resident 105 in the face. The altercation was witnessed by staff and corroborated by interviews and documentation. An RN reported hearing Resident 3 yell "get out of my way" and observed both residents in the hallway, with Resident 3 unable to pass because Resident 105 was blocking his way; the RN stated that Resident 3 then swung his hand and slapped Resident 105’s head. The Social Services Assistant, who heard yelling from his office, also reported seeing Resident 3 slap Resident 105’s face. Resident 105 reported that he was sitting in his wheelchair in the hallway, that the other resident was going in the opposite direction, and that he could not move out of the way fast enough before being hit in the face, which he described as a closed-fist strike. An eINTERACT Change in Condition Evaluation documented that Resident 105 had redness on the face and forehead following the slap. The Administrator later confirmed that the facility substantiated the physical abuse based on the witnessed incident and the observed redness on Resident 105’s face.
Deficiencies in IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the administration and maintenance of IV accesses for six residents. For Resident 83, the facility did not document the initial PICC line external catheter measurements or confirm baseline measurements of the PICC line external catheters and arm circumferences before administering IV antibiotics. Additionally, the PICC dressing was not labeled with the date, and a care plan was not developed for the use of the PICC line. Resident 60's care was compromised as the facility did not accurately document the monitoring of the right arm midline, and a care plan was not developed for its use. The external catheter length measurements were found to be inaccurate, and the documentation of monitoring was for the wrong arm. Resident 716's midline dressing was not changed as required, and Resident 110's PIV site was not labeled with the date and initials of the staff. For Resident 816, the PIV site was not labeled with the date and the nurse's initials, and Resident 818's midline external catheter and arm circumference measurements were not performed and documented upon admission. These failures had the potential to delay the identification of catheter-related complications for the residents, as confirmed by interviews with the facility's RN, DON, and Interim Administrator.
Failure to Follow Dietary Guidelines and Menu Plans
Penalty
Summary
The facility failed to adhere to the dietary requirements and menu plans for its residents, leading to several deficiencies. Residents were served yellow cake instead of the carrot cake with cream cheese frosting as indicated on the menu. Additionally, two residents were not provided with chocolate ice cream as per the menu, and a resident on a renal diet did not receive the appropriate renal diet or the double portion of protein as ordered. These discrepancies were confirmed through observations and interviews with the Certified Dietary Manager (CDM) and other staff members, who acknowledged the substitutions and the lack of notification to residents about these changes. The facility's policies and procedures require that menus be served as written unless a substitution is necessary due to preference, unavailability, or special meals, and that any substitutions be documented and communicated. However, the CDM admitted that the menu was not updated to reflect the substitutions, and residents were not informed of the changes. The facility's failure to follow its own dietary guidelines and communicate effectively with residents about menu changes resulted in the potential for residents not receiving adequate nutrition and appropriate servings to meet their individual needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the care plan intervention of placing bilateral floor mats on both sides of the bed for Resident 4, who was at high risk for falls and had severe cognitive impairment. On observation, the floor mats were found leaning against the wall instead of being placed on the floor as required by the care plan. This oversight was confirmed by LVN 4, who acknowledged the necessity of the floor mats to prevent potential falls. The Director of Nursing and Interim Administrator were informed of these findings, which highlighted the facility's failure to adhere to the care plan designed to mitigate fall risks for Resident 4.
Deficiencies in Gastrostomy Tube Management
Penalty
Summary
The facility failed to provide appropriate care and services related to the management of gastrostomy tubes (GT) for three residents. For Resident 55, the facility did not ensure that the enteral feeding formula and water bag were properly labeled with the date, time, and contents. Additionally, a CNA resumed the GT feeding after providing incontinent care without verifying the GT placement, which is a task that should be performed by licensed nurses to prevent potential dislodgment. For Resident 58, the facility did not ensure that the licensed vocational nurse (LVN) checked the GT placement via auscultation before administering medications through the GT. Furthermore, the resident's care plan required the use of an abdominal binder to prevent the resident from pulling out the GT, but the resident was observed not wearing the binder during medication administration, despite having a history of dislodging the GT. Resident 74 was observed receiving enteral feeding with the head of the bed (HOB) elevated less than the required 30 degrees, which is necessary to prevent aspiration. The LVN confirmed the improper elevation of the HOB, acknowledging that it should have been elevated to at least 30 degrees during feeding. These deficiencies posed risks for complications related to the use of GTs for the residents involved.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe respiratory care for two residents, Resident 816 and Resident 55, as observed during a survey. For Resident 816, the facility did not administer oxygen according to the physician's order. The resident was observed receiving oxygen at three liters per minute, despite a physician's order for six liters per minute to maintain an oxygen saturation level greater than 92%. The resident expressed difficulty breathing, and the oxygen saturation level was recorded at 92%, below the desired range of 95-97%. The Licensed Vocational Nurse (LVN) acknowledged the discrepancy and increased the oxygen flow to six liters per minute, which improved the resident's oxygen saturation level to 95-96%. The Director of Nursing (DON) confirmed that staff should adhere to the physician's orders for oxygen administration. For Resident 55, the facility failed to label the sterile water used for the humidifier with an opened date, as required by the facility's policy and procedure for respiratory equipment care. The resident was observed receiving oxygen via nasal cannula with a bottle of sterile water for humidification that lacked an opened date. The LVN verified the observation and acknowledged that the sterile water should have been dated when opened. The Interim Administrator and DON were informed of these findings and acknowledged the deficiencies.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for Resident 818, who was admitted following an orthopedic surgical procedure and was experiencing severe pain. The facility did not administer pain medication as per the physician's order, which specified morphine for severe pain and hydrocodone-acetaminophen for moderate pain. The medical records showed that the resident was consistently administered morphine for pain levels that were sometimes outside the prescribed parameters, and the hydrocodone-acetaminophen was not administered at all. Additionally, the facility did not consistently provide or document non-pharmacological interventions (NPI) prior to administering narcotic pain medication, as required by the facility's pain management policy. The medical records lacked evidence that NPIs were offered before administering morphine on multiple occasions. The facility's documentation also failed to include a legend explaining the codes used for NPIs, leading to further confusion and lack of clarity in the resident's care. Interviews with Resident 818, RN 1, and the Director of Nursing (DON) confirmed these findings. Resident 818 reported experiencing agonizing pain and taking morphine every four hours. RN 1 and the DON verified that the morphine was administered outside the pain scale parameters and that NPIs were not consistently provided before administering pain medication. This lack of adherence to the pain management protocol potentially compromised the effective management of the resident's pain.
Deficiency in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide necessary dialysis care and services for Resident 21, who required hemodialysis. The facility did not adhere to the physician's orders to hold hypertension medications on dialysis days, as hydralazine Hcl and nifedipine ER were administered on those days without notifying the physician. This oversight was confirmed by RN 1, who verified that the medications were not held as ordered and that there was no documentation of physician notification. Additionally, the facility did not assess Resident 21's AV shunt after dialysis treatment on specific dates, as required by the facility's policy and procedure. LVN 11 confirmed the absence of documented evidence for the assessment of the AV shunt on 1/8/25. Furthermore, the facility failed to document the total daily fluid intake for Resident 21, which was crucial given the fluid restriction orders and recommendations from the dialysis center to monitor for signs of fluid overload. The facility also did not notify the physician of new recommendations from the dialysis center or significant status changes in Resident 21's condition. This included recommendations to limit fluid intake and monitor for fluid overload, as well as the inability to remove interdialytic weight gain due to low blood pressure. The DON acknowledged these findings, indicating a lapse in communication and documentation regarding Resident 21's dialysis care.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for two residents, leading to potential medication administration errors. For Resident 58, the physician's orders inaccurately specified oral administration for medications that should have been given via a gastrostomy tube (GT). This discrepancy was not clarified by the licensed nurses responsible for entering and executing the physician's orders. During a medication administration observation, a licensed nurse failed to administer the complete dose of a multivitamin to Resident 58, as a significant residue was left in the medication cup after administration via GT. Additionally, the facility did not ensure proper documentation and availability of medication for Resident 50. A licensed nurse was unable to administer a scheduled dose of sodium chloride because it was not available in the medication cart and failed to check the central supply or contact the pharmacy promptly. Although the nurse later obtained and administered the medication, there was no documentation in the resident's medical administration record (MAR) or progress notes to reflect this action or the reason for the initial delay. These deficiencies in medication administration and documentation posed risks to the residents' health conditions, as they could lead to complications or delays in necessary interventions. The facility's policies and procedures for medication administration were not followed, resulting in these lapses in care.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to properly monitor two residents, Resident 60 and Resident 110, for signs and symptoms of bleeding related to their use of anticoagulant medications. Resident 110 was prescribed enoxaparin to prevent clotting, with a care plan in place to monitor for potential adverse reactions such as bruising, skin tears, and bleeding. However, there was no documented evidence that Resident 110 was monitored for these signs, as confirmed by LVN 7 during an interview. The Interim Administrator and DON acknowledged the lack of monitoring documentation. Similarly, Resident 60 was prescribed apixaban for the treatment and prevention of blood clots. The physician's orders did not include monitoring for side effects, and the Medication Administration Record (MAR) for February 2025 showed no documentation of monitoring for bleeding signs. Resident 60's care plan also included monitoring for adverse reactions, but this was not carried out as verified by RN 1. The Interim Administrator and DON were informed of these findings and acknowledged the deficiency.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to properly monitor the use of antipsychotic medications for three residents, leading to potential adverse effects and incorrect data for prescribers. For one resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician for the use of Seroquel. The resident's informed consent for Seroquel was also incomplete, lacking the indication for its use and a stop date. Interviews with nursing staff confirmed that the orthostatic blood pressure readings were inaccurately recorded, posing a risk for unrecognized low blood pressure. Another resident's informed consent for Risperdal was missing documentation of frequency and behavior manifestations. The facility also failed to monitor this resident for orthostatic hypotension related to Risperdal use. The physician did not document justification for the continued daily use and the absence of a stop date for the PRN Risperdal. The facility's pharmacist had recommended ensuring physician documentation for the continued use of Risperdal, but this was not followed up in a timely manner. A third resident was not monitored for orthostatic hypotension as ordered by the physician for Seroquel use. The facility's staff acknowledged that the orthostatic blood pressure readings were not conducted as required, which could lead to unrecognized side effects from the medication. The Director of Nursing confirmed these findings and acknowledged the lapses in monitoring and documentation.
Medication Error Rate Exceeds 5% Due to Administration Oversights
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54%. During medication administration observations, three licensed nurses were found to have made errors. One nurse, LVN 1, did not administer zinc to a resident as ordered due to the medication's unavailability in the medication cart. The nurse did not check the central supply or contact the pharmacy in a timely manner to obtain the medication, resulting in the resident missing a dose that was prescribed for wound healing. Another nurse, LVN 2, administered polyethylene glycol 3350 to a resident without verifying the resident's bowel movement history and stool consistency, as required by the physician's order. The resident had a recent bowel movement and loose stools, which should have contraindicated the administration of the laxative. This oversight occurred because the nurse did not review the resident's medical record before administering the medication. Similarly, LVN 10 administered polyethylene glycol 3350 to another resident without checking if the resident had a bowel movement within the last 72 hours. The resident had a bowel movement less than 72 hours prior, which should have prevented the administration of the laxative. The nurse failed to verify the resident's bowel movement history before proceeding with the medication administration.
Inadequate Kitchen Staff Training in Sanitation Procedures
Penalty
Summary
The facility failed to ensure that the kitchen staff possessed the necessary skills to safely perform daily operations in the Food and Nutrition Services Department. Specifically, Dietary Aide 1 was unable to correctly demonstrate the procedure for testing the chemical concentration of the sanitizing solution used on food contact surfaces. During an observation, Dietary Aide 1 used a quaternary test strip incorrectly by dipping it for only four seconds instead of the required ten seconds, as per the guidelines. This incorrect procedure was confirmed by both the Dietary Aide and the Certified Dietary Manager (CDM), who acknowledged the error. Additionally, both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. Dietary Aide 2 incorrectly stated that dishes were washed at 110 degrees Fahrenheit and sanitized at 171 degrees Fahrenheit for 30 seconds, which did not align with the facility's documented procedures. Dietary Aide 1 also provided an incorrect description of the dishwashing process, stating that dishes were sanitized for only three to five seconds. These failures in following proper sanitation procedures had the potential to lead to foodborne illnesses among the residents who consumed food prepared in the facility's kitchen.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation requirements in the kitchen, as evidenced by improper labeling and dating of food items in the freezer. During an initial tour of the kitchen, it was observed that an opened bag of veggie vegan patties, a package of French toast, and a bag of hamburger buns were all unlabeled and undated. The Certified Dietary Manager (CDM) confirmed these findings, which were in violation of the facility's policy and procedure titled 'Food Receiving and Storage,' which mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. Additionally, the facility did not properly store maintenance tools, which could compromise sanitation. According to the USDA Food Code 2022, maintenance tools such as brooms and mops should be stored in an orderly manner to facilitate cleaning. However, during an observation and interview, it was noted that three brooms were stored on the ground outside of the kitchen, contrary to the CDM's statement that cleaning materials should be kept hanging on the wall. These deficiencies had the potential to cause foodborne illnesses among the medically vulnerable resident population consuming food prepared in the kitchen.
Lack of Staff Education on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that staff received education on safe food handling practices for food brought in by family members and visitors. This deficiency was identified through interviews and observations, revealing that staff members, including CNAs and LVNs, were not adequately trained in handling and reheating food safely. The facility's policy required family members to inform nursing staff when bringing food, but there was no consistent practice or education provided to staff on how to manage these situations safely. The DSD admitted to not providing the necessary education, and the past in-service training lacked a clear lesson plan. During the survey, it was observed that food brought in by family members was not labeled, and there was no designated microwave for family use, contrary to what the IP stated. Family members and staff were unsure about safe reheating temperatures, and there was no resident refrigerator due to infection control concerns. The Interim Administrator and DON acknowledged these findings, indicating a systemic issue in ensuring food safety for residents consuming food from outside sources.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool used by the facility did not include all residents with infections, only those prescribed antibiotics. This oversight was acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON), who admitted that residents with signs and symptoms of infection but not on antibiotics were not tracked, potentially missing critical data on infection spread within the facility. Additionally, the facility did not ensure proper use of personal protective equipment (PPE) for staff entering the rooms of residents with infections. In one instance, a Certified Nursing Assistant (CNA) failed to wear a face shield or goggles while caring for a resident with COVID-19, despite facility policy requiring such precautions. This lapse was confirmed by the IP and acknowledged by the Interim Administrator and DON. Similarly, a Licensed Vocational Nurse (LVN) did not don a gown while administering medication to a resident under enhanced barrier precautions, contrary to the facility's infection control policies. Furthermore, the facility did not maintain sanitary conditions for medical equipment, as evidenced by a resident's nasal cannula tubing touching the ground and being placed under a trash can. This was observed and verified by an LVN, who recognized the infection control risk and corrected the situation. These failures collectively posed a risk for the transmission of disease-causing microorganisms and infections within the facility.
Failure to Maintain Complete Advance Directives in Medical Records
Penalty
Summary
The facility failed to obtain and maintain complete copies of advance directives in the medical records for two residents, which could potentially lead to their healthcare decisions not being honored. For Resident 18, only one page of the advance directive was uploaded into the electronic medical record, missing the crucial healthcare directives. This was confirmed during an interview with the SSA and SSD, who acknowledged that the complete document should be available to ensure the resident's wishes are respected if they lose decision-making capacity. For Resident 60, although the POLST indicated the presence of an advance directive, no copy was found in the medical record, and there was no documentation of attempts to obtain it. The SSA confirmed the inaccuracy of the POLST information. The DON explained that the admissions personnel and social services department are responsible for ensuring advance directives are obtained and documented, but this was not done for Resident 60. The Interim Administrator and DON acknowledged these findings during an interview.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to a resident or the resident's representative at the time of transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy, revised in October 2022, mandates that residents and their representatives receive written notice of the bed hold policy both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is an emergency. In the case of a resident who was transferred to the hospital, there was no documentation in the medical records indicating that the bed hold notification was provided. Interviews with LVN 2 and RN 2 confirmed the absence of written documentation regarding the bed hold policy. The Interim Administrator and DON were informed of these findings and acknowledged the lack of compliance with the facility's policy.
Improper Garbage Storage in Facility Dumpster
Penalty
Summary
The facility failed to ensure proper storage of garbage in one of six dumpsters located outside the facility. Observations on two consecutive days revealed that one dumpster was propped open, contrary to the FDA Food Code 2022, which requires receptacles for refuse to be covered with tight-fitting lids or doors when kept outside. This deficiency was confirmed by the Maintenance Assistant, who acknowledged responsibility for maintaining the dumpsters and stated that the lids should be closed for infection control purposes.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure the removal of expired medications from one of its medication carts, specifically Medication Cart B. During an inspection conducted by RN 1, it was observed that 14 packets of Vitamin A & D ointment, which had expired in October 2023, were still present in the cart. The facility's policy and procedure, effective since April 2008, mandates that outdated medications be immediately removed from stock and disposed of according to established procedures. RN 1 confirmed the presence of the expired medications and acknowledged that they should have been removed and discarded.
Infection Control Breach in Laundry Room
Penalty
Summary
The facility failed to maintain proper infection control practices in the laundry room, which could potentially lead to the transmission of communicable diseases to residents. During an inspection, a black fabric bag containing a bottle of Gatorade, a can of soda, and a paper bag with food items was found on top of unopened boxes of laundry detergents. Additionally, a bottle of Sunshine Mimosa Fine Fragrance mist spray was observed on the counter in the clean area. Laundry Staff 1 confirmed these findings and acknowledged that personal belongings, including food and drink, should not be present in the laundry room to maintain infection prevention. The Housekeeping and Laundry Supervisor and the Infection Preventionist (IP) were informed of these findings and acknowledged that staff were expected to adhere to the facility's infection control practices in the laundry room area.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide a floor mat for Resident 2, as specified in the resident's care plan, to prevent or minimize injury in the event of a fall. This deficiency was identified through observation, interviews, and a review of medical records and facility policies. Resident 2, who was at risk for falls due to confusion, attempts to self-transfer, and requiring substantial assistance with activities of daily living, was observed without a floor mat beside her bed. Despite the care plan intervention to place a floor mat on the right side of the bed, both CNA 1 and LVN 1, who were familiar with Resident 2, confirmed that a floor mat had never been used in her room. Resident 2 had a history of falls, as indicated by a Change of Condition Evaluation dated 5/14/24, which documented an episode resulting in a skin tear to the right hand. The care plan, initiated on 7/3/23, specifically addressed the resident's fall risk and included the use of a floor mat as an intervention. However, during an interview and medical record review with RN 1, it was verified that the care plan's intervention to place a floor mat was not implemented. This oversight had the potential to place Resident 2 at risk for serious injury.
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.
