Arroyo Vista Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 3022 45th Street, San Diego, California 92105
- CMS Provider Number
- 055505
- Inspections on file
- 23
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arroyo Vista Nursing Center during CMS and state inspections, most recent first.
A resident with a history of fractures and intact cognition was denied re-entry to the facility after returning from an authorized out on pass, as staff—following NP instructions—considered the resident AMA and directed him to the ER. The resident, who was not informed of any curfew, was left outside until police intervened and required staff to allow him back in.
A resident with intact cognition and independence in ADLs was denied re-entry to the facility after returning late from an OOP leave, without prior notification of such a rule. No IDT meeting was conducted or documented after the incident, and the resident was not included in person-centered care planning, despite facility policy requiring such involvement after significant events.
A resident with a physician's order for Out on Pass privileges was denied re-entry to the facility after midnight due to uncommunicated rules, resulting in the resident being locked out for several hours. The care plan was not updated to reflect this incident, and staff were unclear about the applicable rules and interventions, contrary to facility policy requiring IDT review and revision.
The facility failed to maintain sanitary conditions in the kitchen, with multiple food items improperly dated and an ice machine with mold due to an overdue filter change. These issues were identified during a kitchen tour and interviews with staff, revealing inconsistencies in following food labeling procedures and maintenance schedules.
The facility failed to maintain infection control standards by improperly storing a resident's CPAP mask and not implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices. The CPAP mask was left uncovered near a urinal, and EBP signage and supplies were missing. Additionally, visitors were not educated on hand hygiene, increasing infection risks.
The facility failed to offer and provide education on the pneumococcal vaccine to four residents over 65, as revealed by a review of their records. Interviews with the IP and DON confirmed the expectation to offer the vaccine, but documentation was lacking, indicating non-compliance with the facility's immunization policy.
The facility failed to document the offering of COVID-19 vaccines to four residents, as required by policy. Despite previous vaccinations, there was no record of offers, receipts, or declinations since their admission. The IP and DON highlighted the importance of documentation and regular vaccine offers, aligning with the facility's policy to minimize COVID-19 risks.
The facility failed to implement care plans for two residents, one with end-stage renal disease requiring dialysis and another with substance use disorder and nicotine dependence. The absence of a dialysis care plan led to improper post-dialysis care for a resident, while another resident's care plan contained irrelevant interventions for their substance use disorder. The facility's policy on comprehensive person-centered care planning was not followed, resulting in unmet care needs and poor communication among caregivers.
A resident with severe pain was not administered the correct dosage of Oxycodone as per physician's orders, receiving 5 mg instead of the prescribed 10 mg for severe pain. This occurred on multiple occasions, as confirmed by a nurse and the DON, indicating a failure to follow the facility's pain management policy.
A resident with end-stage renal disease did not receive timely post-dialysis care as required by physician's orders. The dialysis dressing was not removed within the specified four to six hours after treatment, but rather the following morning. This oversight was confirmed by interviews with the resident and nursing staff, including the nurse responsible, who admitted to forgetting the task and inaccurately documenting its completion. The facility's policy emphasized timely assessment and documentation, which was not adhered to, posing a potential risk to the resident's dialysis access site.
A resident with a history of substance use disorder and nicotine dependency did not receive necessary behavioral health services at the facility. Despite being admitted with a history of substance use and cigarette use, the facility's documentation failed to reflect this, resulting in no nicotine replacement therapy or support for substance use disorder being offered. Interviews with staff confirmed the lack of interventions, contrary to the facility's policy on providing necessary behavioral health care.
A resident with a knee replacement surgery did not receive pain medication as ordered. The Lidocaine patch was not removed as scheduled, remaining on the resident's knee 12 hours longer than recommended. The responsible nurse admitted to forgetting to remove the patch, which could affect the medication's efficacy. Facility policies on medication administration were not followed, leading to this deficiency.
The facility's medication error rate was 7.14%, exceeding the acceptable threshold. Errors included a nurse incorrectly mixing a potassium supplement and administering fewer tablets than prescribed. The DON emphasized the importance of following package instructions and physician's orders to ensure medication efficacy.
Resident Denied Re-Entry After Authorized Out on Pass
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by denying re-entry to a resident who returned from an authorized out on pass (OOP). The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was accustomed to leaving the facility on day passes. On the incident date, the resident returned after midnight and was not allowed back into the facility, as staff were instructed by the nurse practitioner (NP) to consider the resident as having left against medical advice (AMA) and to direct him to the emergency room. The resident was not previously informed that returning after midnight would result in being locked out, and the facility's records included a physician's order permitting OOP without a specified curfew. Nursing notes document that the resident arrived at the facility, was informed of the NP's order, and was left outside the facility door. Police were called and, after determining there was no medical reason to send the resident to the emergency room and that he had established residency, instructed staff to allow the resident back inside. The resident was eventually let back into his room after several hours outside. The facility's policy on resident rights and responsibilities was reviewed, but there was no evidence that the resident had been made aware of any curfew or restriction related to OOP returns.
Resident Excluded from Person-Centered Care Planning After OOP Incident
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of his person-centered plan of care following an incident related to his return from an Out on Pass (OOP) leave. The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was denied re-entry to the facility after returning late from a day pass due to unforeseen circumstances. The resident reported not being informed of any rule that would prevent him from re-entering the facility after midnight, and he was only allowed back inside after contacting the police several hours later. A review of the resident's medical record showed a physician's order permitting OOP and no evidence of cognitive impairment. However, there was no documentation of an Interdisciplinary Team (IDT) meeting or care conference following the incident, despite facility policy and staff statements indicating that such meetings should occur quarterly and after significant events or changes in condition. The last documented IDT for the resident was several months prior to the incident, and there was no record of the resident refusing participation in an IDT. Interviews with facility staff, including the Social Service Director, Assistant Director of Nursing, and a licensed nurse, confirmed that no IDT was conducted after the incident. Staff acknowledged that IDTs are essential for collaborative care planning and updating care plans to reflect changes or address issues. The absence of an IDT meant that the resident was not involved in reviewing or updating his care plan after the incident, contrary to facility policy and resident rights.
Failure to Revise Care Plan for Out on Pass Privileges
Penalty
Summary
The facility failed to revise the care plan for a resident who had a physician's order to leave the facility on an Out on Pass (OOP). The resident, who had multiple fractures of the pelvis and right ribs and used a manual wheelchair, was not informed of any time restrictions or rules regarding re-entry to the facility after leaving on a day pass. On one occasion, the resident was denied entry back into the facility after midnight due to facility rules that had not been communicated to him, resulting in him being locked out for three hours until police were called. There was no documentation of an Interdisciplinary Team (IDT) meeting or care plan revision following this incident. Review of the resident's care plan showed it had last been updated months prior to the incident and did not reflect the current situation or address the specific circumstances of the resident's OOP privileges. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan was not updated after the incident, and staff were unclear about the rules and interventions to be applied. The facility's policy required the care plan to be reviewed and revised by the IDT, but this was not done in response to the incident.
Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, specifically regarding food storage methods and ice machine maintenance. During an initial kitchen tour, it was observed that multiple food items were not dated correctly. An open box of corn starch and rice cereal were not transferred to sealed containers and labeled with a use-by date. An open bottle of imitation vanilla flavoring was also not labeled with a use-by date. Additionally, boxes of fountain juices and bags of toasted oats cereal were labeled with numbers and dates without clear indication of their meaning. Interviews with the Certified Dietary Manager and the Registered Dietitian revealed that food items should be marked with received, opened, and use-by dates, which was not consistently done. The ice machine was found to have black residue, identified as mold, inside the ice bin, and the water filter was 45 days past its due date for replacement. The Maintenance Director admitted to finding black residue during monthly cleanings and acknowledged the filter was overdue for a change. The Contracted Technician confirmed that the filter's antimicrobial properties could have prevented mold if it had been changed on time. A review of the contractor's service work order did not include a filter change, and the facility's policy indicated that ice should be handled in a sanitary manner. These deficiencies had the potential to lead to food contamination and foodborne illnesses for the residents.
Infection Control Deficiencies in CPAP Storage and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection control procedures in several instances. A resident's CPAP machine mask and tubing were not stored in a sanitary manner, as the mask was observed dangling uncovered near an empty urinal. The resident confirmed that the CPAP machine was not cleaned at the facility, and the staff, including a licensed nurse and the Director of Nursing (DON), acknowledged that the mask should be stored in a plastic bag and cleaned after each use to prevent respiratory infections. The facility's policy indicated that equipment should be cleaned after use, but this was not adhered to. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, as there was no signage or isolation supplies outside their rooms. The Infection Preventionist and the DON confirmed that EBP should be in place according to CDC guidelines. Furthermore, visitors were not educated on the need for hand hygiene when entering a resident's room under EBP, as observed when two visitors entered without performing hand hygiene. Staff members admitted to not educating visitors, which was against the facility's policy that required all staff to ensure compliance with infection control measures.
Failure to Offer Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to offer and provide education regarding the benefits and potential side effects of the pneumococcal vaccine to four residents reviewed for immunizations. These residents, identified as Residents 18, 71, 105, and 201, were all over the age of 65, a demographic particularly susceptible to pneumococcal infections. The review of their admission and immunization records showed no indication that they were offered or received the pneumococcal vaccine, nor was there documentation of any education provided about the vaccine. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's expectation was to offer the pneumococcal vaccine to eligible residents to protect them from pneumonia and its complications. The facility's policy on immunizations emphasized the importance of vaccinations for the health and well-being of long-term care residents, particularly those aged 65 and older, who are at higher risk for pneumococcal infections. However, the lack of documentation and action in offering the vaccine to the identified residents indicates a failure to adhere to this policy.
Failure to Document COVID-19 Vaccine Offers to Residents
Penalty
Summary
The facility failed to ensure that four out of ten sampled residents were offered the COVID-19 vaccine, as required by their policy. Resident 39, who was admitted to the facility, had received the COVID-19 vaccination in 2021, but there was no documentation indicating that they were offered, received, or declined the vaccine since admission. Similarly, Resident 201 had no documentation of being offered, receiving, or declining the COVID-19 vaccine since their admission. Resident 30 had received a COVID-19 booster shot in 2022, but again, there was no documentation of any offer, receipt, or declination of the vaccine since admission. Resident 9 had received a booster shot in 2021, but there was no documentation of an updated vaccine offer since their admission. During interviews, the Infection Preventionist (IP) stated that the facility offers updated COVID-19 vaccinations to residents every three to four months and that each resident's vaccination status, including refusals or declinations, should be documented in their electronic chart under Immunizations. The IP also mentioned that any education provided to residents regarding the COVID-19 vaccine should be documented. The Director of Nursing (DON) emphasized the importance of offering the COVID-19 vaccine to residents, noting that even if it does not prevent COVID-19, it can prevent severe effects of the disease, especially since residents are older and more susceptible. The facility's policy mandates offering and administering COVID-19 immunizations to eligible residents and documenting whether the resident received or did not receive the vaccine in the electronic health record.
Failure to Implement Care Plans for Dialysis and Substance Use Disorder
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 16, who was admitted with end-stage renal disease and dependent on dialysis, did not have a care plan for dialysis. Observations and interviews revealed that the dialysis dressing was not removed within the recommended timeframe, and the site was not assessed for bleeding or infection as required. The lack of a care plan meant that the necessary guidelines for post-dialysis care were not communicated to the staff, resulting in a lapse in care. Resident 151, admitted with a substance use disorder and nicotine dependence, also lacked an appropriate care plan. The existing care plan contained interventions unrelated to the resident's diagnosis, such as avoiding rearranging furniture, and lacked specific interventions for managing substance use disorder and nicotine dependence. The Director of Nursing acknowledged that the care plan for psychosocial well-being could have been more specific, indicating a failure to provide tailored care instructions for the resident's needs. The facility's policy on comprehensive person-centered care planning emphasizes the importance of developing care plans that include measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs. However, the absence of specific care plans for both residents highlights a failure to adhere to this policy, resulting in unmet care needs and a lack of communication among caregivers.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 200, who was admitted with diagnoses including cancer and acute appendicitis. The resident had physician's orders for Oxycodone HCl to be administered based on their pain level, with 5 mg for moderate pain and 10 mg for severe pain. However, the medication administration record showed that the resident received only 5 mg of Oxycodone on multiple occasions despite reporting severe pain levels ranging from 7 to 8 out of 10. Interviews with Licensed Nurse 1 revealed that the nurse administered the incorrect dosage of Oxycodone, acknowledging that the physician's order was not followed. The Director of Nursing confirmed that the resident was undermedicated for their pain level, which was contrary to the facility's policy on pain recognition and management. This failure had the potential to prevent the resident from receiving adequate pain relief.
Failure to Timely Remove Dialysis Dressing
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease who required dialysis treatment. The resident, who had intact cognition, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. The physician's orders specified that the dialysis dressing should be removed four to six hours after the treatment to assess the site for bleeding or signs of infection. However, on one occasion, the dressing was not removed until the following morning, which was contrary to the physician's orders and facility policy. This oversight was confirmed through interviews with the resident and several licensed nurses, including the nurse responsible for the oversight, who admitted to forgetting to remove the dressing and inaccurately documenting its removal in the Medication Administration Record (MAR). The Director of Nursing (DON) and other nursing staff acknowledged the importance of following the physician's orders to ensure the safety of residents. The facility's policy on dialysis care emphasized the need for timely assessment and documentation of the dialysis access site. Despite these guidelines, the failure to remove the dressing in a timely manner and assess the site as required posed a potential risk to the resident's dialysis access site. The incident highlighted a lapse in adherence to established protocols, which could have led to complications such as infection or damage to the dialysis access site.
Failure to Provide Behavioral Health Services for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a substance use disorder and nicotine dependency. Resident 151 was admitted with a history of psychoactive substance use and cigarette use, and was previously receiving a nicotine patch. However, the facility's medical documentation, including the history and physical written by the attending MD, did not reflect this history. Consequently, the resident did not receive any nicotine replacement therapy or support for substance use disorder, such as resources for Narcotics Anonymous, as confirmed by the Social Services Director (SSD). Interviews with the resident and facility staff revealed that no interventions were provided to address the resident's nicotine use or substance use disorder. The Director of Nursing (DON) acknowledged that the facility should have reviewed the hospital paperwork and conducted an admission smoking assessment to address the resident's needs. The facility's policy on Behavioral Health Services mandates providing necessary care to maintain residents' well-being, which was not adhered to in this case.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a medication was administered as ordered by the physician for one resident, identified as Resident 106. Resident 106, who was admitted with a diagnosis including knee replacement surgery, was observed with two white pain patches on her left knee. These patches were intended for pain management following her surgery. The resident reported that the patches were from the previous day and had not been replaced as scheduled. According to the physician's order, the Lidocaine External Patch 4% was to be applied once a day at 9 A.M. and removed at 9 P.M., in line with the manufacturer's instructions to use the patch for up to 12 hours within a 24-hour period. During an interview and observation, it was revealed that the patch was not removed as scheduled, remaining on the resident's knee approximately 12 hours longer than recommended. Licensed Nurse 12 confirmed that the patch should have been removed 12 hours after application due to potential cardiac effects. The Director of Nursing stated that the patches were to be applied and removed per the physician's orders and manufacturer's recommendations, emphasizing the importance of documenting the date and time of application. Licensed Nurse 11, who was responsible for removing the patch, admitted to forgetting to do so, which could affect the medication's efficacy. The facility's policy on medication administration and the six rights of medication administration were not adhered to, leading to this deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 7.14%. During the medication administration process, two errors were identified among 28 opportunities. One error involved a Licensed Nurse (LN) incorrectly mixing Effer-K, a potassium supplement, with five ounces of water instead of the instructed 2-3 ounces. This error was identified during an observation and interview with LN 13, who acknowledged the mistake and remade the medication. LN 13 emphasized the importance of following the manufacturer's instructions, as different brands might have varying requirements. Another error occurred when LN 13 administered medication to a resident, providing 11 capsules and tablets instead of the prescribed 12, as per the physician's order. This discrepancy was discovered during a record review and interview with LN 13, who recognized the importance of adhering to physician's orders to ensure residents receive necessary medications for their medical conditions. The Director of Nursing (DON) confirmed the facility's standard to follow package instructions and physician's orders, highlighting the potential impact on medication efficacy if not followed correctly.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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