Atherton Baptist Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 214 South Atlantic Blvd., Alhambra, California 91801
- CMS Provider Number
- 555272
- Inspections on file
- 28
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Atherton Baptist Home during CMS and state inspections, most recent first.
Two residents with significant pain management needs received PRN orders for Tramadol and Tylenol without pain scale parameters, resulting in a lack of guidance for nursing staff on when to administer each medication. Interviews with LPNs and the DON confirmed that the absence of pain scale parameters could lead to inappropriate administration, contrary to facility policy requiring such specifications for PRN medications.
The facility failed to prevent accidents for three residents by not ensuring functional bed sensor pads and accessible call lights, and by not addressing underlying causes of falls. A resident with severe cognitive impairment did not have a working bed sensor pad or reachable call light. Another resident with a history of falls lacked specific interventions in their care plan to prevent reoccurrence. A third resident's sensor pad alarm was not properly positioned or turned on, failing to alert staff when the resident attempted to stand.
The facility failed to label and store food items properly in accordance with its policy, as observed in the kitchen's walk-in refrigerator, freezer, and dry storage area. Items such as marinated fish, Jello, banana bread, frozen meat, snap peas, waffles, cream puffs, and biscuit mix were found without necessary labels or coverings, posing a risk of contamination. The dietary supervisor and director confirmed the labeling and covering requirements.
A resident with spinal stenosis and osteoporosis was not provided reasonable accommodation during meals, leading to discomfort and exhaustion. The resident was observed eating with her plate on her lap due to the dining table being too high, causing her to hunch and experience pain. Attempts to adjust her seating were ineffective, and the facility's policy on accommodating individual needs was not followed.
A resident experienced a significant weight loss of 23 pounds over three days, which was not reported to the physician until four days later, contrary to the facility's policy. The resident, with conditions including hyperlipidemia and dementia, had a care plan to maintain a weight of 184 pounds, but their weight dropped to 161 pounds. Interviews with staff revealed that the facility's protocol required notifying the physician of such weight loss within a shift, which was not followed, potentially delaying necessary care.
A resident's EHR was left exposed on an unattended computer screen in a hallway, violating HIPAA and facility policy. An LVN admitted the error, and another LVN emphasized the importance of protecting resident information.
A facility failed to provide Restorative Nursing Services as ordered for a resident with chronic conditions, who required AROM exercises five times a week. The services were only provided three times a week, with no documentation of refusals, despite the resident's need to maintain functional status and prevent contractures. The deficiency was confirmed by the Care Plan Coordinator and the Director of Occupational Therapy.
A facility failed to ensure a physician addressed a pharmacist's recommendation for a gradual dose reduction of Ativan for a resident with anxiety. Despite the recommendation, the physician assistant only changed the administration time and reduced the dose of another medication, mirtazapine, without decreasing the Ativan dose. The medical doctor did not document a reason for not accepting the recommendation, contrary to facility policy, potentially leading to adverse medication outcomes.
A facility failed to assess the continued need for Tylenol for a resident who had not received the medication as needed for over 90 days. The resident, with impaired cognitive skills and no reported pain, was still prescribed Tylenol every four hours as needed. The DON confirmed the medication was unnecessary, as the resident's pain was managed with a regular dose. The facility did not follow its policy to periodically re-evaluate medications.
A facility failed to label a medication bottle with the date it was opened, as required by policy, during administration to a resident with Parkinson's disease. The resident required significant assistance with daily activities and had moderately impaired cognitive skills. LVNs confirmed the importance of labeling for tracking and proper administration, aligning with the facility's policy to record the opening date on multi-dose containers.
A resident with a history of weight loss was not provided with food that matched her preferences, as observed during a survey. Despite having a care plan that required offering alternative meals, the resident's tray lacked items listed on her tray card. The CNA admitted to not checking the tray card, and the DON emphasized the importance of following food preferences to maintain dignity and encourage eating. Facility policies on accommodating dietary needs were not adhered to, resulting in the deficiency.
Failure to Specify Pain Scale Parameters in PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure proper pain management for two residents by not including pain scale parameters in their PRN pain medication orders. One resident, who had recently returned from a general acute care hospital following a right hip hemiarthroplasty, had physician orders for Tramadol and Tylenol, both as routine and PRN, but the PRN Tramadol order did not specify the pain scale (mild, moderate, or severe) for administration. Interviews with nursing staff and the Director of Nursing confirmed that the absence of pain scale parameters could lead to inappropriate administration of pain medication, as the medication could be given for any reported pain level, potentially resulting in overmedication or undermedication. Another resident with diagnoses including dementia, muscle weakness, and chronic right hip pain also had PRN orders for Tylenol Extra Strength and Tramadol without pain scale parameters. The care plan for this resident included interventions for pain management, but the medication orders did not specify which pain levels warranted the use of each medication. The Director of Nursing acknowledged during interviews that both PRN pain medications for this resident should have included pain scale parameters to guide nursing staff in appropriate administration. A review of facility policies indicated that PRN medication orders should specify the type, route, dosage, frequency, strength, and reason for administration, and that pain management should involve identifying and using specific strategies for different levels and sources of pain. Despite these policies, the orders for both residents lacked the necessary pain scale parameters, leading to a deficiency in the facility's pain management practices.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to provide adequate interventions to prevent accidents for three residents, leading to deficiencies in their care. Resident 61, who had severe cognitive impairment and required assistance with daily activities, was not provided with a functional bed sensor pad as ordered by the physician. Additionally, the resident's call light was not within reach, contrary to the fall care plan. Observations revealed that the pad alarm did not sound when the resident attempted to get out of bed, and the call light was placed on the opposite side of the bed, out of reach. Resident 24, with a history of falls and moderately impaired cognitive skills, experienced multiple falls within the facility. Despite the use of a sensor pad alarm, the care plan did not include specific interventions to address the underlying causes of the falls. The resident's care plan lacked detailed safety measures related to wheelchair safety and the risk of sliding from a recliner, which were identified as contributing factors to the falls. Interviews with staff indicated that the care plan should have been revised to include resident-centered interventions to prevent fall reoccurrence. Resident 29, who had severely impaired cognitive skills and a history of falls, was observed with a sensor pad alarm that was not properly positioned or turned on. The resident attempted to stand up from a chair without the alarm sounding, indicating that the sensor pad was not functioning as intended. Staff interviews confirmed that the sensor pad alarm was crucial for notifying staff when the resident needed assistance, and it was the responsibility of CNAs and charge nurses to ensure the alarm was operational. The facility's policy emphasized the importance of implementing resident-centered fall prevention plans and monitoring the efficacy of alarms.
Deficient Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and storage of food items in the kitchen, as observed during a survey. In the walk-in refrigerator, four trays of marinated fish fillet, three trays of prepared Jello, and one loaf of banana bread were found without labels indicating the name of the food item, preparation date and time, and use-by date. Additionally, the Jello trays were not covered with lids, and the banana bread was not wrapped or covered, which is against the facility's policy. The dietary supervisor confirmed that all food trays should be labeled and covered to prevent contamination. Further observations in the walk-in freezer revealed three bags of frozen meat, two packages of snap peas, two packages of breakfast waffles, and one bag of cream puffs without proper labeling, including the food item name, purchase date, expiration date, or use-by date. In the dry food storage area, a bag of buttermilk biscuit mix was also found without a use-by date. The dietary service director and dietary supervisor acknowledged that all food items should be labeled with the food item name and use-by date, as per the facility's policy. The facility's policy, revised in January 2024, mandates that all food and supplies be stored to prevent contamination and maintain safety for consumption, including covering, labeling, and dating unused portions and open packages.
Failure to Accommodate Resident's Dining Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident 9, during meal times. Resident 9, who has diagnoses of spinal stenosis, osteoporosis, and reduced mobility, was observed eating in a hunched position with her plate on her lap because the dining table was too high for her. Despite attempts to adjust her seating with a cushion, this solution was not effective as it caused her feet to hang, which she found uncomfortable. The resident expressed that eating at the table was painful and exhausting, as she had to tilt her head back to reach her food, leading to discomfort and fatigue. Interviews with the Restorative Nursing Aide and the Director of Nursing confirmed that the resident's dining setup was inappropriate, with the table positioned at her eye level rather than at a comfortable height above the waist. The facility's policy on accommodating residents' needs, which includes evaluating and modifying the physical environment, was not adhered to in this case. This oversight resulted in the resident experiencing discomfort and exhaustion during meals, highlighting a failure to provide reasonable accommodation for her specific needs.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its policy regarding notifying a physician of a significant change in a resident's condition, specifically concerning a substantial weight loss. Resident 31, who was admitted with diagnoses including hyperlipidemia, dementia, and a left artificial hip joint, experienced a significant weight loss of 23 pounds over three days, which was not reported to the physician until four days later. The care plan for Resident 31 indicated a weight goal of maintaining 184 pounds plus or minus six pounds, but the resident's weight dropped to 161 pounds, representing a 12.5% weight loss, which was not promptly communicated to the physician as required by the facility's policy. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the facility's protocol required notifying the physician of a weight loss of more than five pounds within a shift or endorsing it to the next shift. However, this protocol was not followed, as the physician was not informed immediately upon noticing the weight loss. The facility's policy, revised in February 2021, mandates that significant changes in a resident's condition be reported to the attending physician within 24 hours, which was not adhered to in this case, potentially delaying necessary care and services for Resident 31.
Failure to Maintain Resident EHR Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's electronic health record (EHR) by leaving a computer screen unattended and visible to unauthorized individuals. This incident involved a resident who was admitted with conditions including Parkinson's disease, benign prostatic hyperplasia, and insomnia. The resident was assessed to have moderately impaired cognitive skills and required substantial assistance with daily activities. During an observation, a Licensed Vocational Nurse (LVN) left the computer monitor on top of a medication cart turned on and unattended in a hallway, exposing the resident's sensitive medical information to passersby. The LVN acknowledged the oversight, recognizing the importance of closing the chart monitor to protect the resident's privacy in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Another LVN confirmed that it is the responsibility of licensed nurses to ensure that EHRs are not exposed to unauthorized individuals. The facility's policy on confidentiality and personal privacy, revised in 2017, mandates the protection of resident information, limiting access to authorized personnel only.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, identified as Resident 2, to maintain or improve their range of motion (ROM). The physician had ordered active range of motion (AROM) exercises for both upper and lower extremities to be performed five times a week. However, the facility only provided these services three times a week, which was not in compliance with the physician's orders. There were no documented notes indicating that Resident 2 refused the services for the missing two sessions per week. Resident 2 had a medical history of chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The resident required substantial assistance with daily activities and had intact cognitive skills for decision-making. The care plan for Resident 2 included RNA services for AROM to be performed five times a week, but the facility's records showed that this was not consistently done. The Care Plan Coordinator confirmed that the services were not provided as ordered, and there was no documentation of refusals by the resident. Interviews with the Restorative Nursing Aide and the Director of Occupational Therapy revealed that the RNA services were crucial for maintaining Resident 2's functional status and preventing contractures, especially since the resident spent most of their time in bed. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, but this was not adhered to in Resident 2's case. The lack of adherence to the physician's orders and the facility's policy led to the deficiency noted in the report.
Failure to Address Pharmacist's Recommendation for Medication Dose Reduction
Penalty
Summary
The facility failed to ensure that the physician addressed the medication regimen review (MRR) for a resident, specifically regarding the pharmacist's recommendation for a gradual dose reduction (GDR) of Ativan. The resident, who was admitted with diagnoses including major depressive disorder, unspecified pain, and anxiety disorder, was receiving Ativan for anxiety manifested by restlessness. Despite the pharmacist's recommendation to reduce the Ativan dose, the physician assistant altered the administration time and reduced the dose of another medication, mirtazapine, but did not decrease the Ativan dose as suggested. The medical doctor did not provide a documented explanation for not accepting the pharmacist's recommendation. The resident's care plan indicated a potential for drug-related complications due to the use of psychotropic medications, and the facility's policy required that recommendations be acted upon or rejected with an explanation. However, the physician did not document a reason for disagreeing with the pharmacist's recommendation. The Director of Nursing confirmed that the physician was informed of the recommendation but did not know why the physician did not provide an explanation for not reducing the Ativan dose. This oversight had the potential to result in adverse medication outcomes for the resident.
Failure to Assess Continued Need for PRN Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not assess the continued need for Tylenol (acetaminophen) for a resident who had not received the medication as needed for pain for over 90 days. The resident, who was admitted with diagnoses including major depressive disorder, unspecified pain, and anxiety disorder, was assessed to have severely impaired cognitive skills for daily decision-making. Despite having an order for Tylenol Extra Strength 500 mg to be taken every four hours as needed for pain, the resident did not receive this medication from August to November 2024, as their pain level was consistently assessed at 0. During a review of the resident's medication records and an interview with the Director of Nursing (DON), it was confirmed that the resident's pain was managed by a regular dose of Tylenol taken twice daily, and the as-needed order was deemed unnecessary. The facility's policy required periodic re-evaluation of medications to ensure their relevance and to avoid undesired complications. However, the facility did not adhere to this policy, resulting in the potential for the resident to suffer adverse reactions from unnecessary medication.
Failure to Label Medication Bottles with Opening Date
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not properly labeling medications with the date they were opened, as required by the facility's policy. This deficiency was observed during a medication administration for a resident diagnosed with Parkinson's disease, benign prostatic hyperplasia, and insomnia. The resident was assessed to have moderately impaired cognitive skills and required substantial assistance with daily activities. During the observation, it was noted that the medication bottle of carbidopa-levodopa, prescribed for the resident's Parkinson's disease, did not have the date it was opened labeled on it. Interviews with Licensed Vocational Nurses (LVNs) revealed that the facility's practice was to label medication containers with the date they were opened to ensure proper tracking and administration of medications. LVN 1 acknowledged the oversight and emphasized the importance of labeling to account for the medication's usage. LVN 2 further explained the procedure for counting and logging medications, especially those from outside pharmacies, and reiterated the necessity of labeling to prevent medication errors. The facility's policy, revised in 2019, mandates that the expiration or beyond-use date be checked before administering medications and that the date of opening be recorded on multi-dose containers.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences of a resident, identified as Resident 40, which was observed during a survey. Resident 40 was admitted with diagnoses including atrial fibrillation, heart failure, and hypertension. Despite being assessed with intact memory and cognitive skills for daily decision-making, the resident required assistance with eating and had a history of weight loss. The care plan indicated the need to offer alternative meals if the resident did not like what was being served, but this was not adhered to. On a specific day, Resident 40 was observed in the dining room with a food tray that did not include all the items listed on her tray card, such as white rice, soy milk, and Jello. The Certified Nursing Assistant (CNA) responsible for serving the meal admitted to not checking the tray card and acknowledged the importance of providing the resident with her preferred food due to her history of weight loss. The Director of Nursing emphasized the importance of following residents' food preferences to maintain their dignity and encourage meal intake. The facility's policies and procedures were reviewed, indicating that residents on modified diets should be offered similar choices as the main meal and that food substitutions should be of equal nutritional value. The policies also highlighted the importance of accommodating individual resident preferences unless it posed a health risk. However, these policies were not followed in the case of Resident 40, leading to the deficiency noted in the survey.
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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