Broadway Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 112 E. Broadway, San Gabriel, California 91776
- CMS Provider Number
- 056201
- Inspections on file
- 27
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Broadway Healthcare Center during CMS and state inspections, most recent first.
A resident with a high fall risk was left unattended in a high back wheelchair, resulting in a fall and significant injuries, including facial fractures. The resident's care plan and therapy evaluations indicated a need for total assistance with mobility, but the facility failed to provide adequate supervision, leading to the incident.
The facility failed to maintain a clean and sanitary food service area, with issues including an unclean juice machine, improperly sealed food containers, stained coffee mugs, and damaged food trays. These deficiencies were confirmed by the Dietary Manager and a dietary assistant, highlighting the risk of cross-contamination and illness.
A facility staff member failed to protect a resident's confidential information by leaving a computer screen open with the resident's medical details visible to others. The resident had serious health conditions, and the incident occurred in a public area, potentially exposing the information to unauthorized individuals. Despite staff training on HIPAA compliance, the screen was left unattended, violating privacy policies.
A facility failed to accurately document a resident's schizophrenia diagnosis in the MDS, despite the resident being treated with Seroquel for this condition. The omission was confirmed by staff, including the DON, who acknowledged that the MDS should reflect the resident's current status to aid in care planning. The MDS nurse cited a lack of comprehensive psychiatric documentation as the reason for not coding schizophrenia, even though the resident had been seen by a psychiatrist multiple times.
A resident with a stage 2 pressure ulcer, UTI, and sepsis experienced a worsening of their condition to a stage 3 ulcer due to non-compliance with care interventions. The facility failed to update the care plan to reflect the resident's refusal to be repositioned or sit in a cushioned wheelchair until after the ulcer worsened. Despite staff awareness of the non-compliance, the care plan was not revised in a timely manner, contrary to facility policy.
A resident with serious health conditions was improperly administered oxygen by a CNA instead of a licensed nurse, contrary to facility policy. The CNA placed a nasal cannula and turned on the oxygen concentrator without consulting a nurse, risking incorrect care. Interviews confirmed that only licensed nurses should administer oxygen, as it is considered a medication.
A resident with serious medical conditions was not provided a communication device in their preferred language, hindering effective communication with staff. Despite the facility's policy requiring trained interpreters, staff failed to use available translation services, leading to a situation where the resident's complaint of shortness of breath was not immediately addressed. The Director of Nursing acknowledged the failure to adhere to language access policies, resulting in a deficiency.
A resident dependent on staff for ADLs was found with long, jagged fingernails, leading to skin injuries due to scratching. Despite the resident's care plan indicating the need for nail maintenance, the facility failed to provide adequate grooming services. Observations and interviews confirmed the deficiency, highlighting a lapse in adhering to facility policies on personal hygiene.
A facility failed to administer oxygen to a resident as per physician's orders, despite the resident's medical conditions requiring continuous oxygen. The resident, who had diagnoses including congestive heart failure and acute respiratory failure, was found without oxygen and experiencing shortness of breath. The deficiency was confirmed through observations and interviews, revealing a lack of adherence to the facility's oxygen administration policy.
A facility failed to accurately measure the salt content in a meal for a resident on a renal diet, risking excessive sodium intake. The resident, with end-stage renal disease, received chicken gravy prepared without precise measurement, contrary to facility policy. The DON confirmed the gravy was salty, and the Dietary Manager emphasized the need for accurate measurements as per dietary recommendations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, contrary to its policy. The resident was not placed on EBP upon admission, and there was no signage or PPE outside the room. Staff misunderstood EBP requirements, believing it was only necessary for wounds with drainage, leading to non-compliance with infection control policy.
The facility failed to post daily staffing information in a visible and prominent location, as required by policy. Observations revealed that the staffing data was placed behind a door, making it inaccessible to residents, staff, and visitors. The DON was unaware of this practice, which contradicted the facility's policy to post staffing data in a clear and readable format.
The facility was found to have five residents in Room O, exceeding the maximum of four residents per room. The administrator confirmed this arrangement and had requested a waiver, arguing that it did not impact resident health and safety. The waiver indicated sufficient space for care and mobility, with room assignments reviewed for appropriateness.
The facility did not meet the required 80 square feet per resident in 14 of 24 rooms, with space ranging from 77.70 to 79.66 square feet per resident. Despite this, residents did not complain, and there was enough room for care and mobility. The Administrator acknowledged the deficiency and requested a waiver, stating that the space was adequate for care and did not affect residents' health and safety.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident 11, who was assessed as being at risk for falls. On the morning of 11/20/2024, Resident 11 was left unattended in a high back wheelchair by a Certified Nurse Assistant (CNA 5) who turned away to retrieve linen. During this brief period, Resident 11 fell forward from the wheelchair, resulting in a fall that caused significant injuries, including a left eyebrow laceration, blunt head injury, and multiple facial fractures. Resident 11 had a documented history of cognitive and physical impairments, including dementia, abnormal posture, and schizophrenia, which contributed to their fall risk. The resident's care plan, dated 8/24/2024, highlighted the potential for falls and included interventions such as not leaving the resident unattended in the shower room. However, it did not explicitly mention supervision requirements when the resident was in a wheelchair. The resident's physical and occupational therapy evaluations indicated a need for total assistance with mobility and wheelchair management, underscoring the resident's dependency on staff for safety. Interviews with facility staff, including the Licensed Vocational Nurse (LVN 1), Registered Nurse (RN 1), and the Director of Nursing (DON), revealed that the resident's high back wheelchair could be tilted and reclined to prevent forward falls. However, it was unclear whether the wheelchair was properly adjusted at the time of the incident. The facility's policies on managing falls and supporting activities of daily living emphasized the need for tailored interventions to prevent falls, but these were not effectively implemented in Resident 11's case, leading to the fall and subsequent injuries.
Deficiencies in Food Service Area Sanitation
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary manner, as observed during a survey. The juice machine was found with dried coffee drippings and a connecting tube with sticky brown and black gunk. Additionally, a container of ground ginger was observed with an improperly sealed lid, and coffee mugs were noted to have stains. Furthermore, food trays were found to be in poor condition, with cracks, chipping, and peeling laminate, which could potentially expose residents to pathogens. Interviews with the Dietary Manager and a dietary assistant confirmed these observations. The Dietary Manager acknowledged the unclean state of the juice machine and the improperly sealed food containers, emphasizing the risk of cross-contamination and illness. The dietary assistant also noted that cracked food trays could harbor bacteria, leading to cross-contamination. The facility's policies and procedures, revised in November 2022, require that the food service area be maintained in a clean and sanitary manner, with all equipment and utensils kept in good repair and free from damage.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility staff failed to protect the confidential personal information of a resident by not closing the computer screen after accessing the resident's medical information at the nursing station. This incident occurred in the presence of other staff, residents, and visitors, potentially exposing the resident's medical records to unauthorized individuals. The resident involved had been admitted with multiple serious health conditions, including acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, and pneumonia, among others. During an observation, a Licensed Vocational Nurse (LVN) was seen leaving the computer screen open and unattended after reviewing the resident's medical information. A Certified Nursing Assistant (CNA) confirmed the screen was left open, and anyone passing by could view the resident's private information. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that staff had been educated on HIPAA compliance, which includes not leaving computer screens with resident information open. The facility's policy emphasizes maintaining the confidentiality of each resident's personal and protected health information.
Failure to Accurately Document Schizophrenia Diagnosis in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of the Minimum Data Set (MDS) for a resident by not including the diagnosis of schizophrenia. The resident, who had a history of schizophrenia, was being treated with Seroquel for this condition. Despite this, the MDS did not reflect schizophrenia as an active diagnosis, which was confirmed by multiple staff members, including a Registered Nurse and the Director of Nursing. The omission was noted during a review of the resident's medical records, which included documentation of schizophrenia in the General Acute Care Hospital Emergency department history and physical, as well as an order for Seroquel specifically for schizophrenia. The MDS nurse stated that schizophrenia could not be coded in the MDS due to a lack of comprehensive psychiatric documentation, despite the resident having been seen by a psychiatrist multiple times. The Director of Nursing acknowledged that the MDS should reflect the resident's current status, including active diagnoses, to assist in developing an appropriate care plan. The facility's policy and procedure indicated that the resident assessment coordinator is responsible for ensuring accurate and timely assessments, which should consistently reflect information in progress notes and care plans.
Failure to Revise Care Plan for Non-Compliant Resident with Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a stage 2 pressure ulcer, which progressed to a stage 3 ulcer due to non-compliance with care interventions. The resident, who was admitted with a stage 2 pressure ulcer, urinary tract infection, and sepsis, required assistance with bed mobility and activities of daily living. Despite the resident's refusal to be repositioned or to sit in a cushioned wheelchair, the care plan was not updated to reflect these compliance issues until after the ulcer worsened. The interdisciplinary team conducted several wound management assessments, noting the resident's non-compliance and the need for repositioning every two hours. However, the care plan was not revised to address the resident's refusal to comply with these interventions until the pressure ulcer had already progressed to a stage 3. Staff interviews revealed that the resident's non-compliance was known but not documented in the care plan in a timely manner, and interventions such as offering soda to encourage cooperation were not included. The facility's policy requires care plans to be revised when there is a significant change in the resident's condition or when desired outcomes are not met. Despite this, the care plan was only updated after the ulcer worsened, highlighting a failure to adhere to the policy. The resident's refusal to participate in care was not documented as required, contributing to the deficiency in care planning and potentially impacting the resident's health outcomes.
Improper Oxygen Administration by CNA
Penalty
Summary
The facility failed to ensure professional standards of quality for administering oxygen to a resident, identified as Resident 9, by allowing a Certified Nurse Assistant (CNA) to administer oxygen instead of a licensed nurse. Resident 9, who was admitted with multiple serious health conditions including acute on chronic congestive heart failure, acute respiratory failure with hypoxia, and pneumonia, was observed without oxygen and short of breath. The CNA placed a nasal cannula on Resident 9 and turned on the oxygen concentrator to 5 liters per minute without consulting a licensed nurse, which is against the facility's policy. The incident occurred when the CNA assisted Resident 9 from a bedside commode back to bed and noticed the resident was short of breath. Despite the resident's request for oxygen, the CNA proceeded to administer it without verifying the physician's order or consulting a licensed nurse. The CNA later acknowledged that she was not aware of the specific oxygen order and admitted that it was not within her scope of practice to turn on the oxygen machine. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Director of Staffing Development (DSD) confirmed that CNAs are not authorized to administer oxygen, as it is considered a medication that should only be administered by licensed nurses. The facility's policy and procedure documents also support this, indicating that oxygen administration requires assessment and monitoring by a licensed nurse to ensure the correct dosage and prevent potential harm to the resident.
Failure to Provide Communication Device in Preferred Language
Penalty
Summary
The facility failed to provide a communication device in the preferred language of a resident, identified as Resident 9, which hindered effective communication with the staff. Resident 9 was admitted with several serious medical conditions, including acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, acute and chronic pulmonary edema, pleural effusion, and pneumonia. Despite having the capacity to understand and make decisions, Resident 9's preferred language was not accommodated, as indicated in the Minimum Data Set (MDS) and care plan. During observations, it was noted that Resident 9 did not have a communication or picture board at the bedside. On one occasion, a Licensed Vocational Nurse (LVN1) attempted to communicate with Resident 9 in a language the resident did not understand, leading to a failure in recognizing the resident's complaint of shortness of breath. The Director of Nursing (DON) acknowledged that it was unacceptable for LVN1 to leave the resident alone while experiencing shortness of breath and confirmed that the facility had a phone service for translation that should have been used. The facility's policy on translation and interpretation services was not adhered to, as it requires trained interpreters and prohibits reliance on family members for interpretation unless explicitly requested by the resident. The DON confirmed discrepancies in the resident's language preferences as recorded in the MDS and face sheet. The lack of appropriate communication tools and adherence to language access policies resulted in a deficiency that compromised Resident 9's ability to communicate effectively with the staff.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who was non-verbal and had severely impaired cognitive skills, was observed with long, jagged fingernails. This condition was noted during an observation by a certified nursing assistant and a registered nurse supervisor, both of whom confirmed the resident's nails were rough and sharp. The resident had multiple wounds on the right leg, attributed to a habit of scratching, which was exacerbated by the condition of the nails. The resident's medical history included diagnoses of lack of coordination, sepsis, and dysphagia, and they were totally dependent on staff for personal hygiene and other ADLs. The resident's care plan, which was reviewed and revised multiple times, indicated the need for assistance with personal hygiene and specifically mentioned the necessity of keeping the resident's nails trimmed to prevent skin injuries. Despite these documented needs and interventions, the facility did not ensure the resident's nails were maintained in a safe condition. The facility's policies and procedures emphasized the importance of providing care to maintain or improve residents' ability to perform ADLs, including grooming and personal hygiene. However, the facility did not adhere to these policies, resulting in the resident having long, jagged fingernails that contributed to skin injuries. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to implement the care plan and facility policies effectively.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for Resident 9 by not administering oxygen according to the physician's orders. Resident 9, who was admitted with acute on chronic combined systolic and diastolic congestive heart failure, acute respiratory failure with hypoxia, acute and chronic pulmonary edema, pleural effusion, and pneumonia, was observed without oxygen and experiencing shortness of breath. The physician's order required continuous oxygen administration at 2 to 5 liters per minute via nasal cannula due to hypoxia related to congestive heart failure. However, during an observation, the resident was found without oxygen, and a Certified Nurse Assistant (CNA) had to ask the resident if they wanted oxygen, which was then administered at 5 liters per minute. The deficiency was further highlighted during interviews and record reviews, where it was confirmed that the resident had an order for continuous oxygen, not as needed (PRN) oxygen. The Director of Nursing acknowledged that oxygen is considered a regular medication order and that the resident was at risk of harm while complaining of shortness of breath because oxygen needed to be administered. The facility's policy and procedure for oxygen administration, which includes placing an 'Oxygen in Use' sign outside the room, was not followed, as there was no sign observed outside Resident 9's room. This failure to adhere to physician orders and facility policies placed the resident at risk for complications such as respiratory distress.
Failure to Measure Salt Content in Renal Diet
Penalty
Summary
The facility failed to accurately measure the salt content of food served to a resident on a renal diet, which is crucial for individuals with kidney disease to limit certain nutrients such as salt. The resident, who was diagnosed with end-stage renal disease and dependent on renal dialysis, was at risk of receiving more sodium than required due to this oversight. During an observation, it was noted that a staff member prepared chicken gravy for the resident without using a measuring device, instead approximating the amount by 'eyeballing' it. This practice was against the facility's policy, which requires precise measurement of ingredients to adhere to dietary recommendations. The Director of Nursing confirmed that the gravy served was salty and emphasized the importance of following exact recipe measurements for therapeutic diets. The Dietary Manager also stated that all ingredients need to be measured accurately, as per the facility's policy. A review of the resident's order summary and the facility's policy on liberal renal diets indicated that salt packages should be eliminated, highlighting the discrepancy in the preparation of the resident's meal. The facility's standardized recipe policy further reinforced the need for exact measurements for all ingredients, underscoring the deficiency in the preparation of the resident's meal.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer, which later regressed to stage three. Despite the facility's policy requiring EBP for residents with wounds, the resident was not placed on EBP upon admission. The resident's admission data tool incorrectly indicated that EBP was not warranted, and there was no EBP signage or PPE cart outside the resident's room. The Infection Preventionist Nurse and Treatment Nurse both stated that EBP was not ordered or implemented because the resident's wounds had no drainage. The Director of Nursing acknowledged that EBP should have been ordered upon the resident's admission and included in the care plan. The facility's policy outlined that EBP is necessary for high-contact activities such as dressing, bathing, and wound care, and requires signage and PPE availability. The lack of EBP implementation was due to a misunderstanding that EBP was only necessary for wounds with moderate to heavy drainage, leading to a failure to follow the facility's infection control policy.
Failure to Post Staffing Information in Visible Location
Penalty
Summary
The facility failed to ensure that staffing information, including the total number of staff and the actual hours worked, was posted in a visible and prominent place on two consecutive days, 1/21/2025 and 1/22/2025. During an observation on 1/21/2025 at 7:45 AM, no visible daily staffing information was found in the facility lobby. On 1/22/2025, during a concurrent observation and interview at 2:42 PM, RN 2 indicated that the staffing information was posted on the wall behind a door leading to resident rooms, making it not visible to residents, staff, and visitors. Further investigation on 1/22/2025 at 2:44 PM with the Director of Nursing (DON) revealed that the DON was unaware that the staffing information was being posted behind the door. The facility's policy, revised in August 2022, requires that staffing data be posted daily in a prominent location accessible to residents and visitors. The DON acknowledged the importance of posting this information visibly to ensure that residents and visitors are informed about the facility's staffing levels, which are necessary to deliver care in accordance with regulations.
Facility Exceeds Resident Capacity in Room O
Penalty
Summary
The facility failed to comply with regulations by accommodating five residents in Room O, which exceeds the maximum allowable number of four residents per room. This was observed during a survey on January 24, 2025, where all five beds in Room O were occupied. The facility's administrator confirmed the room's occupancy and stated that a waiver had been requested to allow this arrangement, arguing that it did not affect the health and safety of the residents and that there was sufficient space for staff to provide care. The room waiver, dated January 16, 2024, indicated that Room O had five beds with a total area of 511.60 square feet. The facility's waiver request, dated January 21, 2025, sought continued permission for reduced square footage per resident, provided that room assignments were reviewed during the admission process and checked frequently for appropriateness. The waiver also claimed that ample space was available for resident care and mobility, and that room rounds were conducted to ensure no unnecessary items or equipment hindered access.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for 14 out of 24 rooms, as observed during a tour. These rooms, labeled A through N, did not meet the square footage requirement, with measurements ranging from 77.70 to 79.66 square feet per resident. Despite this, residents did not express complaints about the space, and there was sufficient room for staff to provide care and for residents, including those who are wheelchair-bound, to move without difficulty. The facility's Administrator acknowledged the deficiency, stating that 14 rooms did not meet the required space per resident. The Administrator indicated that a room waiver had been requested from CMS, arguing that the space was adequate for care and did not impact residents' health and safety. The facility's Client Accommodation Analysis and room waiver letter supported this claim, noting that room assignments were reviewed for appropriateness and that there was ample space for resident care and mobility. The recertification survey confirmed that the rooms had adequate ventilation, lighting, and privacy features, with sufficient space for wheelchair access and movement.
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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