Baldwin Gardens Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple City, California.
- Location
- 10786 Live Oak Avenue, Temple City, California 91780
- CMS Provider Number
- 555055
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Baldwin Gardens Nursing Center during CMS and state inspections, most recent first.
A resident with intellectual disabilities and muscle weakness was found with a skin discoloration under the eye, and the cause was undetermined due to the resident's inability to communicate. Despite facility policy requiring immediate reporting of such injuries, the incident was not reported to the appropriate authorities within the required timeframe. The DON and ADM acknowledged the oversight, recognizing the incident as an IUO that should have been reported to ensure resident safety.
A facility failed to maintain a functioning call light system in one of its bathrooms, as observed during a survey. A CNA and the Maintenance Worker confirmed that the call light button did not stay activated, preventing staff from being alerted if a resident needed assistance. The DON acknowledged the issue, and the facility's policy requires defective call lights to be reported promptly, which was not adhered to.
The facility failed to ensure call lights were within reach for four residents, including those with hemiplegia and paraplegia, leading to potential delays in care. Observations showed call lights were either hanging out of reach or on the floor, contrary to care plans and facility policy. Staff confirmed the need for call lights to be accessible for timely assistance.
The facility failed to provide Advance Directive information for two residents with severely impaired cognition, as required by their policy. Both residents lacked the necessary Advance Directive Acknowledgement Forms in their charts, which should have been initiated upon admission to ensure their treatment preferences were documented.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect reporting to CMS. A resident was discharged to an SNF but was coded as discharged to home/community, and another resident's MDS inaccurately indicated a PTSD diagnosis. These errors were confirmed by facility staff and attributed to previous mistakes.
The facility failed to implement safety measures for two residents, leading to potential accident hazards. One resident's siderails were not padded as ordered for seizure precautions, and another resident's bed was not lowered, with floor mats improperly positioned, despite a high fall risk. These oversights were contrary to physician orders and facility policies.
The facility failed to provide proper care for the gastrostomy tube sites of three residents, as per physician orders and care plans. One resident's GT stoma was found uncovered and red, another's GT tubing was left uncapped, and a third resident did not receive the ordered water infusion, risking dehydration. These deficiencies were acknowledged by the staff, including the DON.
The facility failed to attempt appropriate alternatives to siderails before their installation for two residents, placing them at risk for entrapment and injury. One resident, with intact cognition and requiring assistance with daily activities, had no documented evidence of alternatives being tried. Another resident, with severely impaired cognition and dependent on assistance, also had no alternatives attempted before siderail installation. The facility's policy requires attempts of least restrictive alternatives prior to siderail use.
A facility failed to follow up on a pharmacist's medication regimen review (MRR) recommendation for a resident prescribed Cyclobenzaprine, identified as inappropriate for the elderly. The Director of Nursing admitted the oversight, noting that the MRR should have been sent to the prescribing physician for evaluation, as per facility policy.
A facility failed to offer a pneumococcal vaccine to a resident with COPD and diabetes, as per CDC guidelines. The resident had received previous pneumococcal vaccines, but the Infection Prevention Nurse did not inform the resident or their responsible party about the overdue PCV20 vaccine. This oversight was against the facility's policy, which requires offering vaccines per CDC recommendations.
A resident with osteomyelitis and a left foot amputation had an IV site that was not labeled or dated, and the IV tubing port was not capped or covered, contrary to facility policy. This oversight was confirmed by interviews with nursing staff, who acknowledged the importance of these measures to prevent infection.
A resident dependent on supplemental oxygen had their nasal cannula (NC) tubing unlabeled, which was required for infection control purposes. The resident, who had no speech and was dependent on others for care, was observed receiving oxygen via NC without a date label. The facility's Infection Prevention Nurse confirmed the NC should be labeled and changed weekly, but without labeling, staff could not determine when it was applied or due for change.
A facility failed to maintain a resident's Foley catheter tubing free from kinks, as observed during an interview with a Treatment Nurse. The resident, who had a history of UTIs and chronic kidney disease, was found with kinked catheter tubing, which could lead to urine backflow and increased infection risk. The facility's policy required frequent checks to ensure tubing was clear, but this was not followed.
A resident with a history of pressure injuries had their Low Air Loss (LAL) mattress incorrectly set at 280 lbs instead of their actual weight of 162 lbs. This discrepancy was observed and confirmed by staff, who acknowledged the importance of setting the mattress according to the resident's weight to prevent pressure injuries. The facility's policy and the mattress manual both emphasize the need for weight-based adjustments.
The facility failed to include census information in daily shift staffing postings for three consecutive days, as required by policy. Interviews with the Lobby Receptionist and DON confirmed the omission, which could mislead residents and visitors and affect care quality.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO) involving a resident to the appropriate authorities, including the State Survey Agency (SSA) and adult protective services (APS), within the required timeframe of 24 hours. The facility's policy and procedure on abuse, neglect, exploitation, or misappropriation reporting and investigating mandates such incidents be reported promptly. This failure was identified for one of two sampled residents, who had a small skin discoloration under the right lower eye, and the cause of the injury could not be determined due to the resident's inability to communicate. The resident in question had been admitted with diagnoses including unspecified intellectual disabilities and generalized muscle weakness, and was assessed to have severely impaired cognition, requiring significant assistance with daily activities. On the day of the incident, the resident was noted to be agitated and attempting to hit staff, and later was found to have redness under the right eye. The Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) both observed the resident rubbing their eyes aggressively, but neither witnessed any fall or impact that could have caused the discoloration. The LVN reported the incident to the resident's sister and the DON, but the incident was not reported to external authorities as required. Interviews with the DON and ADM revealed that they recognized the incident as an IUO and acknowledged that it should have been reported to the department of public health, local law enforcement, and the ombudsman. The facility's policy, revised in November 2024, clearly states that all injuries of unknown source should be reported immediately, but this protocol was not followed in this case. The failure to report the IUO in a timely manner had the potential to allow similar incidents to occur without appropriate investigation and intervention, compromising resident safety.
Non-Functioning Call Light in Bathroom
Penalty
Summary
The facility failed to ensure that a functioning call light system was available in one of the three sampled bathrooms, specifically Bathroom Room 1. During an observation and interview with a Certified Nursing Assistant (CNA 1), it was noted that the call light button in BR 1 did not remain activated when pressed. CNA 1 acknowledged that the malfunctioning call light posed a risk, as staff would not be alerted if a resident required assistance in the bathroom. Further interviews with the Maintenance Worker and the Director of Nursing (DON) confirmed the issue, with both acknowledging that the call light button should remain activated when pressed. The facility's policy and procedure on answering call lights, revised in October 2010, requires staff to promptly report defective call lights to the nurse supervisor. However, this protocol was not effectively followed, leading to the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, which could lead to delayed care or lack of necessary assistance. Resident 12, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was assessed as high risk for falls. Despite the care plan indicating that the call light should be within easy reach, observations showed that the call light was hanging on the left side rail, out of reach. The Infection Prevention Nurse confirmed that the call light needed to be accessible for emergencies or assistance. Resident 23, diagnosed with paraplegia, also had a care plan that required the call light to be within easy reach. However, during an observation, the call light was found hanging on the left side rail, and the resident confirmed it was unreachable. The Infection Prevention Nurse reiterated the necessity for the call light to be accessible. Similarly, Resident 7, with intervertebral disc disorder and epilepsy, had a call light that was found on the floor, and the Licensed Vocational Nurse acknowledged it should be placed close to the resident. Resident 9, who had metabolic encephalopathy and hemiplegia, was also affected by this deficiency. The call light was found under the bed, tangled and inaccessible. The Licensed Vocational Nurse stated it should be within reach. The Director of Nursing confirmed that call lights should be placed next to the resident's strong arm to ensure timely assistance. The facility's policy indicated that call lights should be within easy reach and answered promptly, which was not adhered to in these cases.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding Advance Directives (AD) for two residents, which is a violation of their own Policy and Procedure (P&P) titled Advance Directives. Resident 11 was admitted with diagnoses including dependence on supplemental oxygen and gastrostomy status, and was noted to have severely impaired cognition for daily decision making. During a review of Resident 11's medical records, it was found that there was no Advance Directive Acknowledgement Form in the chart, which the Social Services Director (SSD) acknowledged should have been initiated upon admission. Similarly, Resident 25, who was admitted with essential hypertension and gastrostomy status, also had severely impaired cognition and required total dependence for daily activities. A review of Resident 25's chart revealed the absence of an Advance Directive Acknowledgement Form, which the SSD confirmed was necessary. The Director of Nursing (DON) also stated that the form needed to be in the resident's chart to identify the resident's preferences. The facility's P&P requires that residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive upon admission, which was not adhered to in these cases.
Inaccurate MDS Coding for Resident Discharges and Diagnoses
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to incorrect reporting to the Centers for Medicare and Medicaid Services (CMS). Resident 16 was discharged to a Skilled Nursing Facility (SNF) but was incorrectly coded in the Minimum Data Set (MDS) as being discharged to home or community. Additionally, Resident 16's MDS inaccurately indicated an active diagnosis of Post-Traumatic Stress Disorder (PTSD), despite the resident and the facility's Minimum Data Set Nurse (MDSN) confirming there was no such diagnosis. This error was attributed to a mistake by a previous MDSN. Similarly, Resident 55 was discharged to an SNF, but their MDS was incorrectly coded as discharged to home/community. The facility's Social Services Director and the MDSN both confirmed the error, acknowledging that the MDS should have accurately reflected the discharge to an SNF. These inaccuracies in the MDS assessments resulted in incorrect information being reported to CMS, potentially affecting the residents' care interventions.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. For Resident 7, the facility did not pad the bilateral 1/4 siderails as ordered by the physician, despite the resident's severe cognitive impairment and seizure disorder. Observations confirmed that the siderails were not padded, and interviews with the LVN and DON corroborated the need for padding to prevent harm during seizure activity. The facility's policy on bed safety emphasized the importance of additional safety measures for residents at higher risk of injury, which was not adhered to in this case. For Resident 53, the facility did not position the floor mat close enough to the bed, nor was the bed lowered to its lowest position, as required for fall risk management. Resident 53 had a high fall risk score and required substantial assistance for mobility. Observations showed the bed was in a high position, and the floor mat was two feet away from the bed's edge, which was confirmed by an LVN. The LVN acknowledged that the current setup would not prevent injury if the resident fell, as the mat was not positioned to cushion a fall effectively. The facility's policy on fall risk assessment highlighted the need to address environmental factors contributing to falls, which was not followed in this instance. These deficiencies in adhering to physician orders and facility policies for safety measures had the potential to result in accidents and hazards for the residents involved. The lack of proper implementation of safety interventions for both residents indicates a failure to provide adequate supervision and a safe environment, as required by the facility's own policies and procedures.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of three residents, as ordered by the physician and indicated in their care plans. Resident 1, who was admitted with a gastrostomy, hemiplegia, and hemiparesis, had a care plan that required the GT stoma to be cleansed with normal saline, patted dry, and covered with a T-drain sponge dressing daily. However, during an observation, the resident's GT stoma was found uncovered and the skin around it was red, indicating a failure to follow the physician's orders and care plan. Resident 36, who had diagnoses including dysphagia, gastrostomy, and dementia, was observed to have their GT tubing hanging with the end exposed and not capped. This was contrary to the facility's policy, which required the tubing to be capped when not in use to prevent contamination and infection. The Licensed Vocational Nurse (LVN) acknowledged that the tubing should have been capped, and the Director of Nursing (DON) confirmed the necessity of capping to prevent bacterial entry. Resident 26, with diagnoses including gastrostomy and diabetes mellitus, had a physician's order for continuous water infusion via GT at 40ml/hr for 20 hours. However, the LVN failed to start the water infusion as ordered, leaving the resident without the necessary hydration. The LVN admitted to not being aware of the order and acknowledged the importance of following it to prevent dehydration and maintain resident safety. The DON reiterated the need to adhere to physician orders to ensure adequate hydration and quality of care.
Failure to Attempt Alternatives Before Siderail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to siderails before their installation for two residents, placing them at risk for entrapment and injury. Resident 39, who was admitted with diagnoses including depression and a compression fracture, had intact cognition and required varying levels of assistance with daily activities. Despite this, there was no documented evidence that alternatives to siderails were attempted before their installation. The Registered Nurse Supervisor (RNS) acknowledged that other options, such as a trapeze, should have been considered to prevent the risk of entrapment and injury. Similarly, Resident 9, who was admitted with conditions such as metabolic encephalopathy and hemiplegia, had severely impaired cognition and was dependent on assistance for most activities. The resident had an order for bilateral 1/4 siderails for bed mobility, but the RNS confirmed that no alternatives were attempted before their installation. The resident's contracture of upper extremities rendered the siderails ineffective for turning and repositioning. The facility's Director of Nursing (DON) also stated that least restrictive alternatives should have been attempted prior to the installation of siderails, as per the facility's policy.
Failure to Address Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to follow up on the pharmacist's medication regimen review (MRR) recommendations for a resident prescribed Cyclobenzaprine, a muscle relaxant. The MRR identified Cyclobenzaprine as an inappropriate drug therapy for the elderly due to its anticholinergic and sedative side effects, which are poorly tolerated by the geriatric population. Despite this, there was no documentation in the resident's medical record indicating that the MRR recommendation had been addressed by the prescribing physician. The Director of Nursing (DON) acknowledged that the MRR for the resident's Cyclobenzaprine use should have been followed up by sending the recommendation to the prescribing physician for evaluation. The DON admitted that this step was missed and stated that the facility's policy requires the pharmacist's monthly MRR to be acted upon within 3 to 5 days, with follow-up calls to the physician if no response is received within 24 hours. The facility's policy emphasizes collaboration with the interdisciplinary team to minimize adverse consequences and potential risks associated with medications.
Failure to Administer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal vaccine to a resident, identified as Resident 10, in accordance with the Centers for Disease Control and Prevention (CDC)'s recommended schedule guidelines. Resident 10, who was admitted with chronic obstructive pulmonary disease (COPD) and diabetes mellitus, had previously received the PPSV23 pneumococcal vaccine in 2014 and the Prevnar13 pneumococcal vaccine in 2019. According to the CDC's guidelines, Resident 10 was eligible to receive the PCV20 pneumococcal vaccine more than five years after the last Prevnar13 dose, which was due in February 2024. The Infection Prevention Nurse (IPN) acknowledged during an interview that they had missed informing Resident 10 or their responsible party about the overdue pneumococcal vaccine. This oversight was contrary to the facility's policy and procedure, which mandates offering pneumococcal vaccines to all residents unless contraindicated, unknown, or refused, following CDC recommendations. The failure to update Resident 10's vaccination status left the resident at risk of pneumococcal disease, which could lead to pneumonia and potential hospitalization.
Failure to Label and Cap IV Site
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous (IV) fluids for a resident, identified as Resident 157. The resident was admitted with osteomyelitis and a left foot amputation and had an order for Ceftriaxone IV to treat the infection. During an observation, it was noted that the IV site on the resident's right forearm was not labeled or dated, and the IV tubing port was neither capped nor covered. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Director of Nursing, who both acknowledged the importance of labeling and dating the IV site and covering the IV tubing port to prevent infection. The facility's policies and procedures, which were reviewed, indicated that the dressing on the IV site should include the date, time, and initials of the nurse who started the IV, as well as details about the catheter. Additionally, the policy stated that the IV tubing should have a sterile end cap when disconnected. The failure to follow these procedures had the potential to result in an infection for Resident 157, as the necessary precautions to maintain sterility and track the IV site usage were not implemented.
Failure to Label Nasal Cannula Tubing for Resident
Penalty
Summary
The facility staff failed to label the nasal cannula (NC) tubing for a resident, identified as Resident 41, who was dependent on supplemental oxygen. Resident 41 was readmitted to the facility with diagnoses including dependence on supplemental oxygen and dysphagia. The Minimum Data Set (MDS) indicated that Resident 41 had no speech, rarely/never understood others, and was dependent on others for personal hygiene and transfers. The Order Summary Report (OSR) specified that Resident 41 was ordered oxygen at two liters per minute via NC continuously for shortness of breath. During an observation, it was noted that Resident 41 was receiving oxygen via NC, but the tubing was not labeled with the date of application. The facility's Infection Prevention Nurse (IPN) confirmed that the NC should be labeled with the date it was applied and changed weekly for infection control purposes. Without labeling, staff would not know when the NC was applied or when it was due to be changed, potentially leading to infection.
Failure to Maintain Foley Catheter Tubing
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a Foley catheter, as per the facility's Policy and Procedure on catheter care. The deficiency was identified during an observation and interview with the Treatment Nurse, where it was noted that the resident's Foley catheter tubing was kinked at the connection point. This kink in the tubing could potentially lead to backflow of urine and increase the risk of urinary tract infections (UTIs). The Treatment Nurse acknowledged that the tubing should be straight and free from kinks to prevent such complications. The resident involved had a history of urinary tract infection and chronic kidney disease and was dependent on staff for personal hygiene and toileting. The facility's Director of Nursing confirmed that the catheter tubing should be clear and straight to allow urine to flow freely and prevent backup. The facility's policy, revised in September 2014, also indicated that residents should be checked frequently to ensure the catheter and tubing are free of kinks. Despite these guidelines, the facility did not adhere to its own procedures, leading to the identified deficiency.
Improper Setup of LAL Mattress for Resident
Penalty
Summary
The facility failed to ensure that a Low Air Loss (LAL) mattress was set up accurately based on a resident's weight, which is crucial for the prevention, treatment, and management of pressure injuries. The resident, who was admitted with chronic obstructive pulmonary disease and diabetes mellitus, had a history of pressure injuries and was dependent on assistance for toileting hygiene and transfers. Despite the resident's actual weight being 162 lbs, the LAL mattress was set at 280 lbs, as observed during two separate instances. This discrepancy was confirmed by a Licensed Vocational Nurse, who acknowledged that the mattress should be set according to the resident's weight to prevent pressure injuries. The Treatment Nurse also confirmed that the LAL mattress should be adjusted per the manufacturer's recommendations to provide proper relief of pressure points. The facility's policy indicated that individuals at risk for pressure ulcers should be placed on appropriate support surfaces. However, the failure to adjust the mattress according to the resident's weight posed a potential risk for the development of pressure injuries. The Proactive Operation Manual for the LAL mattress also supported the need for weight-based adjustments to ensure effective pressure relief.
Failure to Include Census Information in Daily Staffing Postings
Penalty
Summary
The facility failed to include the census information on the daily shift staffing postings for three consecutive recertification days. This omission was identified during a review of the facility's daily shift staffing postings dated 11/19/2024, 11/20/2024, and 11/21/2024. The postings included the name of the facility, the date, type and category of nursing staff, and the projected and actual hours worked, but lacked the resident census at the beginning of each shift. This information is crucial to ensure that there is adequate staffing to meet the needs of the residents. Interviews with the Lobby Receptionist and the Director of Nursing confirmed that the daily shift staffing postings should include the census information. The facility's policy and procedure, revised in July 2016, also indicated that the resident census should be recorded on the Nursing Staff Directly Responsible for Residents Care form for each shift. The failure to include this information could mislead residents and visitors and potentially affect the quality of nursing care provided.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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