Bixby Towers Post-acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3747 Atlantic Avenue, Long Beach, California 90807
- CMS Provider Number
- 056283
- Inspections on file
- 40
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Bixby Towers Post-acute Rehab during CMS and state inspections, most recent first.
A resident with complex medical needs, including use of a life vest and requiring maximal assistance, eloped from the facility without staff awareness after exiting through an unsecured dining room door. Staff interviews revealed lapses in supervision, unclear monitoring responsibilities for certain facility areas, and failure to implement additional interventions despite observed risk behaviors. The resident was missing for several hours before being found by family.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Surveyors observed an uncovered bowl of dry cereal stored past its use-by date and multiple expired, unlabeled canned food items in the emergency food supply. The Dietary Manager and DON confirmed that these practices did not follow facility policy and could result in expired food being served to residents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not maintain or document preventive maintenance for three pieces of electrical rehabilitation therapy equipment, including an ultrasound unit, TENS combination unit, adjustable therapy mat, and a bicycle. Staff interviews revealed no process or records for routine checks, and policy reviews showed that required maintenance schedules and documentation were not followed.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
A resident's Foley catheter drainage bag was found uncovered, contrary to facility policy requiring dignity bags to protect privacy and dignity. Staff interviews confirmed awareness of the policy and responsibility for compliance, but the omission was not noticed or corrected at the time.
A resident with severe cognitive impairment and significant care needs reported to the ADON that a CNA was rough with her during personal care. The resident's family also informed staff and provided a photo of the CNA. Despite these reports, the ADON did not notify required authorities, as she did not consider the incident abuse because the resident said she was fine. Other staff confirmed that such actions should be reported as abuse, but the facility failed to follow its abuse reporting policy.
A resident with severe cognitive impairment and high ADL needs was allegedly handled roughly by a CNA during incontinence care, as reported by the resident's family member to facility staff. Despite the report and facility policy requiring investigation of all abuse allegations, the ADON did not initiate an investigation, and the incident was not reported or documented as required. Staff interviews confirmed that such actions should be considered and treated as abuse.
The facility did not properly complete or document PASARR screenings for two residents with mental health conditions, resulting in missed or incorrect assessments following admission and readmission. Staff interviews confirmed that required screenings were either not done or documented inaccurately, contrary to facility policy.
A resident with severe cognitive impairment and arthritis reported physical abuse by a CNA during personal care. Despite this, staff did not develop or implement a care plan addressing the abuse allegation, as confirmed by record review and staff interviews. This failure resulted in the omission of necessary care and services.
A resident who was fully dependent on staff for ADLs and had chronic urinary incontinence was left in a wet adult brief for about an hour, resulting in distress. Staff acknowledged the need for a change but did not provide care at the time, citing the need for assistance. Facility policy and the resident's care plan required prompt incontinence care, but this was not followed.
A resident with multiple health conditions and a care plan indicating risk for dehydration did not have their water pitcher within reach, as required by physician orders and facility policy. The resident reported being unable to access water and feeling thirsty, and staff confirmed the water pitcher should have been accessible to prevent dehydration.
A resident with significant mobility limitations and a physician's order for PT and OT evaluation and treatment did not receive a PT evaluation as required. The order was not communicated to therapy staff, and the evaluation was not completed within the facility's required timeframe, resulting in a delay in necessary rehabilitative services.
The facility did not fully resolve previously identified deficiencies in resident rights, quality of care, food safety, and infection control. Despite regular QAPI meetings and involvement of leadership, ongoing issues were attributed to inconsistent staff education, lack of monitoring, and insufficient follow-through on corrective action plans.
The facility did not ensure that staff and family members wore required PPE while providing care or visiting two residents under enhanced barrier precautions due to indwelling medical devices. Observations showed that family members assisted a resident with a urinary catheter without PPE, and a CNA provided direct care to another resident with a G-tube without an isolation gown, contrary to facility policy and infection control protocols.
A resident with severe cognitive impairment and multiple medical conditions had a cell phone that was not documented on the belongings list and subsequently went missing. Staff interviews and policy review confirmed that all personal property should be inventoried and tracked, but this was not done, resulting in the loss of the resident's cell phone.
A resident with severe cognitive impairment and multiple care needs did not have their family’s request accommodated to ensure feeding and adult brief checks before Ativan administration. Documentation and staff interviews confirmed the absence of evidence that these steps were taken prior to giving the medication, despite facility policy requiring accommodation of individual needs and preferences.
A resident with severe cognitive impairment and incontinence was not provided toileting hygiene at least every two hours as required by their care plan. Documentation and staff interviews confirmed the resident was left in a soiled adult brief for extended periods, with feces and urine present, contrary to facility policy and care plan interventions.
A resident with severe cognitive impairment and dysphagia, who required substantial assistance, did not receive the physician-ordered oral gratification diet with pureed foods and thickened fluids for several days. Facility documentation and the DON confirmed that the resident was not assisted with meals as required, contrary to facility policy.
Three staff members, including a receptionist, a CNA, and a maintenance worker, were found not wearing required identification badges while on duty. The receptionist was awaiting her badge, the CNA forgot to wear hers, and the maintenance worker was not wearing his during rounds. This failure to follow facility policy did not support resident rights to know who was providing care and to be treated with respect.
A resident with metabolic encephalopathy and muscle weakness, who required partial assistance with daily activities, was found to have their call light out of reach during an observation. Both an LVN and the ADON confirmed that call lights should always be accessible, and facility policy requires staff to ensure this before leaving the room.
A resident with severe cognitive impairment and a history of falls did not have an extended floor mattress placed as required by their care plan, due to concerns about a roommate tripping. Staff found the resident on the floor after an unwitnessed fall, and the DON confirmed the intervention should have been implemented or alternatives considered.
Nursing staff transferred a resident with cognitive impairment and legal blindness into a Tilt-in-space wheelchair without prior training on its use. After being positioned upright, the resident began to slide down the chair. Both the CNA and LVN involved confirmed they had not received training on the equipment before the incident, contrary to facility policy requiring instruction for unfamiliar wheelchair models.
A resident with cognitive impairment and legal blindness was seen by ophthalmology and ENT specialists without the knowledge or authorization of their DPOA, despite clear documentation and staff awareness that the DPOA was to be notified and involved in all medical decisions beyond primary care, podiatry, and dental services. This failure resulted in a violation of the resident's rights.
A resident with cognitive impairment and legal blindness used a personal Tilt-in-space wheelchair, but facility staff did not obtain or follow the manufacturer's maintenance guidelines for the equipment. Both the DOR and Maintenance Supervisor confirmed the absence of the user manual, and maintenance was performed without reference to manufacturer instructions, contrary to facility policy.
The facility failed to report an Influenza A outbreak to CDPH immediately, involving two residents who tested positive. Despite positive test results, the outbreak was reported three days late, acknowledged by the IP Nurse as an oversight. This delay hindered CDPH's ability to investigate promptly.
A resident was denied readmission to a facility after being cleared by a GACH psychiatrist following a transfer for psychiatric evaluation due to inappropriate sexual behaviors. Despite having a bed hold policy, the facility cited safety concerns for other residents and refused readmission, lacking resources for a 1:1 sitter. The facility's policies on bed-hold and transfer documentation were not followed.
A resident with schizophrenia and cognitive impairments was left unsupervised with another resident, leading to two incidents of sexual abuse. Despite witnessing the first incident, staff failed to separate the residents, allowing a second assault to occur. The facility did not follow its policy on abuse reporting and investigation, resulting in a serious deficiency.
A facility failed to evaluate and treat a resident with schizophrenia and aggressive behaviors, leading to the resident assaulting another vulnerable resident twice. The resident was not assessed by a psychiatrist or prescribed necessary medications upon admission, resulting in unchecked aggressive behaviors. Staff failed to maintain supervision after the first incident, allowing a second assault to occur.
The facility failed to provide abuse training to two LVNs before they began direct patient care, as required by policy. The DSD could not find records of such training, which is mandatory upon hire and conducted twice a year. The Administrator confirmed the necessity of this training to prevent potential abuse risks.
The facility's QAA and QAPI committee failed to ensure the Medical Director attended monthly meetings, as revealed through interviews and record reviews. The DON admitted the MD's absence in July 2024 and did not relay meeting minutes to the MD. The Administrator stressed the MD's role in addressing medical concerns and implementing corrective actions, but the facility did not adjust the meeting schedule to fit the MD's availability.
Two LVNs at the facility were found to have provided direct patient care without receiving mandatory abuse training. The Director of Staff Development could not locate training records for these staff members, which is a requirement before they engage in resident care. The Administrator confirmed that abuse training is provided upon hire and biannually, and emphasized the necessity of this training to prevent potential abuse risks. The facility's policy requires regular in-service education, including abuse prevention, before staff provide services.
The facility failed to maintain a tracking system for staff participation and competency in its online learning program, risking resident safety. The DSD admitted to not keeping data on staff progress and not knowing how to retrieve lesson plans from the software. The Administrator confirmed the DSD's responsibility for maintaining the education program and expressed concern about the lack of tracking, which could lead to untrained staff providing inadequate care.
A facility failed to ensure a PCP signed admission orders for a resident with multiple diagnoses, including cerebrovascular disease and diabetes. Although the physician visited within the required 72 hours, they did not sign the necessary orders, as confirmed by the MRD and DON. The facility's policy mandates signed and dated physician orders to ensure appropriate care.
A resident who underwent left leg surgery did not receive a timely follow-up appointment with an orthopedic surgeon, resulting in the discontinuation of necessary physical therapy services. Despite the resident's admission with conditions requiring therapy, the facility staff failed to communicate the need for a follow-up consult, leading to a delay in treatment and potential decline in the resident's condition.
A resident with a history of BPH was not properly monitored for urinary retention, leading to a lack of urine output documentation for over 24 hours. CNAs did not report dry diapers to licensed nurses, and necessary assessments were not conducted. The resident was later transferred to a hospital with a UTI, severe sepsis, and significant urine retention.
A resident was prescribed and administered Seroquel without appropriate documentation of behaviors or non-pharmacologic interventions. The facility failed to conduct comprehensive evaluations to justify the medication's use, and the resident's psychiatrist made a preliminary diagnosis of schizophrenia to facilitate admission. The facility's policy on antipsychotic medication use was not followed.
Two residents were not treated with dignity in a LTC facility. A resident's bedside commode was not promptly cleaned, leading to feelings of sadness. Another resident, dependent on staff for eating, was fed by a CNA standing over them, contrary to facility policy. The DON confirmed these practices compromised resident dignity.
The facility failed to document advance directives and POLST for four residents, violating their rights to be informed about end-of-life care options. Despite having severe cognitive impairments and multiple diagnoses, these residents and their responsible parties were not provided with necessary discussions or documentation, as required by facility policy.
The facility did not provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents after their Medicare Part A coverage ended, as revealed during an interview and record review with the DON. The residents continued to stay at the facility without being informed of their financial liability and appeal rights.
The facility failed to maintain accurate medication counts and proper storage, leading to discrepancies in controlled medication for a resident, improper storage temperatures for two residents' medications, and expired medications in a cart affecting multiple residents. An LVN confirmed these issues, which were against the facility's medication storage policy.
The facility failed to ensure safe food storage practices, with unlabeled food in the refrigerator and staff personal items stored near food in the dry storage room. This could lead to cross-contamination and foodborne illnesses.
A resident with quadriplegia and spastic hemiplegia was not provided with a touch pad call light, leading to frustration and delayed care. Despite facility policies requiring functional call devices and accommodation of individual needs, the resident's inability to use the standard call light due to hand stiffness was not addressed, as confirmed by staff interviews and observations.
A resident on Xarelto, a blood thinner, had multiple skin discolorations that were not assessed or documented by facility staff, despite being at high risk for bleeding. The care plan required monitoring for bruising, but staff failed to follow the facility's policy for documenting and reviewing skin issues, leading to a deficiency.
A resident with hearing difficulties was not referred to an audiologist as required by her care plan, despite being identified as hard of hearing. Staff interviews confirmed the oversight, and the facility's policy emphasized the need for effective communication and necessary services for hearing-impaired residents.
A resident with a high risk for falls was not enrolled in the Falling Star Program, contrary to the facility's policy. Despite having a history of falls and a high fall risk score, the resident lacked necessary fall prevention measures such as identifying symbols and landing pads. Interviews with staff confirmed the oversight, highlighting a failure to adhere to the facility's fall prevention procedures.
A resident with loose dentures experienced difficulty eating, leading to weight loss, as the facility failed to provide timely dental services. Despite staff awareness of the issue, necessary referrals were not made according to the facility's policy, resulting in a deficiency in care.
Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident with significant medical needs, including ventricular tachycardia, hypotension, depression, and the use of a life vest for cardiac risk, eloped from the facility without staff knowledge or supervision. The resident required substantial to maximal assistance with activities of daily living and was known to need continuous monitoring due to his medical condition and the use of a life vest. Despite these needs, the resident was able to exit the facility through the dining room exit doors in a wheelchair, as confirmed by video surveillance footage. Staff interviews revealed that the resident was last seen by a CNA during routine rounds and was later observed attempting to get out of bed and pull out his G-tube. This behavior was reported to nursing staff, but no further interventions were implemented. The CNA and LVN both stated that residents were not permitted to go downstairs unsupervised, and there was no nursing personnel assigned to the first floor to monitor residents in that area. The lack of supervision and unclear responsibility for monitoring residents on the first floor contributed to the resident's ability to leave the facility undetected. The facility's maintenance supervisor confirmed that while the dining room exit doors could be locked from the outside, they could be freely opened from the inside, allowing residents and visitors to exit at any time. The Director of Nursing acknowledged that the resident was unsupervised and away from the facility for approximately five hours. The facility's policy emphasized the importance of resident safety and supervision, but these measures were not effectively implemented, resulting in the resident's elopement.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the particular medical history or condition of the resident at the time of the deficiency.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Improper Storage and Use of Expired Food Items
Penalty
Summary
The facility failed to properly store and manage food items in accordance with professional standards and its own policies. During an observation in the dry food storage room, an uncovered bowl of dry cereal was found on a tray labeled with dates that had already passed. The Dietary Manager (DM) discarded the cereal upon discovery, acknowledging it was past its use-by date. Additionally, in the facility basement, six cans of corned beef hash with expired dates and a box of canned pulled chicken with an expired date were found. These items were part of the emergency food supply and were not labeled, which the DM stated was necessary to prevent them from being circulated for resident consumption. Interviews with the DM and the Director of Nursing (DON) confirmed that expired and improperly stored food items could be present in the facility's food supply. The DM admitted that expired food in the emergency supply was being discarded slowly and recognized the risk of foodborne illness from consuming such items. The DON also acknowledged the potential for residents to experience symptoms such as stomach pain, diarrhea, nausea, vomiting, and even botulism from expired canned foods. Review of the facility's policy indicated that opened dry food items should be tightly closed, labeled, and dated, which was not followed in these instances.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain and Document Preventive Maintenance of Therapy Equipment
Penalty
Summary
The facility failed to maintain three pieces of electrical rehabilitation therapy equipment, including an ultrasound unit, a TENS combination unit, an adjustable therapy mat, and a bicycle, for resident use. During an observation and interviews, the Rehabilitation Director was unable to provide records of maintenance or calibration for any of the therapy equipment and stated that neither therapy nor maintenance staff had checked or maintained the equipment. The Maintenance Director confirmed that there was no process in place for preventive maintenance checks on therapy equipment, and maintenance staff only responded to work orders if equipment was reported as broken. The Director of Nursing also acknowledged the importance of preventive maintenance to ensure resident safety during therapy sessions. A review of the facility's policies revealed that the Maintenance Director was responsible for developing and maintaining a schedule of maintenance services to ensure equipment was kept in a safe and operable condition. Additionally, policies required that inspections include checks of equipment functioning and general condition, with records kept for each piece of equipment. Despite these policies, there were no records or evidence of maintenance or inspection for the therapy equipment, indicating a failure to follow established procedures.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable level of physical, mental, and psychosocial well-being for residents. The report specifically notes that the staff's competencies were insufficient to ensure that all residents received care tailored to their needs, as required by regulatory standards.
Failure to Cover Foley Catheter Drainage Bag with Dignity Bag
Penalty
Summary
A deficiency was identified when a resident's Foley catheter drainage bag was observed to be uncovered, lacking the required dignity bag. During an observation and interview, a CNA confirmed that the dignity bag was not in place and acknowledged that it is the responsibility of all staff to ensure Foley catheter drainage bags are covered. The CNA was unable to provide a reason for the omission and recognized that leaving the drainage bag uncovered would be considered disrespectful to the resident. A treatment nurse also confirmed awareness of the facility's policy requiring dignity bags and acknowledged responsibility for ensuring compliance, but was unaware of the uncovered drainage bag at the time of the observation. Further interviews with the Director of Staff Development and the Director of Nursing confirmed that the facility's policy and procedure mandate the use of dignity bags on all Foley catheter drainage bags to maintain resident privacy and dignity. Both leaders stated that staff are trained on this requirement during orientation and ongoing education. A review of the facility's policy indicated that demeaning practices, such as failing to cover urinary catheter bags, are prohibited and that staff are expected to promote resident dignity by assisting with such measures.
Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident, who had diagnoses including osteoarthritis and rheumatoid arthritis, reported to the Assistant Director of Nursing (ADON) that a Certified Nurse Assistant (CNA) was rough with her while providing personal care. The resident's family member also reported the incident to staff and provided a photograph of the CNA involved. Despite these reports, the ADON did not report the allegation to the required authorities, stating that she did not consider the incident abuse because the resident said she was fine. Interviews with other staff, including another CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered a form of abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged that the allegation should have been reported and investigated, but at the time, it was not considered abuse. A review of the facility's abuse reporting policy indicated that all allegations of abuse must be promptly reported to the appropriate agencies, including the state licensing agency, the Ombudsman, and law enforcement, which was not done in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure by not investigating an allegation of abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident's family member reported to staff that a CNA was rough while changing the resident's incontinent pad and provided a photo of the CNA involved. The family member stated they informed facility staff of the incident. Despite this, the Assistant Director of Nursing (ADON) did not report or investigate the allegation, stating that the resident said she was fine. Other staff, including a CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged being informed that the resident was changed despite refusing care and agreed that the allegation should have been reported and investigated, but at the time did not consider it abuse. Review of the facility's policies confirmed the requirement to thoroughly investigate all allegations of abuse, including interviewing all involved parties and documenting evidence. The failure to follow these procedures resulted in the facility not investigating the reported incident of rough handling, contrary to its own abuse prevention and reporting policies.
Failure to Complete and Document PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was properly completed and documented for two residents with mental health diagnoses. For one resident admitted with depression, schizoaffective disorder, anxiety, psychosis, and insomnia, the facility did not resubmit a new Level I PASARR screening as required after an exempted hospital discharge. The resident's records indicated ongoing needs for nursing staff assistance with daily activities and the ability to make healthcare decisions, but the necessary PASARR review to determine appropriate services was not completed. For another resident with a diagnosis of schizophrenia, the PASARR Level I screening was documented incorrectly, indicating the resident did not have schizophrenia, despite medical records stating otherwise. This resident also required significant assistance from nursing staff for daily care. Interviews with facility staff confirmed that the PASARR screenings were either not completed or documented incorrectly, and that these omissions could affect the care and services provided to the residents. The facility's policy required coordination with the PASARR program and prompt referral for Level II review upon significant changes, but these procedures were not followed in these cases.
Failure to Develop and Implement Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being physically abused by a Certified Nurse Assistant (CNA) during personal care. The resident, who had diagnoses of osteoarthritis and rheumatoid arthritis, was noted to have severe cognitive impairment and required maximal assistance with activities of daily living. Despite the resident's report of abuse to the Assistant Director of Nursing (ADON), a review of the resident's records confirmed that no care plan addressing the abuse allegation was created or implemented. Interviews with facility staff, including two Registered Nurse Supervisors (RNS) and the Director of Nursing (DON), confirmed that a care plan should have been developed following the abuse allegation to guide staff interventions and ensure the resident's safety. The facility's own policy required care plans to be updated when there is a significant change in a resident's condition, but this was not done in response to the reported abuse. This omission resulted in a failure to deliver necessary care and services as required.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including toileting and personal hygiene, was not provided timely incontinence care. The resident, who had diagnoses including diabetes mellitus, seizures, hypertension, muscle weakness, and was always incontinent of urine, was observed crying in bed with a wet adult diaper. Both a Registered Nurse Supervisor and a Certified Nursing Assistant checked the resident and acknowledged the need for a diaper change but left the bedside without providing the necessary care. The Certified Nursing Assistant later stated she did not change the resident because she needed assistance, and confirmed that the resident should not have to wait for a diaper change. Interviews with staff confirmed that residents who are wet or soiled should be changed immediately to prevent complications such as skin irritation, yeast infections, and pressure ulcers. The facility's care plan for the resident specified that good skin care should be performed after each episode of incontinence. The facility's policy also required that residents receive care to maintain or improve their ability to carry out activities of daily living. Despite these requirements, the resident was left wet for approximately an hour, resulting in distress.
Water Pitcher Not Accessible to Resident at Risk for Dehydration
Penalty
Summary
A deficiency occurred when a resident's water pitcher was placed out of reach, contrary to the facility's policy and physician orders. The resident, who had diagnoses including dementia, Alzheimer's disease, hypertension, failure to thrive, and generalized muscle weakness, was assessed as being at risk for dehydration and was on a no added salt diet with extra hydration. The care plan and physician orders specifically indicated the need for additional hydration and that water should be encouraged and accessible. During observation, the water pitcher was found on the dresser, not within the resident's reach. The resident reported being unable to reach the water pitcher and expressed feeling thirsty as a result. Interviews with staff, including an LVN and the DON, confirmed that the water pitcher should have been placed within easy reach to prevent dehydration, in accordance with facility policy. The facility's policy and procedure for serving drinking water also required that the water pitcher and cup be placed within easy reach of the resident.
Failure to Provide Timely Physical Therapy Evaluation and Treatment
Penalty
Summary
The facility failed to provide a Physical Therapy (PT) evaluation and treatment as ordered by a physician for a resident with significant mobility and functional limitations. The resident, who had diagnoses including hemiplegia, hemiparesis, aphasia, and joint stiffness following cerebrovascular disease, was admitted and had a physician's order for PT and Occupational Therapy (OT) evaluation and treatment. Review of the resident's records showed that the PT evaluation was not completed, despite the order being present and the facility's policy requiring evaluations to be completed within 72 hours of the order. The Rehab Director confirmed that she was unaware of the order and that the nursing staff typically informs therapy of such orders, but this communication did not occur in this case. Observations of the resident revealed significant physical limitations, including a bent left elbow, fisted left hand, and limited movement in the right leg, consistent with the documented diagnoses and assessment findings. Interviews with facility staff, including the Rehab Director and DON, confirmed that the PT evaluation was missed and should have been completed as ordered. The facility's policy also required timely completion of such evaluations for residents referred by a physician, but this was not followed, resulting in a delay in the provision of necessary rehabilitative services.
Unresolved Deficiencies in Resident Rights, Quality of Care, Food Safety, and Infection Control
Penalty
Summary
The facility failed to correct deficiencies identified during the prior recertification survey conducted by the California Department of Public Health. These deficiencies were related to Resident Rights, Quality of Care, Food Safety, and Infection Control. The ongoing issues were confirmed through interviews and record reviews, which revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program, although meeting regularly and including key leadership and department heads, did not fully resolve the previously cited deficiencies. The Administrator acknowledged that the QAPI committee reviews data, tracks trends, and conducts root cause analyses when issues are identified. However, the Administrator also stated that the previous deficiencies persisted due to inconsistent staff education, lack of monitoring, and insufficient follow-through on corrective action plans. As a result, the facility continued to have unresolved issues in ensuring resident dignity, quality care, food safety, and infection control.
Failure to Enforce Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow infection control precautions for two residents who were under enhanced barrier precautions (EBP) due to their medical conditions. One resident, admitted with hypertension and urinary retention and with a urinary catheter in place, had an active order for EBP. Despite this, observations on multiple occasions revealed that the resident’s family members were present at the bedside assisting with care without wearing the required personal protective equipment (PPE). Both the LVN and the Infection Prevention Nurse confirmed that family members should have been wearing PPE to prevent the spread of infection, as outlined in the facility’s infection prevention and control policy. Another resident, admitted with multiple diagnoses including dysphagia, a gastrostomy tube, myocardial infarction, depression, heart failure, and respiratory failure, also had an order for EBP. During care, a CNA was observed changing the resident’s gown and providing a bed bath without wearing an isolation gown, which is required under EBP protocols. The CNA acknowledged the omission and stated that gloves and an isolation gown should have been used. The Infection Prevention Nurse and the DON both confirmed that staff providing direct care to residents with indwelling devices or wounds must adhere to EBP, including the use of gowns and gloves. The facility’s policies and procedures for infection prevention and EBP were reviewed and both require the use of appropriate PPE by staff and visitors when providing care or having direct contact with residents under EBP. The observed failures to ensure compliance with these precautions for both staff and visitors constituted a deficiency in the facility’s infection prevention and control program.
Failure to Safeguard and Account for Resident's Personal Property
Penalty
Summary
The facility failed to ensure that a resident's personal possession, specifically a cell phone, was properly accounted for and kept safe. Upon review of the resident's admission record, it was noted that the resident, who had diagnoses including osteoarthritis, muscle weakness, dysphagia, metabolic encephalopathy, and dementia, was severely cognitively impaired and required substantial to total assistance with daily activities. The Minimum Data Set confirmed the resident's significant cognitive and physical limitations. Despite these needs, the belongings list for the resident did not include the cell phone, even though the resident had been using one prior to its disappearance. During interviews, an LVN acknowledged that the belongings list should have included the cell phone, and the DON confirmed that all residents are required to have a belongings list to track personal items. Review of facility policies indicated that personal property should be inventoried and documented upon admission and as items are replenished, and that residents' property should always be respected. The failure to document and track the cell phone resulted in its loss, demonstrating noncompliance with facility policy and the resident's right to have personal possessions respected and safeguarded.
Failure to Accommodate Resident and Family Preferences Prior to Medication Administration
Penalty
Summary
The facility failed to accommodate the specific needs and preferences of a resident as requested by the resident's family member. The resident, who had severe cognitive impairment, required substantial assistance with personal care and was dependent on staff for toileting and hygiene. The resident had a physician's order for Ativan to be administered via G-tube as needed for anxiety, with instructions to notify a family member prior to each dose. The family member also requested that the resident be fed and have their adult disposable diaper checked before Ativan was given. Record review and staff interviews revealed there was no documented evidence that the resident was fed or that their adult disposable diaper was checked prior to the administration of Ativan. Although the nurse stated the request was verbally communicated, it was not documented in the medical record or Medication Administration Record (MAR). The facility's policy required accommodation of individual resident needs and preferences to the extent possible, but this was not followed in this instance.
Failure to Provide Timely Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide toileting hygiene at least every two hours and as needed for a resident who was dependent on staff for activities of daily living. The resident, who had severe cognitive impairment, osteoarthritis, muscle weakness, dysphagia, metabolic encephalopathy, and dementia, was care planned to be checked and assisted with toileting every two hours due to incontinence. However, documentation and staff interviews confirmed that the resident was not checked or changed according to this schedule on all shifts. On one occasion, a family member assisted with toileting hygiene and found feces embedded in the vaginal area and urine leaking onto the wheelchair. A CNA confirmed that the resident's adult disposable brief was not checked for nearly three hours, during which time the resident was found soiled with urine and feces. The Assistant Director of Nursing reviewed records and confirmed the lack of timely checks and changes, and the Director of Nursing acknowledged that dependent residents need to be kept clean. The facility's policy required appropriate care and toileting assistance, which was not provided in this case.
Failure to Provide Ordered Oral Gratification Diet to Dependent Resident
Penalty
Summary
A resident with diagnoses including muscle weakness, dysphagia, metabolic encephalopathy, and dementia was admitted to the facility and assessed as having severely impaired cognition. The resident required substantial to total assistance with activities of daily living, including oral hygiene and eating. Physician orders were in place for an oral gratification diet with pureed texture and honey consistency fluids, intended to be provided three times daily. From June 1 to June 4, 2025, facility documentation and interviews confirmed that the resident was not assisted with meals during mealtimes as ordered. The Director of Nursing acknowledged that the resident did not receive the prescribed oral gratification diet during this period. Facility policies required that residents receive appropriate care and assistance with meals, but these were not followed for the resident in question.
Staff Failure to Wear Identification Badges Violates Resident Rights
Penalty
Summary
Three of five sampled staff members, including a receptionist, a certified nurse assistant (CNA), and a maintenance worker, were observed not wearing identification badges as required by the facility's policy. The receptionist stated she was new and still waiting for her badge to be issued. The CNA admitted to forgetting to wear her badge that day, and the maintenance worker indicated he was not wearing his badge while doing rounds in residents' rooms. These observations were confirmed during interviews with the staff involved. The facility's policy, updated in January 2021, mandates that all employees must wear a visible identification badge with their full name, position, and photo at all times while on the premises. The Assistant Director of Nursing (ADON) confirmed that all staff are expected to comply with this policy so residents can identify facility staff. The failure of these staff members to wear their badges did not support a culture of safety and transparency and violated residents' rights to know who was providing care and to be treated with respect.
Call Light Not Within Reach for Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of four sampled residents. The resident, who had diagnoses including metabolic encephalopathy and muscle weakness, was assessed as having intact cognition and required setup assistance with eating, oral hygiene, personal hygiene, and partial assistance with showering. During an observation and interview with a licensed vocational nurse, it was noted that the resident's call light was not accessible. Both the nurse and the Assistant Director of Nursing confirmed that call lights should always be within reach so residents can request assistance. Review of the facility's policy indicated that staff are required to ensure call lights are within residents' reach before leaving the room.
Failure to Implement Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident assessed as high risk for falls, who had a history of falling and severe cognitive impairment. The resident's care plan, revised after a previous fall, required the use of an extended floor mattress to provide protection in the event of a fall. Despite this intervention being documented, the mattress was not placed next to the resident's bed as required. On the date of the incident, staff responded to a bed alarm and found the resident on the floor without the extended mattress in place. Nursing notes indicated the mattress was not used due to concerns that the resident's ambulatory roommate might trip over it. The Director of Nursing confirmed that the care plan intervention should have been implemented, or alternative interventions considered if the mattress was not appropriate. The facility's policy required a resident-centered fall prevention plan for those at risk or with a history of falls.
Failure to Train Nursing Staff on Tilt-in-Space Wheelchair Use
Penalty
Summary
Nursing staff failed to receive proper training on the use of a Tilt-in-space wheelchair prior to its use for a resident with cognitive communication deficits, Alzheimer's disease, and legal blindness. The resident, who required maximum assistance for activities of daily living, was transferred from a mechanical lift into the Tilt-in-space wheelchair by a CNA and an LVN. After the transfer, the resident was positioned upright in the chair and began to slide down towards the floor, as documented in a witnessed fall report. Interviews with the CNA and LVN involved in the transfer revealed that neither had been trained on the use of the Tilt-in-space wheelchair before the incident. The Director of Rehabilitation confirmed that she had not provided training to the CNA prior to the event and stated that all staff should be trained on such equipment before use. The facility's policy required staff unfamiliar with a wheelchair model to receive instruction or guidance before use, but this was not followed in this case.
Failure to Notify DPOA Prior to Specialist Appointments
Penalty
Summary
The facility failed to ensure that a resident's appointed Durable Power of Attorney (DPOA), who was also a family member, was notified and authorized specialist medical appointments, as required by the resident's care plan and legal documentation. The resident, who had diagnoses including cognitive communication deficit, Alzheimer's disease, and legal blindness, was assessed as having mildly impaired cognition and required maximum assistance with daily activities. Documentation in the resident's records and interviews with staff confirmed that the DPOA had explicitly requested to be notified and to authorize any specialist visits beyond the primary care physician, podiatrist, and dentist/dental hygienist. Despite this, the resident was seen by an ophthalmologist and an ENT specialist without the DPOA's knowledge or documented authorization. Interviews with the MDS Coordinator and Social Services Director confirmed that staff were aware of the DPOA's role and the requirement to notify and obtain authorization for specialist visits. However, there was no documentation indicating that the DPOA was informed or had authorized the ophthalmology or ENT appointments. The facility's own policy stated that residents have the right to be informed of and participate in their care planning and treatment, and to appoint a legal representative. The failure to notify and involve the DPOA in these medical decisions resulted in a violation of the resident's rights.
Failure to Maintain Resident's Tilt-in-Space Wheelchair per Manufacturer Guidelines
Penalty
Summary
The facility failed to obtain and maintain the manufacturer's guidelines for a Tilt-in-space wheelchair used by a resident with cognitive communication deficit, Alzheimer's disease, and legal blindness. The resident required maximum assistance for activities such as toileting hygiene, showering, and dressing, and used a personal Tilt-in-space wheelchair. During interviews, both the Director of Rehabilitation and the Maintenance Supervisor confirmed they did not have the user manual for the wheelchair because it was owned by the resident. The Maintenance Supervisor acknowledged that although adjustments had been made to the wheelchair in the past to ensure it was working, the absence of the manufacturer's manual meant they could not be certain that all necessary maintenance and safety checks were performed according to the manufacturer's recommendations. The facility's policy required maintenance personnel to follow the manufacturer's recommended maintenance schedule for all equipment, but this was not done for the resident's wheelchair.
Delayed Reporting of Influenza A Outbreak
Penalty
Summary
The facility failed to report an Influenza A outbreak to the California Department of Public Health (CDPH) immediately, as required. This deficiency involved two residents who tested positive for Influenza A. Resident 9, who had chronic obstructive pulmonary disease and bronchitis, tested positive for Influenza A on February 15, 2025, after exhibiting flu-like symptoms. Similarly, Resident 10, diagnosed with asthma, tested positive for Influenza A on February 18, 2025. Despite these positive test results, the facility did not report the outbreak to CDPH until February 24, 2025, three days after Resident 10's positive test result. The delay in reporting was acknowledged by the Infection Prevention (IP) Nurse, who admitted forgetting to report the outbreak to CDPH promptly. The facility's policy and procedure for Infection Prevention and Control Program, dated March 6, 2025, clearly indicated that outbreak management involves reporting information to appropriate public health authorities. The failure to report in a timely manner resulted in CDPH being unaware of the outbreak and unable to investigate it promptly, potentially leading to the loss of pertinent information and unreported cases.
Facility Denies Readmission After Hospitalization
Penalty
Summary
The facility failed to uphold a resident's rights when they denied readmittance to a resident after hospitalization, despite the resident being cleared for return by a General Acute Care Hospital (GACH). The resident, who had been living in the facility for approximately 38 days, was initially transferred to the GACH for evaluation due to inappropriate sexual behaviors. The resident's medical history included schizophrenia, malignant neuroleptic syndrome, and diabetes mellitus type 2, and they had impaired cognitive skills for daily decision-making. The facility had informed the resident's conservator of the right to a bed hold for seven days in the event of hospitalization. However, after the resident was cleared by the GACH's psychiatrist for return, the facility refused readmission, citing concerns for the safety of other residents due to the resident's sexually impulsive behaviors. The facility's Director of Nursing and Administrator both expressed that the safety of current residents would be at risk if the resident were readmitted. The facility's policy and procedure on bed-hold and returns indicated that residents may return to the facility after hospitalization, but the facility did not have the resources to provide a 1:1 sitter to ensure safety. The GACH's discharge case manager confirmed that the facility refused to readmit the resident after being cleared, stating the resident was a danger to other residents. The facility's policy on transfer or discharge documentation required communication of the basis for transfer or discharge, including specific needs that could not be met, but this was not adhered to in this case.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, resulting in two incidents of non-consensual sexual contact. Resident 1, who had a history of schizophrenia and cognitive impairments, was admitted to the facility with a lack of awareness of place, location, and time. Despite these conditions, Resident 1 was left unsupervised with Resident 2, who had severe cognitive impairments and was dependent on staff for daily activities. This lack of supervision led to Resident 1 inappropriately touching Resident 2 on two separate occasions. The first incident occurred when a CNA found Resident 1 and Resident 2 in bed together, with Resident 1 engaging in inappropriate sexual behavior. The CNA reported the incident but left the residents alone in the room, contrary to the facility's policy that required separating residents involved in such incidents. This inaction allowed Resident 1 to assault Resident 2 a second time, as witnessed by another CNA who heard Resident 2 calling for help. The facility's policy on abuse reporting and investigation was not followed, as staff failed to separate the residents and provide necessary supervision. The DON acknowledged that Resident 1's impulsive behaviors were not managed, leading to the repeated assault on Resident 2. The facility's failure to adhere to its own procedures and ensure the safety of its residents resulted in a serious deficiency, as identified by the surveyors.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring for emotional distress, and Resident was seen by a Psychologist and Psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and staff regarding any abuse incidents, with any issues identified to be investigated by the Abuse Coordinator/Administrator.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including medication regimen and need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- Facility staff will be in-serviced and educated on the immediate action required during an alleged abuse situation, including separating residents and providing immediate 1:1 supervision.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education, including abuse, review of admission documents, separating residents, and all resident interviews regarding any alleged abuse, will be completed.
- The Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Failure to Manage Resident's Psychiatric Needs Leads to Assault
Penalty
Summary
The facility failed to ensure that a resident with a history of schizophrenia and aggressive, inappropriate sexual behaviors was properly evaluated and treated upon admission. The resident, who had been receiving Clozapine for disorganized thoughts and aggressive behavior at a previous facility, was not assessed by a psychiatrist or prescribed the necessary medications upon admission to the current facility. This oversight led to the resident not receiving any treatment for his schizophrenia since his admission. As a result of the facility's inaction, the resident sexually assaulted another resident twice. The first incident was witnessed by a Certified Nursing Assistant (CNA), who separated the residents but failed to maintain supervision. Shortly after, the resident assaulted the same individual again, which was witnessed by another CNA. The assaulted resident had severe cognitive impairments and was dependent on staff for daily activities, making them particularly vulnerable. The facility's failure to review the resident's psychiatric history and medication needs, as well as the lack of immediate and appropriate intervention by staff, resulted in the resident's aggressive behaviors going unchecked. This placed other residents at risk and led to the sexual assault of a vulnerable resident. The facility's Director of Nursing admitted to overlooking the resident's psychiatric history and failing to ensure the resident received the necessary behavioral care and services.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring Resident for emotional distress. Resident was seen by a psychologist and psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and inquired if they have experienced abuse or know of any abuse in the facility. Staff were interviewed regarding residents who were not able to be interviewed.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, the Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- The Administrator, the Director of Nursing, the Director of Staff Development or Clinical Resources will in-service and educate facility staff on the immediate action required during an alleged abuse situation.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed.
- This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Failure to Provide Abuse Training to LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 1 and LVN 2) received abuse training before providing direct patient care. During a review of employee files by the Director of Staff Development (DSD), it was found that there was no record of abuse training for these two staff members. The DSD acknowledged that employees must undergo abuse training prior to engaging in direct resident care, and the absence of such training could potentially place residents at risk for abuse. The Administrator confirmed that the DSD is responsible for maintaining the facility's education program and hiring frontline staff. The Administrator also stated that abuse training is mandatory upon hire and is conducted twice a year. The facility's policy requires all staff to participate in regular in-service education, which includes training on preventing abuse, neglect, exploitation, and misappropriation of resident property. This training is required before staff provide services to residents, annually, and as necessary based on facility assessment.
Medical Director's Absence in QAA Meetings
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to ensure the Medical Director (MD) attended the monthly meetings. This deficiency was identified during interviews and record reviews conducted with the Director of Nursing (DON) and the Administrator. The DON acknowledged that the MD's attendance is crucial for addressing medical concerns and conducting root cause analyses of issues within the facility. However, the MD did not attend the QAA meeting in July 2024, and the DON admitted to not informing or relaying the meeting minutes to the MD. The Administrator emphasized the importance of the MD's presence at these meetings, as the MD is a key member of the governing body responsible for implementing corrective actions. The facility's policy and procedure for the QAPI program, effective since February 2023, outlines the necessity of data-driven, facility-wide processes to improve the quality of care and outcomes for residents. Despite this, the facility failed to adjust the meeting schedule to accommodate the MD's availability, leading to a lack of collaboration and potential oversight in addressing systemic problems.
Failure to Provide Abuse Training to LVNs Before Direct Care
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 1 and LVN 2) received mandatory abuse training before providing direct patient care. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the training records for these two staff members were missing. The DSD acknowledged that employees must complete abuse training prior to engaging in direct resident care, and the absence of such training could potentially place residents at risk for abuse. The Administrator confirmed that the DSD is responsible for maintaining the facility's education program and hiring frontline staff. The Administrator also stated that abuse training is required upon hire and biannually, emphasizing that staff must be trained before providing direct care to residents. The facility's policy, dated August 2022, mandates regular in-service education for all staff, including training on preventing abuse, neglect, exploitation, and misappropriation of resident property. This training is required before staff provide services to residents, annually, and as needed based on facility assessment.
Failure to Track Staff Competency in Online Learning
Penalty
Summary
The facility failed to maintain a tracking system for staff participation and competency in its online learning program, which is essential for ensuring the safety of residents. During an interview with the Director of Staff Development (DSD), it was revealed that she was responsible for managing the education program but did not keep any data regarding staff progress in the online learning system. The DSD admitted to not being able to retrieve lesson plans from the online education software and acknowledged the need to learn how to use the software better. This lack of tracking and competency assessment posed a risk to resident safety, as untrained staff might not provide appropriate care. The Administrator confirmed that the DSD's role included maintaining the facility's education program and ensuring staff competency through the online learning application. The Administrator expressed concern that without proper tracking, it was possible to overlook which staff members completed the necessary in-services. The facility's policy on staffing and competency emphasized the importance of tracking mechanisms to evaluate training effectiveness, yet this was not being implemented. The deficiency highlighted the potential risk to residents if staff were not adequately trained to manage their medical conditions.
Physician's Failure to Sign Admission Orders
Penalty
Summary
The facility failed to ensure that the primary care physician (PCP) signed the admission orders for a resident who was admitted from the hospital. This oversight involved a resident with multiple diagnoses, including cerebrovascular disease, diabetes mellitus, and vascular dementia. The resident was admitted on a specific date, and the facility's policy required the physician to visit within 72 hours of admission to evaluate the resident's condition, perform a History and Physical (H & P), and sign the Physician Orders (PO). However, the PCP did not sign the admission orders, which is a necessary step to ensure the resident receives appropriate medical intervention during their stay. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) confirmed that the physician visited the facility within the required timeframe but failed to sign the necessary orders. The facility's policy, dated November 2014, mandates that physician orders and progress notes must be signed and dated. The DON acknowledged the responsibility to ensure compliance with this regulation, emphasizing the importance of the physician's visit and signature to provide appropriate care and services to the resident.
Failure to Schedule Follow-Up Appointment and Continue Therapy Services
Penalty
Summary
The facility failed to schedule a follow-up appointment with an orthopedic surgeon for a resident who had undergone left leg surgery. This oversight resulted in the resident not being cleared to continue receiving necessary physical therapy services. The resident, who was admitted with conditions including acute osteomyelitis of the left femur and muscle contracture, was initially receiving physical therapy until it was discontinued. The resident expressed concerns about the lack of therapy, stating that his strength was deteriorating due to inactivity. Interviews with facility staff revealed that the Director of Rehabilitation acknowledged the cessation of therapy services and noted that an order for physical and occupational therapy was received but not acted upon. The Registered Nurse Supervisor indicated that the hospital's referral documents included a post-surgery follow-up plan, which was not communicated to the admitting physician. The Director of Nursing confirmed that the nursing staff did not notify the physician about the need for an orthopedic consult, as they believed the resident was improving. The facility's policies and procedures were reviewed, highlighting the responsibilities of the Case Manager and Director of Rehabilitation in coordinating care and ensuring follow-up appointments. However, these procedures were not followed, leading to a lapse in the resident's care. The failure to arrange the necessary follow-up appointment and continue therapy services resulted in a delay in treatment and placed the resident at risk of further decline.
Failure to Monitor Urinary Retention and Hydration
Penalty
Summary
The facility's nursing staff failed to adequately monitor and assess a resident at risk for urinary retention due to benign prostatic hypertrophy (BPH). The staff did not report or act upon the resident's dry diaper, indicating no urine output, over an extended period. Certified Nursing Assistants (CNAs) did not report the absence of urine output to licensed nurses, and the licensed nurses did not conduct necessary physical assessments to check for signs of urinary retention, such as abdominal distension or pain. This lack of communication and assessment led to the resident not having documented urine output for over 24 hours. The resident, who had a history of BPH and was at risk for urinary retention, was admitted with diagnoses including secondary malignant neoplasm of the brain and acute kidney failure. Despite the care plan indicating the need to observe and report decreased urine output, the facility failed to ensure that the nursing staff followed these directives. The resident's fluid intake was documented, but there was no documentation of fluid output, and the resident was noted to be incontinent on several occasions without any recorded urine output. The deficiency resulted in the resident being transferred to a General Acute Care Hospital after suffering a seizure. At the hospital, the resident was diagnosed with a urinary tract infection, severe sepsis, and urine retention, with a significant amount of urine retained in the bladder. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition and care plan, contributing to the failure to monitor and address the resident's urinary retention and hydration status effectively.
Failure to Document Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed and administered the antipsychotic medication Seroquel, received the medication for appropriate indications. The resident was admitted with diagnoses including secondary malignant neoplasm of the brain and traumatic hemorrhage of the right cerebrum with loss of consciousness. Despite these conditions, there was no documentation of behaviors related to a diagnosis of schizophrenia, which was the stated reason for the Seroquel prescription. The medication was administered multiple times without detailed evidence of the resident's behaviors or attempts at non-pharmacologic interventions. The facility's records lacked documentation of a comprehensive evaluation by a physician, psychiatrist, psychologist, or nursing staff to determine the necessity of Seroquel for the resident. Interviews revealed that the resident's family member stated there was no history or diagnosis of schizophrenia. The Assistant Director of Nursing acknowledged that non-pharmacologic interventions should have been attempted and documented prior to administering antipsychotic medications, but this was not done for the resident in question. The resident's psychiatrist indicated that the resident was diagnosed with delirium and psychosis in the hospital, but due to the acute nature of delirium, a preliminary diagnosis of schizophrenia was made to facilitate admission to the facility. The psychiatrist ordered Seroquel for paranoia and agitation based on a report from the facility but did not have the opportunity to assess the resident personally. The facility's policy required that antipsychotic medications be used only for documented conditions and that non-pharmacological interventions be attempted and documented, which was not adhered to in this case.
Failure to Maintain Resident Dignity in Care Practices
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity. Resident 80 experienced neglect when their bedside commode, which contained feces, was not promptly emptied and cleaned by the nursing staff. Despite having the ability to understand and express ideas, Resident 80 reported feeling sad due to the delay in cleaning the commode, which sometimes took up to four hours or until the next day. This issue was confirmed during an observation where a plastic bag filled with feces was found in the commode, and a CNA admitted to being too busy to clean it immediately. The Director of Nursing acknowledged that the commode should be cleaned right away to prevent odor and maintain dignity. Additionally, Resident 30, who was dependent on staff for eating and lacked the capacity to make decisions, was fed by a CNA who stood over them instead of sitting at eye level. This practice was against the facility's policy, which emphasizes the importance of sitting at eye level to promote engagement and respect. The CNA admitted to not sitting due to the unavailability of chairs, while another CNA and the DON confirmed that sitting at eye level is necessary to make residents feel respected and to properly assess them during feeding.
Failure to Document Advance Directives and POLST
Penalty
Summary
The facility failed to ensure that the medical records of four residents included documentation of advance directives and physician orders for life-sustaining treatment (POLST). This deficiency was identified through interviews and record reviews, revealing that the facility did not provide or discuss the necessary documentation with the residents or their responsible parties. This oversight violated the residents' rights to be informed about their options for end-of-life care and to have their wishes documented and respected. Resident 77 was admitted with diagnoses including adult failure to thrive and dementia. Although an Advance Directive Acknowledgement was signed, the facility did not ensure that the necessary discussions and documentation were completed. Resident 85, admitted with chronic cholecystitis and hypertension, did not have an Advance Directive Acknowledgement on record, and the Social Services Director admitted to not assisting in formulating an advance directive for this resident. Resident 82, with severe cognitive impairment and multiple diagnoses, did not have a valid advance directive or POLST. The responsible party was not informed about these documents upon admission. Similarly, Resident 45, who was severely impaired and receiving hospice care, did not have an Advance Directive Acknowledgement on file. The facility's policy required that residents and their families be provided with information about their rights to formulate an advance directive, which was not adhered to in these cases.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), form CMS-10055, to two residents when their Medicare Part A coverage ended, and they continued to stay at the facility. During an interview and record review with the Director of Nursing (DON), it was revealed that Resident 2's last covered day for Medicare Part A Skilled Services was on January 19, 2024, and Resident 27's last covered day was on February 5, 2024. Despite the end of coverage, both residents remained at the facility without receiving the required SNF ABN, which would have informed them of their financial liability and appeal rights. The DON acknowledged that the facility did not provide the necessary notifications to these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate count and proper storage of medications, leading to several deficiencies. For Resident 32, there was a discrepancy in the controlled medication count of lorazepam, where the bottle contained 8 mL instead of the 4 mL documented on the controlled drug reconciliation record. This discrepancy was identified during an observation and interview with an LVN, who acknowledged the error and highlighted the potential risk of seizures or anxiety if the medication was not administered as recorded. On the second floor, the facility did not store medications according to the manufacturer's requirements. Resident 447's arformoterol tartrate inhalation solution was found without an open date label, and the refrigerator temperature was below the recommended range, potentially compromising the medication's effectiveness. Similarly, Resident 53's semaglutide was stored in a refrigerator that was too cold, which could alter the medication's chemical composition, as noted by an LVN during an interview. Additionally, expired medications were found in a medication cart on the third floor, affecting multiple residents. Medications with expiration dates ranging from May to June 2024 were still present, including those for Residents 36, 40, 19, and 32. An LVN confirmed that these expired medications should have been discarded, as their efficacy could be reduced, impacting the residents' treatment. The facility's policy on medication storage, which mandates proper labeling and disposal of expired medications, was not adhered to, contributing to these deficiencies.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. In the walk-in refrigerator, a bag of salad was found without an open date label, which is necessary to track when the food was received and when it should be discarded. This oversight was acknowledged by a staff member, who confirmed the importance of labeling to prevent serving potentially expired food to residents, who are at high risk for foodborne illnesses. Additionally, in the dry storage room, staff personal items were improperly stored near food items. A personal bag and a hat belonging to a dietary aide were found on a shelf beside food products, such as elbow macaroni and spaghetti noodles. The dietary aide admitted to storing personal items in the dry storage room but could not explain why this practice was inappropriate. The dietary manager and another dietary aide confirmed that personal items should be kept in staff lockers to prevent cross-contamination with resident food.
Failure to Provide Appropriate Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide a touch pad call light for a resident with quadriplegia, bipolar disorder, and spastic hemiplegia, who was unable to use the standard push button call light due to stiff and rigid hands. This deficiency was identified through observations, interviews, and record reviews. The resident expressed frustration over the inability to use the call light, which led to delays in receiving care. The resident's Minimum Data Set indicated impairments in both upper and lower extremities, requiring a two-person assist for activities of daily living, bed mobility, and transfers. Interviews with facility staff, including a CNA and an LVN, confirmed the resident's inability to effectively use the current call light system due to hand spasms and stiffness. The facility's policies and procedures on call systems and accommodation of needs were reviewed, indicating that residents should be provided with functional call devices and that individual needs and preferences should be accommodated. Despite these policies, the facility did not identify and address the resident's need for a touch pad call light, resulting in the deficiency.
Failure to Monitor Skin Discolorations in High-Risk Resident
Penalty
Summary
The facility staff failed to assess and monitor multiple skin discolorations for a resident identified as being at high risk for bleeding. The resident, who was on Xarelto, a blood thinner, had skin discolorations on the left hand, right arm, and left upper arm, which were not documented or assessed by the staff. The resident's care plan required staff to observe and report signs and symptoms of bruising, but there was no documentation of skin assessments after a certain date, despite the resident's condition and medication increasing the risk of bleeding. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) and Certified Nurse Assistant (CNA) did not document or report the skin discolorations. The Director of Nursing (DON) confirmed that the care plan required monitoring of the resident's skin due to the anticoagulant use, and acknowledged that bruising could worsen and lead to bleeding. The facility's policy required CNAs to document skin issues and for LVNs/RNs to review and sign off on these forms, but this process was not followed, leading to the deficiency.
Failure to Address Hearing Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident with hearing difficulties received the necessary services and treatment to address her hearing loss. The resident, who was admitted with various medical conditions including cellulitis, ulcerative proctitis, and generalized abdominal pain, was identified through the Minimum Data Set (MDS) as having difficulty hearing. Despite this, the resident was not referred to an audiologist as indicated in her care plan. Interviews with staff, including a CNA, LVN, and RNS, confirmed that the resident was hard of hearing and did not use a hearing aid. The staff acknowledged that the resident's hearing issues should have been reported to the social worker for a referral to an audiologist. The Social Services Director and the Director of Nursing both stated that residents with hearing problems should be seen by an ENT doctor or audiologist to determine if a hearing aid is needed. The facility's policy and procedure for hearing-impaired residents emphasized the importance of maintaining effective communication and arranging necessary services. However, the resident's hearing issues were not addressed, potentially impacting her ability to communicate effectively with staff and understand the care being provided.
Failure to Enroll High-Risk Resident in Fall Prevention Program
Penalty
Summary
The facility failed to ensure that a resident, identified as high risk for falls, was enrolled in the Falling Star Program as per the facility's Fall Prevention policy. The resident, who was admitted with a history of falls, neck fracture, spinal stenosis, muscle weakness, and difficulty walking, did not have the necessary fall prevention measures in place. During observations and interviews, it was noted that the resident did not have a star symbol outside their room, which is used to identify residents in the Falling Star Program. Additionally, the resident lacked fall prevention measures such as landing pads or a bed alarm. Interviews with facility staff, including a CNA, LVN, RNS, and the DON, confirmed that the resident was not placed in the Falling Star Program despite having a high fall risk score. The staff acknowledged that the resident qualified for the program based on their fall risk score and medical history. The facility's policy indicated that residents with a history of falls should be included in the program, which involves placing identifying symbols and implementing specific interventions. The failure to enroll the resident in the program and implement these measures had the potential to result in another fall with injury.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 87, which impacted her ability to eat adequately. Resident 87, who was admitted with conditions including diabetes mellitus, Parkinson's disease, muscle weakness, and gastro-esophageal reflux, was observed cutting her food into tiny pieces due to discomfort caused by loose dentures. Despite the resident's capacity to make decisions and her dependency on nursing staff for various activities, her dental issues were not addressed promptly. Interviews with staff revealed that although the resident's difficulty in eating was noted, appropriate referrals for dental services were not made in a timely manner. The facility's policy required that residents with damaged or lost dentures be referred for dental services within three days, with documentation provided if there was a delay. However, this protocol was not followed for Resident 87, who had lost three pounds since May 2024. The Director of Nursing acknowledged that staff should have identified the resident's difficulty in chewing and swallowing during mealtimes and taken steps to address the issue, including obtaining a speech therapist evaluation and a dentist consult. The failure to adhere to the facility's policy and procedure for dental services resulted in a deficiency in care for Resident 87.
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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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