Bonnie Brae Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 420 South Bonnie Brae St., Los Angeles, California 90057
- CMS Provider Number
- 055538
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bonnie Brae Skilled Nursing during CMS and state inspections, most recent first.
A facility failed to maintain an effective pest control program, as evidenced by the observation of a cockroach at the nurses' station and daily sightings reported by a resident with multiple chronic conditions. Staff acknowledged the issue as related to cleanliness and infection control, and facility policies required ongoing pest control, but cockroaches remained present despite regular pest control visits.
The facility failed to protect residents from abuse, as a resident with known behavioral issues was not provided with necessary psychiatric evaluations, leading to a verbal and physical altercation with another resident. Despite being aware of the resident's disruptive behavior, the facility did not take appropriate action to prevent the incident, resulting in physical injury.
The facility failed to complete annual competency and performance evaluations for two CNAs, three LVNs, and an RN, as required by policy. The evaluations were either outdated or missing, potentially compromising resident care. The Administrator confirmed the oversight, which was the responsibility of the Director of Staff Development.
The facility failed to properly label, store, or discard medications, including insulin, Aplisol, and Pneumovax 23, according to professional standards. Insulin vials were found without proper labeling, and expired medications were not removed from storage. An expired emergency medication kit was also not replaced, posing a risk to resident safety.
The facility failed to document discussions and provide written information about advance directives for two residents with severe cognitive impairments. Both residents' acknowledgment forms lacked signatures from responsible parties, confirming receipt of information. The Social Services Director confirmed the oversight, violating residents' rights to be informed about advance directive options.
Two residents in an LTC facility had inaccurate MDS assessments, leading to potential delays in care. One resident's COPD diagnosis was omitted, while another's psychiatric diagnoses were not continued after hospital readmission, despite receiving related medications. The facility's policies on accurate MDS completion and psychotropic medication management were not followed, contributing to these deficiencies.
A resident with limited ROM did not receive required quarterly joint mobility assessments, increasing the risk of contractures. Despite an initial assessment showing limitations, no follow-up assessments were documented. The DON and PT acknowledged the oversight, citing high demands and lack of specific policy on assessment timing.
The facility failed to label and date oxygen humidifier bottles for two residents with COPD, as confirmed by an LVN and the DON. This oversight increased the risk of infection control issues, potentially leading to resident discomfort or infection.
The facility did not complete annual performance evaluations for two CNAs, as required by its policy. CNA 1 and CNA 2, hired in 2016 and 2020 respectively, lacked documented evaluations in their files. The Administrator confirmed that the Director of Staff Development was responsible for ensuring these evaluations were completed. This oversight increased the risk of not identifying staff weaknesses, potentially affecting resident care.
Two residents experienced medication errors, resulting in a 12% error rate. A resident was not instructed to properly use their Qvar inhaler, leading to improper dosage. Another resident received a crushed ferrous sulfate tablet instead of the prescribed liquid form and pantoprazole at the wrong time. The errors were acknowledged by the LVN and confirmed by the DON, highlighting a failure to follow physician orders and facility policies.
A resident with Type II diabetes mellitus received insulin injections at the same site repeatedly, contrary to facility policy and manufacturer guidelines. This practice, confirmed by the RN and DON, increased the risk of adverse effects such as lipodystrophy. The facility's policies emphasized the importance of rotating injection sites to minimize adverse consequences.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and schizophrenia, as there were no documented visits from hospice staff and no hospice care plan. Interviews with staff confirmed the absence of necessary documentation and coordination, which is required by the facility's hospice policy.
A resident's oxygen nasal cannula was found on the floor, posing an infection risk. The resident, with COPD, had a physician's order for oxygen via nasal cannula. An LVN confirmed the cannula should not be on the floor, and the DON stated it should be covered in a plastic bag when not in use. The facility's policy also required this practice.
The facility failed to meet the required square footage per resident in 10 rooms and two single rooms, as observed by the Maintenance Supervisor. Despite some residents and a CNA reporting no issues with room size, the facility's policy mandates specific space requirements, which were not met, resulting in a deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches within the building. During an observation at the nurses' station, a large cockroach was seen crawling on the floor. A registered nurse confirmed the insect was a cockroach and acknowledged that its presence was related to cleanliness and posed a pest control and infection control issue. A resident reported seeing cockroaches daily and expressed concern about the cleanliness of the environment, stating that the situation was not right and could lead to illness. The interim Director of Nursing also stated that cockroaches in the facility could cause residents to become ill, particularly those with weakened immune systems. A review of the facility's pest control policy indicated that the facility was supposed to maintain an ongoing pest control program to keep the building free of insects. The administrator stated that the pest control company visited the facility monthly and as needed, with the most recent visit occurring earlier in the month. Despite these measures, the continued presence of cockroaches was observed and reported by both staff and a resident. The facility's infection prevention and control policy also referenced pest control as part of maintaining a safe and sanitary environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident verbal and physical abuse, involving two residents. Resident 1 exhibited behavioral symptoms, such as entering other residents' rooms without permission and shouting at them. Despite these behaviors, the facility did not provide necessary behavioral health assessments or refer Resident 1 for psychiatric or psychological evaluations as required by the care plan. This lack of intervention allowed Resident 1's disruptive behavior to continue unchecked. On a specific day, Resident 1 engaged in verbal abuse towards Resident 2, leading to a physical altercation. Resident 1 was yelling and irritating Resident 2, who then struck Resident 1 with a cellphone, causing physical injury. Resident 1 sustained redness and bruising on the right side of the face and complained of blurry vision. The facility's failure to address Resident 1's behavioral issues and provide timely psychiatric consultation contributed to the escalation of the situation. Interviews with staff and residents revealed that Resident 1 was known to be loud and disruptive, often going into other residents' rooms and causing disturbances. Despite these known behaviors, the facility did not perceive Resident 1 as a threat and did not take appropriate action to prevent the altercation. The facility's policies and procedures for resident assessment and abuse prevention were not effectively implemented, resulting in a failure to protect residents from abuse.
Failure to Complete Annual Competency and Performance Evaluations
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), three Licensed Vocational Nurses (LVNs), and one Registered Nurse (RN) had completed their annual competency and performance evaluations. This deficiency was identified through interviews and record reviews, revealing that the evaluations were either outdated or missing entirely. Specifically, CNA 1's last competency evaluation was completed in August 2023, while CNA 2's was last done in October 2021. LVN 3 had no records of competency or performance evaluations, LVN 4 had a recent performance evaluation but no competency evaluation, and LVN 5's last competency evaluation was in April 2021. RN 2 also lacked both competency and performance evaluations. The Administrator confirmed that the Director of Staff Development was responsible for ensuring timely completion and updating of these evaluations in employee files. The facility's policy mandates that job performance and competency evaluations be conducted annually. The failure to adhere to these policies potentially compromised the quality of care provided to residents, as acknowledged by the Administrator during the interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled, stored, or discarded according to current professional standards. During an observation, it was found that insulin Humulin R vials for two residents were improperly stored at room temperature without appropriate labeling of the open date. One vial was found without any date indicating when it was opened, while another vial was labeled with an expired date. This oversight led to the potential risk of administering expired insulin, which could be ineffective in managing blood sugar levels. Additionally, in the medication room, two Aplisol multi-dose vials were found stored in the refrigerator with labels indicating they were opened beyond the manufacturer's recommended 30-day usage period. An unopened Pneumovax 23 syringe was also found stored at room temperature, contrary to the manufacturer's requirement for refrigeration. Furthermore, an expired emergency medication kit was not removed or replaced, increasing the risk of using ineffective medications in emergencies. Interviews with the LVN and the DON revealed a lack of adherence to the facility's policies and procedures regarding medication labeling and storage. The DON acknowledged that the emergency medication kit and expired medications should have been removed and replaced. The facility's failure to follow its own policies and the manufacturer's guidelines resulted in the presence of expired and improperly stored medications, posing a risk to resident safety.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect discussions and provision of written information regarding advance directives for two residents. Resident 2, who was admitted with diagnoses including dementia, dysphagia, and gastrostomy, was found to have severe cognitive impairment and was unable to make decisions. The Advance Directive Acknowledgment form for Resident 2, dated January 30, 2024, indicated the resident's incapacity to sign, and there was no signature from the responsible party acknowledging receipt of information about the resident's right to formulate an advance directive. Similarly, Resident 4, admitted with diagnoses of senile degeneration of the brain and schizophrenia, also had severe cognitive impairment and was unable to make decisions. The Advance Directive Acknowledgment form for Resident 4, dated February 1, 2021, similarly lacked a signature from the responsible party. During an interview and record review, the Social Services Director confirmed that written information regarding the right to formulate an advance directive was not provided to the responsible parties for both residents. This oversight violated the residents' rights to be fully informed about their options for advance directives.
Inaccurate Resident Assessments Lead to Care Deficiencies
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident 18's Minimum Data Set (MDS) did not include a diagnosis of chronic obstructive pulmonary disease (COPD), despite the resident's history and physical records indicating this condition. The MDS Nurse acknowledged the omission and emphasized the importance of including all diagnoses to prevent delayed treatment. The Director of Nursing (DON) also confirmed that all active diagnoses should be reflected in the MDS to avoid missing critical information that could delay care. Resident 25's MDS failed to list psychiatric diagnoses such as depression, bipolar disorder, and schizophrenia, despite the resident receiving medications for these conditions. The MDS Nurse noted that these diagnoses were not continued upon the resident's return from the General Acute Care Hospital (GACH), leading to a potential delay in care continuity. The Licensed Vocational Nurse (LVN) confirmed the importance of matching diagnoses with medications to ensure proper treatment. The DON explained that the admitting nurse should verify all diagnoses during re-admission, but this process was not followed, resulting in the omission. The facility's policies and procedures require accurate completion and signing of the MDS assessment form, as well as proper management of psychotropic medications, including monitoring for efficacy and adverse effects. However, these protocols were not adhered to, leading to the deficiencies observed in the residents' care. The failure to accurately document and continue diagnoses upon re-admission contributed to the potential for delayed treatment and improper medication management.
Failure to Conduct Quarterly Joint Mobility Assessments
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received quarterly joint mobility assessments, as required. Resident 11, who was admitted with a diagnosis of muscle weakness, had an initial joint mobility assessment indicating limitations, but no subsequent assessments were documented. This lack of follow-up assessments increased the risk of contractures and hindered the ability to monitor and maintain the resident's mobility. Interviews with the Director of Nursing (DON) and the Physical Therapist (PT) revealed that the facility lacked a specific policy on the timing of joint mobility assessments, although a general policy on resident mobility and ROM existed. The DON acknowledged that quarterly assessments should occur every three months, but no recent assessments were found for Resident 11. The PT admitted that despite a low workload, the demands were high, and many residents, including Resident 11, had not been reassessed, leaving no measurement of progress.
Failure to Label Respiratory Equipment in COPD Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents diagnosed with chronic obstructive pulmonary disease (COPD). Both residents, identified as Resident 18 and Resident 34, had oxygen humidifier bottles that were not labeled or dated, which is a requirement according to the facility's policy. This oversight was confirmed during observations and interviews with Licensed Vocational Nurse 1 (LVN 1) and the Director of Nursing (DON). The lack of labeling on the oxygen humidifier bottles increased the risk of infection control issues, potentially leading to resident discomfort or infection. Resident 18 was admitted with a diagnosis of COPD and had a physician's order for oxygen at two liters per minute via nasal cannula as needed. The resident's care plan indicated a risk for respiratory distress, yet the oxygen humidifier bottle was not labeled or dated. Similarly, Resident 34, also diagnosed with COPD, had a physician's order for oxygen administration under specific conditions. During an observation, it was noted that both the oxygen humidifier bottle and nasal cannula were not labeled or dated. The DON confirmed the importance of labeling respiratory equipment to ensure timely changes and prevent potential health risks.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) had completed annual performance evaluations, which is a requirement according to the facility's policy and procedure. CNA 1, hired on April 23, 2016, and CNA 2, hired on August 13, 2020, both lacked documented performance evaluations in their employee files. During an interview and record review with the Administrator, it was confirmed that the Director of Staff Development was responsible for ensuring these evaluations were completed and updated in the files. The absence of these evaluations was acknowledged by the Administrator, who noted the potential risk to the quality of care provided to residents due to this oversight. The facility's policy, revised in 2024, mandates that employee job performance be reviewed and evaluated at least annually. The failure to adhere to this policy resulted in an increased risk of not identifying areas of weakness in staff performance, potentially affecting the services provided to residents.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, resulting in a 12% error rate during a survey. This was due to three medication errors observed among 35 opportunities for two residents. Resident 34 was not instructed to properly use their Qvar inhaler, leading to medication escaping and not being fully inhaled. This was contrary to the manufacturer's instructions, which require a full seal around the mouthpiece to ensure proper dosage. Resident 36 experienced two medication errors. The resident was administered a crushed ferrous sulfate tablet instead of the prescribed liquid form, and the pantoprazole oral packet was given at an incorrect time. The Licensed Vocational Nurse (LVN) acknowledged these errors, noting that the administration did not follow the physician's orders or the facility's policy, which allows a 60-minute window for medication administration. The Director of Nursing confirmed these errors, emphasizing the importance of following physician orders and manufacturer instructions to prevent potential harm. The facility's policies on medication administration and error prevention were not adhered to, contributing to the observed deficiencies.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Specifically, the facility did not rotate the subcutaneous injection sites for insulin administration for a resident with Type II diabetes mellitus. The resident was prescribed Humulin 70/30 insulin to be administered subcutaneously once a day in the morning and in the evening. However, the Medication Administration Record (MAR) for November 2024 showed that the insulin was repeatedly administered in the same site, the right arm, by several licensed nurses over multiple days. Interviews with a Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the failure to rotate injection sites was against facility policy, standard practice, and manufacturer guidelines. This practice increased the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. The facility's policies and procedures emphasized the importance of rotating injection sites to minimize adverse consequences, as outlined in the manufacturer's guide for Humulin 70/30.
Lack of Coordination in Hospice Care for Resident
Penalty
Summary
The facility failed to ensure consistent coordination of care for a resident receiving hospice services, leading to a deficiency in the provision of necessary care. Resident 4, who was admitted with diagnoses including senile degeneration of the brain and schizophrenia, was supposed to receive hospice care as per the physician's orders. However, a review of the hospice records revealed that there were no signatures from a skilled nurse or home health aide on the sign-in sheets, indicating a lack of documented visits. Additionally, there was no hospice care plan in place for Resident 4, which is crucial for addressing the specific needs of the resident. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of documented hospice visits and a care plan. The RN acknowledged the importance of ensuring hospice staff visits and having a care plan, while the DON emphasized the need for hospice staff to sign in and maintain a care plan to prevent compromising the resident's care. The facility's policy on hospice care mandates coordination with hospice representatives to meet the resident's needs, which was not adhered to in this case.
Infection Control Deficiency: Oxygen Cannula on Floor
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, identified as Resident 34, when the resident's oxygen nasal cannula was observed on the floor. This incident was noted during an observation and interview with an LVN, who confirmed that the nasal cannula should not be on the floor due to infection control concerns. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), had a physician's order for oxygen administration via nasal cannula as needed for shortness of breath and low oxygen saturation levels. The Director of Nursing (DON) confirmed that the nasal cannula should be covered in a plastic bag when not in use to prevent infection, as the floor is considered a dirty surface. The facility's policy on infection prevention for respiratory therapy also indicated that oxygen cannulae and tubing should be kept in a plastic bag when not in use. Despite these guidelines, the nasal cannula was found on the floor, posing a risk of contamination and infection to the resident.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 10 out of 22 rooms met the required 80 square feet per resident in multiple occupancy rooms and failed to ensure that two rooms met the required 100 square feet for single occupancy. This deficiency was identified during an observation and interview process. The Maintenance Supervisor measured several rooms, and it was found that Rooms 1, 3, 4, 5, 6, 12, 15, 18, 13, and 24 did not meet the required space per resident. Additionally, two single rooms did not meet the 100 square feet requirement. The measurements were consistent with a client accommodation analysis conducted earlier. Interviews with residents and staff revealed that some residents, such as Resident 3 and Resident 12, did not express concerns about the room sizes, indicating they were able to move around without issues. A Certified Nurse Assistant also reported no concerns with the room size while providing care. Despite these individual experiences, the facility's policy requires specific square footage per resident, which was not met, leading to the deficiency.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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