Arcadia Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arcadia, California.
- Location
- 1601 S Baldwin Ave., Arcadia, California 91007
- CMS Provider Number
- 555729
- Inspections on file
- 33
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Arcadia Care Center during CMS and state inspections, most recent first.
Surveyors found that two CNAs did not have timely, fully documented annual performance evaluations, and one CNA lacked a complete pre-employment background check. One CNA had no evaluation for the most recent year, and another’s evaluation was completed late; both evaluations lacked supervisor comments on new goals, objectives, and commitments. The same CNA’s file contained only a limited county criminal search without required abuse registry and OIG LEIE exclusion checks, despite facility policies requiring comprehensive background screening and annual performance reviews to support ongoing CNA competency.
A resident with asthma and a history of acute respiratory failure was allowed to self-administer a Fluticasone Furoate-Vilanterol inhaler unsupervised over several months without an IDT assessment, despite facility policies requiring such evaluation before self-administration. Physician orders and MARs documented daily unsupervised self-use of the inhaler, while the IDT care conference form left the self-medication section unaddressed and contained no assessment of self-administration capability. Nursing notes later showed the resident was using the inhaler on a PRN basis instead of as ordered, and staff interviews revealed that no formal self-medication assessment had been completed and that key team members were unaware the resident was self-administering. Facility P&Ps required the attending physician and IDT to assess mental and physical abilities and specific medication-management skills before permitting self-administration, which was not done in this case.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required this intervention due to fall risk and functional limitations. One resident with hemiplegia, hemiparesis, generalized weakness, COPD, moderate cognitive impairment, and dependence in multiple ADLs was observed in bed with the call light pad hanging under the bed, and both the resident and a CNA stated the resident could not reach it. Another resident with prostate cancer, bone metastases, difficulty walking, generalized weakness, type 2 DM, and intact cognition was observed sitting on one side of the bed while the call light lay on the floor on the opposite side; the resident and an LVN confirmed it was out of reach. The DON and facility policies required that call lights be kept within easy reach of residents to accommodate their needs and support safe functioning.
A deficiency occurred when a physician-ordered Nystatin powder for treatment of scrotal MASD was found stored at a resident's bedside rather than in a locked medication area, contrary to facility policy. The resident, who had multiple serious diagnoses and required extensive assistance with ADLs, had an active order for Nystatin application every shift, documented on the TAR and OSR. During observation, the Nystatin bottle with its label was seen on the bedside drawer, and the resident and family member reported it was kept there and accessible to anyone. A review of the treatment cart with a treatment nurse confirmed the medication was not stored there, and both the TN and DON stated medications should be kept locked and accessed only by licensed nurses, as required by the facility's medication storage policy.
A resident with hemiplegia, hemiparesis, DM, and recent right thigh tumor surgery was admitted with a right thigh JP drain and an abdominal wound VAC, but staff did not obtain physician orders on admission to monitor, drain, and record JP output or to monitor and change the wound VAC canister. Documentation showed no monitoring of the JP drain, its stoma sites, or the wound VAC on the evening and night shifts following admission, and TAR entries for JP and wound VAC monitoring did not begin until the next day. In interviews, the admitting RN and LVNs confirmed they did not secure appropriate orders or perform and document required monitoring, and the DON referenced facility policy requiring the admitting nurse to contact the physician, review assessment findings, and obtain and record admission orders based on those findings.
A resident with neuromuscular bladder dysfunction and extrarenal uremia underwent a bladder scan performed by an LVN, who then contacted the physician and received an order for PRN straight catheterization. Although the SBAR form reflected that the scan was done and an order was obtained, the electronic order summary contained no physician order for either the bladder scan or the straight catheter. The LVN acknowledged that the order was not entered into the medical record, and the DON confirmed that such an order should have been documented, resulting in inaccurate clinical documentation.
A resident with dementia and mobility needs was left alone at an outside medical appointment without a facility escort present, despite facility policy requiring staff to remain with cognitively impaired residents until family arrives. The resident was found by family unaccompanied, raising concerns about safety and adherence to established protocols.
A resident with hypertension and other conditions was provided with salt packets despite a physician's order for no added salt. The dietary supervisor gave the resident salt upon request, did not document communication with the family or physician, and did not follow facility policy for handling declined therapeutic diets.
A facility failed to notify a resident's representative when the resident was transferred to a hospital due to a respiratory infection. The resident, who had multiple diagnoses and was dependent on staff, was transferred without documented notification to their representative, violating the facility's policy. The LVN responsible did not recall the notification time, and the transfer form lacked this documentation.
A facility failed to document the notification to a resident's representative about the resident's transfer to a General Acute Care Hospital. The resident, with conditions including encephalopathy and acute respiratory failure, was transferred due to a respiratory infection. The LVN did not remember the notification time, and the DON confirmed that if it was not documented, it was not done, violating the facility's charting policy.
A facility failed to notify a resident's responsible party when the resident's antibiotic treatment was discontinued, contrary to policy. The resident, admitted for IV antibiotics for a complicated UTI, did not receive alternative treatment, leading to increased confusion and pain. Staff assumed the physician had informed the responsible party, resulting in a communication breakdown.
A resident admitted with a UTI did not receive prescribed IV antibiotics due to cost concerns, and no alternative treatment was provided. The facility also failed to conduct a timely urinalysis to guide treatment, leading to the resident's rehospitalization with altered mental status.
A resident with a UTI did not receive timely laboratory services, leading to a delay in antibiotic treatment. The facility failed to collect a urine sample for urinalysis with C&S as ordered, resulting in the resident experiencing altered mental status and requiring transfer to a hospital for further evaluation and treatment.
A facility failed to implement proper infection control measures, as evidenced by a CNA entering a resident's isolation room without PPE and an LVN using potentially contaminated toilet paper during eye drop administration. These actions violated facility policies and CDC guidelines, increasing the risk of infection spread.
The facility failed to maintain resident dignity by not responding to call lights promptly, standing while feeding residents, and not respecting private spaces. Two residents experienced long waits for assistance, leading to frustration and potential incontinence. Staff were observed standing while feeding, against policy, and entering rooms without knocking, violating privacy and dignity.
The facility failed to educate the representatives of two residents on their rights to formulate Advance Directives. One resident, with COPD and other conditions, lacked decision-making capacity, and their representative did not receive complete information. Another resident, with lung cancer and cognitive impairment, had documents signed by staff not legally recognized as decision-makers. The facility did not involve its Bioethics Committee as required, risking unwanted life-sustaining treatment.
The facility failed to provide written Medicare Advance Beneficiary Notices (ABN) to the responsible parties of two residents, despite notifying them by phone. Both residents had significant cognitive impairments and required substantial assistance. The ABNs indicated that Medicare coverage for skilled services would end, necessitating out-of-pocket payments. The Business Office Manager confirmed the lack of written notification, which was against facility policy.
The facility failed to implement fall safety interventions for two residents, leading to potential fall risks. One resident, with conditions like osteoarthritis and cerebral palsy, was left to ambulate alone due to delayed staff response. Another resident, at high risk for falls, had their bed in a raised position without required floor mats, contrary to their care plan.
A facility failed to monitor and document fluid intake and output for a resident on dialysis, as per physician's orders. The resident, with severe cognitive impairment and dependent on staff, had a fluid restriction due to heart failure and end-stage renal disease. Interviews confirmed missing documentation on multiple dates, violating the facility's policy for intake and output recording, and preventing verification of compliance with the fluid restriction.
A resident with multiple health conditions, including dementia and diabetes, was served fish despite a documented preference against it. The oversight occurred during lunch tray line service, where the resident's meal tray card indicated 'No Fish'. The Dietary Services Supervisor emphasized the importance of adhering to food preferences, as outlined in the facility's policies.
The facility failed to follow its dishwashing and standard precautions policies, as a dishwasher improperly handled sanitized trays, risking cross-contamination. The Dietary Services Supervisor confirmed the error, noting that another staff member was responsible for handling sanitized items. Facility policies required proper sanitization and handling of tableware.
A facility failed to ensure a responsible party understood a binding arbitration agreement before signing. The resident, with dementia and requiring substantial assistance, had an agreement signed electronically by their representative without a clear explanation of its terms. The Admissions Coordinator communicated via email and phone but did not provide adequate information, despite facility policy allowing refusal or rescission of the agreement.
A resident with End Stage Renal Disease and hypertension used a shared restroom not designated for them, potentially invading the privacy of other residents. The resident, who had intact cognition, was directed by a staff member to use the restroom across the hallway due to an urgent need. Facility staff confirmed that this practice violated privacy policies.
A resident's representative was not properly informed of the facility's bed hold policy during a transfer, as the Bedhold Notification form lacked the necessary signature. The resident, who was dependent on staff and had multiple diagnoses, had their consent obtained over the phone without proper documentation. The facility's policy requires documentation and witness signatures for phone consents.
A resident with type 2 diabetes had a blood sugar level of 420 mg/dL recorded, but the facility staff failed to notify the physician as required. The resident's MAR indicated a need to inform the MD for levels above 400 mg/dL. The LVN could not recall notifying the MD, and there was no documentation of such action. The DON confirmed that the facility's policy required notifying the physician of changes in the resident's condition.
Failure to Complete Annual CNA Evaluations and Full Background Screening
Penalty
Summary
Surveyors identified that the facility did not ensure required annual performance evaluations were completed and properly documented for two of four CNAs reviewed, and did not complete a full pre-employment background check for one CNA. Personnel file review showed CNA 2, hired on 9/28/23, had a performance evaluation dated 9/28/24 but no evaluation for 2025, and the existing evaluation lacked supervisor comments regarding new goals, objectives, and commitments. CNA 4’s performance evaluation was dated 7/20/25, although the CNA’s hire date of 6/1/19 indicated the annual evaluation was due on 6/1/25, and this evaluation also lacked supervisor comments on new goals, objectives, and commitments. During interview, the DSD confirmed there was no 2025 performance evaluation for CNA 2 and stated that performance evaluations should be completed annually and that annual reviews of CNA skills are important to ensure safe resident care. Record review further showed that CNA 4’s personnel file did not contain a full background check as required by facility policy. The file only included a 7-year criminal court record search for Los Angeles County and lacked documentation of an abuse registry check and an exclusion list database check, including the OIG LEIE. Facility policies titled “Background Screening Investigations,” “Hiring,” “Staff Development Program,” and “Performance Evaluations” indicated that background and criminal checks must be initiated within two days of an employment offer and completed prior to employment, including checks of the state nurse aide registry and applicable licensing boards, and that each employee’s job performance must be reviewed at least annually. The policies also stated that CNAs must complete at least 12 hours of annual in-service training to ensure continuing competency and address weaknesses identified in performance evaluations and the facility assessment.
Failure to Assess Resident Before Allowing Unsupervised Self-Administration of Inhaler
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer medication, as required by facility policies. The resident was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia and asthma, and was prescribed a Fluticasone Furoate-Vilanterol inhaler for asthma as an unsupervised self-administered medication. Physician orders and MARs for multiple months documented that the resident was self-administering this inhaler daily and unsupervised. However, the IDT care conference record for the resident’s admission showed that the self-medication administration section was left unmarked, and there was no documentation in the conference summary that an IDT assessment for self-administration had been conducted. Further record review showed that the resident’s MDS indicated intact cognition for daily decision-making but dependence or need for assistance with several ADLs, including toileting hygiene, dressing, footwear, personal hygiene, and bathing. Nursing progress notes later documented that the resident reported taking the inhaler on an as-needed basis, despite the physician’s order specifying daily administration. The nurse documented reviewing proper inhaler technique with the resident and seeking clarification from the physician regarding whether the medication should remain a daily routine or be changed to PRN, and the physician confirmed it should be administered once daily as ordered. A care plan for self-administration of medication was initiated and revised later, indicating that the resident self-administers the inhaler and that reassessments would occur periodically, but this was not in place during the earlier period of self-administration. Interviews with staff and family further highlighted the lack of required assessment and oversight. A family member stated that the resident did not receive the inhaler for approximately two and a half months starting from the time of the order. An LVN reported that the resident had been self-administering the inhaler from December through March and stated that there should be a self-medication assessment in the electronic medical record completed by an RN supervisor or charge nurse, but confirmed that she had not completed such an assessment. The MDS nurse stated that residents who self-administer medications should have both a physician’s order and an IDT assessment of their ability to self-medicate, and reported having no knowledge that this resident was self-administering until preparing the quarterly MDS. Review of facility policies confirmed that residents may self-administer medications only if the attending physician and IDT determine, through assessment of mental and physical abilities and specific medication-related skills, that it is clinically appropriate and safe, which had not been documented for this resident during the period in question.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to keep call lights within reach of residents in accordance with its Call Light and Accommodation of Needs policies. The policies require that when a resident is in bed or confined to a chair, the call light must be within easy reach, and that staff behaviors support residents in maintaining safe independent functioning and that individual needs and preferences are accommodated. The Director of Nursing confirmed that the facility should ensure call lights are always kept within residents’ reach. For one resident admitted with hemiplegia and hemiparesis following a cerebral infarction, generalized muscle weakness, and COPD, the care plan identified the resident as a fall risk and specified interventions to maintain the call light within reach and to place the call light and frequently used items within reach to improve functional ability in bed. The resident’s history and physical indicated capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills and dependence for multiple ADLs, including eating, toileting hygiene, bathing, dressing, and personal hygiene. During observation and interview, the resident was awake in bed with the call light hanging on the left bedrail and the call light pad hanging under the bed; the resident stated being barely able to move hands and arms and unable to reach the call light pad. A CNA confirmed during the same observation that the resident could not touch the call light pad under the bed and acknowledged staff should have placed it within reach. For another resident admitted with prostate cancer, secondary malignant neoplasm of bone, difficulty in walking, generalized muscle weakness, and type 2 DM, the care plan also directed staff to place the call light and frequently used items within reach to improve functional ability in bed and to maintain the call light within reach due to fall risk. The history and physical documented that this resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills, with partial/moderate assistance needed for toileting hygiene, bathing, and dressing, and supervision or touching assistance for eating, oral hygiene, and personal hygiene. During observation and interview, the resident was sitting on the left edge of the bed with feet on the floor, while the call light was on the floor on the opposite side of the bed; the resident stated being unable to use the call light because it could not be reached. An LVN present at the time confirmed the call light was on the floor on the other side of the bed and that the resident could not reach it, acknowledging staff should have kept it within reach.
Improper Bedside Storage of Nystatin Powder
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a physician-ordered Nystatin powder for treatment of scrotal moisture-associated skin damage (MASD) was found stored at a resident's bedside instead of in a locked medication area. The resident, admitted with diagnoses including muscle wasting and atrophy, generalized muscle weakness, liver cell carcinoma, secondary malignant neoplasm of the nervous system, and type 2 DM, had an active treatment order dated 2/26/2026 to cleanse the scrotum with normal saline, pat dry, and apply Nystatin powder every shift for 14 days, documented on the Treatment Administration Record and Order Summary Report. The resident's MDS indicated intact cognitive skills but dependence or substantial/maximal assistance with toileting, bathing, dressing, footwear, and personal hygiene. During observation at the bedside, surveyors saw a bottle of Nystatin powder with the pharmacy label on top of the bedside drawer, and both the resident and a family member stated the Nystatin was kept at the bedside and accessible to everyone. A subsequent observation of the treatment cart with the treatment nurse showed that the Nystatin powder ordered for this resident was not stored in the cart. The treatment nurse stated the Nystatin should have been stored in the treatment cart and that only licensed nurses should obtain and apply it. The DON stated that all ordered medications should be kept in a locked place with access limited to licensed nurses. Review of the facility’s “Storage of Medications” policy, revised April 2019, showed that all drugs and biologicals are to be stored in locked compartments, with nursing staff responsible for maintaining safe and secure medication storage areas, which was not followed in this instance.
Failure to Obtain Orders and Monitor JP Drain and Wound VAC After Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement physician orders and to monitor a resident’s right thigh Jackson Pratt (JP) drain and right lower quadrant (RLQ) abdominal wound vacuum following admission. The resident was admitted with a history of hemiplegia and hemiparesis following cerebral infarction and diabetes mellitus, and had recently undergone surgery on a right thigh tumor. The admission assessment documented the presence of a wound vacuum from the RLQ abdomen to the perineal area and a JP drain on the right thigh, and the physician’s plan included wound care for the right thigh ulcer with monitoring for drainage. However, the Order Summary Report on the admission date showed no physician orders to monitor, empty, and record JP drain output, and no orders to monitor or change the wound vacuum canister. Record review showed no evidence that the JP drain and wound vacuum were monitored on the evening shift of the admission date or on the subsequent night shift. The Treatment Administration Record for that month confirmed that monitoring and recording of JP drainage every shift did not begin until the day after admission and that there was no monitoring of the JP drain or its stoma sites on the evening and night shifts of the admission date. Similarly, orders and documentation for continuing and monitoring the wound vacuum every shift began the day after admission, with no such monitoring documented for the evening and night shifts immediately following admission. In interviews, treatment nurses and LVNs acknowledged that there were no orders on the admission date to monitor, drain, and record JP drainage or to monitor, continue, and change the wound vacuum canister, and they confirmed that they did not perform or document these tasks on the evening shift. The admitting RN stated that although the resident was admitted with a JP drain and wound vacuum, the RN did not verify and obtain orders from the physician to monitor, drain, and record JP output or to monitor and change the wound vacuum on the admission date. The DON stated that the facility should monitor, drain, and record JP drainage and monitor, continue, and change the wound vacuum canister after admission for residents with these devices, and the facility’s admission assessment policy required the admitting nurse to contact the attending physician, review assessment findings, and obtain admission orders based on those findings, documenting them in the medical record.
Failure to Document Physician Orders for Bladder Scan and Straight Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident who had neuromuscular dysfunction of the bladder and extrarenal uremia. The resident was admitted in mid-November 2025 and required varying levels of assistance with activities of daily living, including toileting and personal hygiene. Review of the resident’s Order Summary Reports for November and December 2025 showed no physician’s order for a bladder scan or for insertion of a straight catheter on an as-needed basis. However, an SBAR Communication Form dated December 8, 2025 documented that an LVN performed a bladder scan on the resident, notified the physician, and received a physician’s order to insert a straight catheter as needed at 12:45 PM that day. During interview and concurrent record review, the LVN confirmed performing the bladder scan and obtaining a physician’s order for straight catheterization to drain urine as needed, but acknowledged that there was no documented order in the medical record for either the bladder scan or the straight catheter on that date and stated that this documentation should have been completed. The DON also stated that the nurse should have obtained and documented a physician’s order to perform the straight catheter. Facility policies on Charting and Documentation required that all services provided and changes in condition be documented in the resident’s clinical record, and the Electronic Signatures and Electronic Orders policy required that the time and date of orders entered or changed in electronic records be recorded. The lack of a documented physician’s order for the bladder scan and straight catheterization on December 8, 2025 resulted in inaccurate documentation in the resident’s medical record and had the potential for delaying interventions and services for the resident.
Resident with Dementia Left Unescorted at Medical Appointment
Penalty
Summary
A resident with diagnoses including hypertension, epilepsy, and unspecified dementia was admitted to the facility and assessed as cognitively intact but requiring substantial to maximal assistance with walking and being dependent for transfers. The resident had an outside medical appointment, and according to family interview, was found alone at the appointment site with their wheelchair and medical documents, without a facility escort present. The family member expressed concern for the resident's safety due to the dementia diagnosis. Facility staff interviews revealed that the protocol is to send an escort with residents, especially those with cognitive impairment or dementia, unless family is present to assume responsibility. Documentation and staff statements indicated that the expectation was for an escort to remain with the resident until the family arrived. However, the escort left the resident at the appointment before the family arrived, contrary to facility policy and procedure, which requires staff to accompany residents with cognitive impairment when family is not available. This resulted in the resident being left unsupervised at the appointment site.
Failure to Follow Physician-Ordered Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served as ordered for one resident. The resident had a physician's order for a controlled carbohydrate diet with no additional salt due to medical conditions including hypertension, epilepsy, and dementia. Despite this order, the resident was provided with salt packets upon request. The dietary supervisor confirmed that the resident frequently asked for additional salt and was given salt packets, even though the order specified no added salt. Mrs. Dash, a salt-free seasoning, was offered as an alternative but was refused by the resident. There was no documentation that the dietary supervisor communicated with the resident's family or the physician regarding the resident's requests for additional salt or the provision of salt packets. The facility's policy required collaboration with the resident or representative if a therapeutic diet was declined, but there was no evidence that such collaboration or communication occurred in this case. The failure to follow the physician's diet order and lack of documentation led to the deficiency.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding notifying a resident's representative of changes in the resident's condition or status. Specifically, the facility did not notify the representative of a resident when the resident was transferred to a General Acute Care Hospital due to a respiratory infection. The resident, who had been admitted with diagnoses including encephalopathy, acute respiratory failure with hypoxia, and pneumonitis, was dependent on staff for various activities of daily living and was rarely understood by others. The facility's policy required prompt notification of the resident's representative in such situations, but there was no documentation indicating that this notification occurred. Interviews and record reviews revealed that the Licensed Vocational Nurse responsible for the transfer did not remember the time of notification, and the transfer form did not document the notification to the resident's representative. The Director of Nursing confirmed that if the notification was not documented, it was considered not done, as per the facility's policy. The failure to document the notification violated the resident's and the representative's right to be informed of changes in the resident's condition or status.
Failure to Document Notification of Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Charting and Documentation' by not documenting the notification to a resident's representative regarding the resident's transfer to a General Acute Care Hospital (GACH). The resident, who was originally admitted on January 13, 2025, and readmitted on February 6, 2025, had diagnoses including encephalopathy, acute respiratory failure with hypoxia, and pneumonitis due to inhalation of food and vomit. The resident was rarely/never understood by others and was dependent on staff for various personal care activities. On January 29, 2025, the resident was transferred to GACH due to a respiratory infection, but the time of notification to the resident's emergency contact was not documented. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) responsible for the transfer did not remember the time of notification to the resident's representative. The Director of Nursing (DON) confirmed that if the notification was not documented in the resident's Progress Notes or Transfer Form, it was considered not done. The facility's policy required that all services provided to the resident, including notifications of changes in the resident's condition, be documented in the medical record. The lack of documentation of the notification to the resident's representative was identified as a deficiency.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident when there was a change in the resident's condition, specifically when the resident's primary care provider discontinued the antibiotic Avycaz. This failure was contrary to the facility's policy and procedure, which mandates notifying the resident's representative of significant changes in the resident's medical condition. The resident was admitted to the facility with a diagnosis of a complicated urinary tract infection and was supposed to receive intravenous antibiotics therapy. The physician order dated January 8, 2025, indicated the discontinuation of Avycaz, but the responsible party was not informed until four days later. During this period, the resident did not receive any alternative treatment for the urinary tract infection, leading to increased confusion and pain. The facility staff assumed that the physician had notified the responsible party, which was not the case, resulting in a communication breakdown. Interviews with the facility's administrator, licensed vocational nurse, and director of nursing revealed that there was no documentation of notification to the responsible party regarding the discontinuation of Avycaz. The responsible party expressed concern over the lack of communication and the facility's failure to follow the hospital's instructions for the resident's care. The resident also reported feeling neglected and uninformed about their treatment plan.
Failure to Administer Prescribed Antibiotics and Conduct Timely Urinalysis
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident 2, according to the facility's policy and procedures on antibiotic stewardship and urinary tract infection management. Resident 2 was admitted to the facility with a diagnosis of a urinary tract infection (UTI) and was supposed to continue intravenous antibiotic therapy with ceftazidime-avibactam (Avycaz) as recommended by the discharging hospital. However, the facility did not ensure that the primary care provider continued this therapy or provided an alternative treatment. The resident's physician, MD 1, discontinued the Avycaz order due to its high cost without ordering an alternative antibiotic treatment. This decision was made without prior authorization for the medication, which was necessary due to its expense. As a result, Resident 2 did not receive any antibiotics from 1/8/2025 to 1/12/2025, leading to a deterioration in the resident's condition, including altered mental status, which necessitated a transfer back to the hospital for further evaluation and treatment. Additionally, the facility failed to carry out a physician's order for a urinalysis with culture and sensitivity on 1/9/2025, which was intended to guide alternative antibiotic therapy. The delay in obtaining this test contributed to the lack of appropriate treatment for the resident's UTI. Interviews with facility staff, including the Director of Nursing and the admitting nurse, revealed that the facility did not follow the discharge instructions from the hospital, resulting in a delay in care and the resident's rehospitalization.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, resulting in a delay in treatment for a urinary tract infection (UTI) caused by Pseudomonas aeruginosa. The resident was admitted with a diagnosis of UTI and was a carrier of Carbapenem-resistant Enterobacterales (CRE). A physician order dated 1/8/2025 required a urinalysis with culture and sensitivity (C&S) to be conducted on 1/9/2025 to determine the appropriate antibiotic treatment. However, the facility staff did not collect the urine sample as ordered, leading to a lack of antibiotic therapy from 1/8/2025 to 1/12/2025. On 1/13/2025, the resident experienced altered mental status (AMS) and was transferred to a general acute care hospital (GACH) for further evaluation and treatment. The emergency department provider note indicated that the resident was brought in due to increased confusion and abnormal laboratory test results. The resident was started on ceftazidime-avibactam, an antibiotic that had been discontinued earlier due to its high cost, and was discharged back to the skilled nursing facility (SNF) to continue the antibiotic therapy. Interviews with the facility's registered nurse (RN), licensed vocational nurse (LVN), and the director of nursing (DON) confirmed that the urinalysis with C&S was not carried out as ordered, resulting in a delay in care. The physician also confirmed that the delay in obtaining the urine sample caused a delay in the resident's treatment, leading to rehospitalization. The facility's policy and procedures required that diagnostic and lab tests be processed and arranged promptly, which was not adhered to in this case.
Infection Control Lapses in PPE Use and Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control measures as evidenced by two specific incidents. In the first incident, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation precautions without donning the required personal protective equipment (PPE). The resident, who was diagnosed with enterocolitis due to Clostridium difficile, required isolation to prevent the spread of infection. Despite the presence of signage and an isolation cart with PPE at the room entrance, the CNA did not wear the necessary gown and gloves, stating that PPE was not needed for merely delivering a meal tray. In the second incident, a Licensed Vocational Nurse (LVN) attempted to use toilet paper from a shared bathroom while administering eye drops to another resident. The resident had severe cognitive impairment and required assistance with medication administration. The LVN acknowledged that using toilet paper from the restroom was inappropriate due to potential contamination, as the restroom was shared and the toilet paper could have been touched by multiple individuals. These incidents were in violation of the facility's policies and procedures, as well as national health guidelines. The facility's policies required the use of PPE for contact precautions and specified the use of cotton balls for drying eyelids during eye drop administration. The Centers for Disease Control and Prevention (CDC) guidelines also mandated the use of PPE upon room entry for residents on contact isolation. The facility's failure to adhere to these protocols increased the risk of infection transmission within the facility.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of six residents by not responding to call lights in a timely manner, standing while feeding residents, and not respecting residents' private spaces. Residents 120 and 279 experienced significant delays in having their call lights answered, with Resident 279 waiting 45 minutes and Resident 120 waiting up to 2 hours during nighttime shifts. These delays forced Resident 279 to attempt to use the bathroom independently, risking incontinence, while Resident 120 experienced frustration due to the inability to move their legs without assistance. Additionally, staff members were observed standing while feeding Residents 13 and 15, which is against the facility's policy that requires staff to be seated to maintain eye-level contact and dignity. The Director of Nursing confirmed that standing while feeding is degrading to residents. This practice was observed during dining times, where staff did not adhere to the policy, potentially impacting the residents' sense of dignity and respect. Furthermore, the facility staff failed to knock before entering residents' rooms, as observed with Residents 13, 75, and 86. LVNs entered rooms and restrooms without knocking, startling residents and violating their privacy. The facility's policy mandates knocking and introducing oneself before entering to maintain dignity and respect. These actions led to residents feeling embarrassed and disrespected, as confirmed by interviews with the Director of Nursing and affected residents.
Failure to Educate on Advance Directives
Penalty
Summary
The facility failed to ensure that the representatives of two residents were provided with complete and accurate education regarding the residents' rights to formulate an Advance Directive (AD). Resident 4, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and heart failure, did not have the capacity to understand or make decisions. The Admission Record indicated that the Advance Directive Acknowledgement was not properly completed, as there were no check marks to confirm that the resident's representative understood the provided materials or the resident's rights concerning medical care decisions. Similarly, Resident 19, who was admitted with diagnoses including lung cancer, muscle weakness, and COPD, was severely impaired in cognitive skills and dependent on staff for daily activities. The facility's staff, specifically RN 1 and RN 3, signed the resident's documents as representatives, despite not being legally recognized decision-makers. The facility's Administrator acknowledged that if a resident did not have a representative and lacked decision-making capacity, the facility should refer to its Bioethics Committee, which was not done in this case. The facility's policies and procedures on Advance Directives and Bioethics were not followed, as the residents' rights to participate in medical decisions were not upheld. The Bioethics Committee, which should have been involved in decision-making for residents without representatives, was not utilized. This oversight resulted in the potential for residents to receive life-sustaining care and/or treatment against their will, as the necessary steps to ensure informed decision-making were not taken.
Failure to Provide Written Medicare ABN to Residents' Representatives
Penalty
Summary
The facility failed to provide written notification to the responsible parties of two residents regarding the Medicare Advance Beneficiary Notice (ABN), which informs beneficiaries of services that Medicare may not cover. For Resident 178, who was admitted with serious medical conditions including intracerebral hemorrhage and chronic kidney disease, the facility did not provide a written ABN to the responsible party, despite notifying them by phone. The resident had moderate cognitive impairment, and the ABN indicated that Medicare coverage for skilled services would end, requiring out-of-pocket payment if no other insurance covered the costs. Similarly, for Resident 179, who had severe cognitive impairment and required significant assistance with daily activities, the facility also failed to provide a written ABN to the responsible party. The ABN for this resident indicated that Medicare coverage for skilled services would end, necessitating out-of-pocket payment. The responsible party could not recall receiving any written notification, and the Business Office Manager confirmed that no written ABN was provided, which was against the facility's policy.
Failure to Implement Fall Safety Interventions
Penalty
Summary
The facility failed to implement fall safety interventions for two residents, leading to potential fall risks. Resident 279, who was admitted with conditions such as osteoarthritis, cerebral palsy, and hyperlipidemia, required assistance for transferring and ambulating due to a history of falls. However, the resident reported waiting 45 minutes for staff assistance during the night shift, resulting in the resident walking to the bathroom unassisted. Observations confirmed that Resident 279 was walking alone in her room without staff supervision, and interviews with staff indicated a lack of communication regarding the need for assistance. Resident 55, with a history of falls and conditions including a wedge compression fracture, malignant neoplasm of the stomach, and hypertension, was assessed as high risk for falls. The care plan required the bed to be in the lowest position and floor mats to be placed on both sides of the bed. However, during an observation, the bed was found in a raised position without floor mats, contrary to the care plan. The Director of Nursing acknowledged the purpose of the floor mats was to minimize injuries in case of a fall, indicating a failure to adhere to the facility's fall prevention protocol.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document fluid intake and output for a resident requiring dialysis care, as per the physician's orders. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was on a fluid restriction of 1000 milliliters per 24 hours due to conditions including heart failure and end-stage renal disease. The facility's records showed no documentation of the resident's fluid intake or output on multiple dates, despite an active order for fluid restriction. Interviews with the Licensed Vocational Nurse and the Director of Nursing confirmed the absence of documentation for the specified dates, indicating a failure to adhere to the facility's policy and procedure for intake and output documentation. This lack of documentation meant the facility could not verify compliance with the fluid restriction, which was crucial for the resident's health management. The facility's policy required nursing staff to document intake and output each shift, but this was not followed, leading to the deficiency.
Failure to Follow Resident's Food Preferences
Penalty
Summary
The facility failed to adhere to the food preferences of a resident during the lunch tray line service. The resident, who was admitted with multiple diagnoses including dementia, type 2 diabetes mellitus, and various vitamin deficiencies, had a documented preference against fish. Despite this, the resident was initially served a meal containing fish, contrary to the instructions on their meal tray card which indicated 'No Fish' under dislikes. This oversight was observed during a tray line observation, where it was noted that the resident should have been served chicken instead of fish. The Dietary Services Supervisor acknowledged the importance of reviewing meal tray cards to ensure residents' food preferences are respected and adequate nutrition is provided. The facility's policies and procedures require that food preferences be adhered to and that substitutes be provided for disliked foods. However, in this instance, the cook did not initially provide the appropriate substitute, leading to a failure in meeting the resident's dietary needs as documented.
Dishwashing and Standard Precautions Deficiency
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding dishwashing and standard precautions, as observed in the kitchen. During an observation, a dishwasher (DW 1) was seen washing and rinsing dirty pans and trays in the sink and then touching sanitized metal trays, which were supposed to be handled by another staff member to prevent cross-contamination. The Dietary Services Supervisor (DSS) confirmed that DW 1 was not supposed to touch the sanitized trays, as another staff member, Dietary Aide 2 (DA 2), was assigned to handle them. The facility's policy, dated 2018, required all dishes to be properly sanitized through the dishwasher, and the policy on standard precautions, dated 6/25/2024, indicated that all tableware must be treated as contaminated and sanitized according to facility protocol.
Failure to Ensure Informed Consent for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP 85) for Resident 85 understood the binding arbitration agreement (BAA) before signing it. Resident 85, who was originally admitted to the facility in June 2022 and readmitted later, had diagnoses including dementia and adult failure to thrive, indicating significant cognitive and physical impairments. The Minimum Data Set (MDS) assessment showed that Resident 85 required substantial assistance with daily activities and had increased confusion, lacking the capacity to make decisions. Despite these conditions, RP 85 signed the arbitration agreement electronically without a clear understanding of its purpose or terms. The Admissions Coordinator (AC) communicated with RP 85 via email and telephone, sending the arbitration agreement electronically and instructing RP 85 to call with any questions. However, RP 85 did not receive an explanation of the agreement's purpose or terms, nor did they contact AC for clarification. The facility's policy stated that signing the arbitration agreement was not a condition for admission and that residents had the right to refuse or rescind the agreement within 30 days. Despite this policy, the AC was unable to explain the details of the arbitration process, including the selection of a neutral arbitrator or venue, contributing to the deficiency in ensuring RP 85's informed consent.
Resident Privacy Breach Due to Shared Restroom Use
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not allowing them to use a shared restroom, which could potentially invade the privacy of other residents. The incident involved a resident who was admitted with End Stage Renal Disease and essential hypertension. The resident had intact cognition and the capacity to make decisions. During an observation, a Licensed Vocational Nurse (LVN) found the resident using a shared restroom that was not designated for them, as they were from another room. Interviews with staff, including the Infection Preventionist and the Director of Nursing, confirmed that residents from different rooms should not use shared restrooms to maintain privacy and dignity. The resident explained that they used the restroom because their designated restroom was occupied, and they had an urgent need due to an appointment. A staff member had directed the resident to use the restroom across the hallway. The facility's policy on providing a homelike environment emphasizes the importance of privacy and the use of personal belongings, which was not adhered to in this case.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify the representative of a resident, who lacked decision-making capacity, about the facility's bed hold policy during a hospital transfer or therapeutic leave. The resident, who had been diagnosed with type 2 diabetes mellitus, liver cirrhosis, and hyperlipidemia, was dependent on staff for personal hygiene and toilet use. The Admission Coordinator stated that the bed hold notification was part of the admission packet and required a signature upon readmission. However, during the review, it was found that the Bedhold Notification form was incomplete, lacking the representative's signature. Licensed Vocational Nurse 4 admitted to obtaining verbal consent over the phone from the resident's representative but failed to document it properly. The Director of Nursing confirmed that if consent is obtained over the phone, it should be documented with the name of the person giving consent and witnessed by two staff members. The absence of proper documentation and signature on the Bedhold Notification form indicated a failure to inform the resident's representative of their rights, as required by the facility's policy.
Failure to Notify Physician of Elevated Blood Sugar
Penalty
Summary
The facility staff failed to notify the physician of a resident's elevated blood sugar level, which was recorded at 420 mg/dL. This incident involved a resident with a history of type 2 diabetes mellitus, liver cirrhosis, and hyperlipidemia. The resident's Medication Administration Record (MAR) indicated that the blood sugar level was recorded on 7/1/2024, and there was a standing order to notify the medical doctor if the blood sugar exceeded 400 mg/dL. However, the Licensed Vocational Nurse (LVN) responsible could not recall notifying the physician, and there was no documentation to confirm that the notification occurred. The Director of Nursing (DON) confirmed that according to the facility's policy, the physician should have been notified of the change in the resident's condition. The policy, titled 'Change in a Resident's Condition or Status,' required the nurse to inform the attending physician of any specific changes in the resident's condition. The DON acknowledged that if it was not documented, it was not done, emphasizing the importance of notifying the physician to determine if the resident's insulin needed adjustment and to decide on the appropriate care.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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