Brookfield Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Downey, California.
- Location
- 9300 Telegraph Road, Downey, California 90240
- CMS Provider Number
- 056014
- Inspections on file
- 27
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Brookfield Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and mobility impairments experienced a fall, but the subsequent fall risk reassessment did not document the recent fall or include key risk factors such as incontinence and wheelchair use. The incomplete evaluation resulted in a lower fall risk score, contrary to facility policy requiring accurate post-fall assessments.
A resident with significant mobility and cognitive impairments experienced a fall, but staff did not initiate a care plan or implement specific interventions to address the incident. Despite facility policy requiring a comprehensive, person-centered care plan after such events, no plan was developed to ensure the resident's safety.
A resident with asthma and COPD was administered both Advair Diskus and Serevent Diskus, leading to duplicate drug therapy with excessive salmeterol dosages. Nursing staff failed to consult drug references or pharmacists, resulting in 33 days of unnecessary medication. The oversight was identified during a review of medication records, revealing a lapse in adherence to facility policies.
A facility failed to obtain a complete informed consent for a resident receiving citalopram for major depressive disorder. The consent form lacked details on dosage, frequency, and behavioral manifestations, which are essential for informed decision-making. Interviews with the RN and DON highlighted the responsibility of licensed nurses to ensure residents and their Responsible Parties are fully informed about medication treatments.
The facility failed to ensure accurate MDS assessments for four residents, omitting diagnoses of depression and seizure disorder, and not recording significant weight loss. These inaccuracies could negatively impact the residents' care plans and necessary interventions.
The facility failed to develop timely, person-centered care plans for three residents, leading to deficiencies in their care. A resident with cancer did not have a care plan for her condition, another resident using a nicotine patch lacked a care plan for smoking cessation, and a third resident with an ileostomy had no care plan for its management. These oversights resulted in inadequate monitoring and support for the residents' health needs.
A resident with a history of falls and dementia experienced multiple falls, but the care plan was not updated to prevent future incidents. Despite the facility's policy requiring care plan revisions after falls, the plan remained unchanged, lacking new interventions. Interviews with staff confirmed the necessity of updating care plans to prevent further falls.
A resident with a history of falls and dementia experienced a fall, but the facility failed to conduct an interdisciplinary team (IDT) meeting to address the incident. Despite the requirement for such meetings to develop a care plan and prevent future falls, no IDT notes were found for the fall, delaying necessary interventions.
The facility failed to ensure safety for two residents by not using floor mats for a resident with seizures and not conducting an IDT review after another resident's fall. The first resident, with severe cognitive impairment, was observed without a required floor mat on one side of the bed, increasing the risk of injury during seizures. The second resident, with a history of falls and dementia, did not have an IDT meeting after a fall, delaying necessary interventions. These actions were against the facility's policies, potentially compromising resident safety.
The facility failed to ensure safe medication administration for four residents. A resident did not receive timely medication, and medications were left for self-administration. Another resident experienced delays due to an LPN running late, and a nurse documented administering medication they did not give. The DON confirmed these practices were unacceptable.
A resident was prescribed duplicate drug therapy with Serevent Diskus and Advair Diskus, both containing salmeterol, which was not identified during the Monthly Regimen Review. The facility's Consultant and Dispensing Pharmacists failed to recognize the duplicate therapy, contrary to the facility's policy requiring identification of such irregularities.
A facility failed to label opened inhalers with an open date for three residents, as required by manufacturers' guidelines. The medications, including Advair Diskus, Serevent Diskus, and Arnuity Ellipta, were found in the MedCart without the necessary labeling. An LVN and the DON confirmed the oversight, acknowledging the risk of using expired medications. The facility's policy and manufacturers' instructions emphasized the need for proper labeling to ensure medication effectiveness and resident safety.
A resident with severe cognitive impairment was prescribed Triamcinolone Acetonide Ointment for itching, but the facility failed to document the specific site of application. Staff interviews revealed a lack of assessment and communication, with the DON acknowledging the physician's order was incomplete, risking incorrect medication administration.
Failure to Accurately Reassess Fall Risk After Resident Fall
Penalty
Summary
The facility failed to conduct an accurate fall reassessment for one resident following a fall incident. The resident, who had diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was admitted with significant physical and cognitive impairments. The initial fall risk evaluation identified the resident as high risk, noting incontinence, balance problems, and the use of assistive devices. However, after the resident was found on the floor in their room, the subsequent fall risk evaluation did not document the recent fall, omitted the resident's incontinence and use of a wheelchair, and assigned a lower fall risk score. During interviews and record reviews, it was confirmed that the fall risk reassessment was incomplete and inaccurate. The MDS Nurse acknowledged that the evaluation did not reflect the resident's true risk factors and that the incorrect scoring could result in improper care planning. Facility policy required appropriate assessment and interventions after a fall, but these were not followed in this instance.
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a resident-centered care plan following a fall experienced by one of the residents. The resident, who was admitted with diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was found sitting on the floor in his room. Documentation indicated that the resident required significant assistance with activities of daily living, including being dependent or requiring maximal assistance for mobility and transfers. Despite these needs and the occurrence of a fall, there was no care plan initiated to address the incident or to implement interventions for the resident's safety. Interviews and record reviews confirmed that the MDS Nurse acknowledged the absence of a care plan after the fall and recognized that the facility's policy required the development of care plan interventions to prevent further falls. The facility's policies also specified that the interdisciplinary team should create a comprehensive, person-centered care plan with measurable objectives and time frames based on the resident's assessment. However, these procedures were not followed after the resident's fall, resulting in a lack of documented interventions to address the identified risk.
Duplicate Drug Therapy Leads to Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving duplicate drug therapy. A resident, who had been diagnosed with asthma and COPD, was prescribed both Advair Diskus and Serevent Diskus, which both contain the active ingredient salmeterol. This resulted in the resident receiving excessive dosages of salmeterol, as both medications were administered concurrently from mid-September to mid-October. The issue was identified during a review of the resident's medication administration records, which showed that the resident was given both medications daily for 33 days. Interviews with nursing staff revealed that they administered both inhalers at the same time, under the assumption that it was acceptable due to their simultaneous scheduling. The nursing staff did not consult with a pharmacist or use a drug reference to verify the safety of administering these medications together. The Director of Nursing and the facility's pharmacists acknowledged the oversight, noting that the duplication in drug therapy was missed during the Monthly Regimen Review. The facility's policy and procedure documents emphasized the importance of consulting drug references when unfamiliar with medications, but this protocol was not followed. The manufacturer's labeling for both medications clearly warned against using them in conjunction due to the risk of overdose and serious cardiovascular side effects.
Incomplete Informed Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure a complete informed consent form was obtained for the administration of citalopram to a resident diagnosed with major depressive disorder. The resident, who had a history of Parkinson's disease, osteoarthritis, and hypertension, was moderately cognitively impaired but had the capacity to understand and make decisions. The resident's Minimum Data Set indicated feelings of depression, and the resident was dependent on staff for daily activities. Despite this, the informed consent form for citalopram did not include the medication's dosage, frequency, or behavioral manifestations, which are necessary for informed decision-making. Interviews with the facility's RN and DON revealed that the licensed nurse was responsible for verifying that the resident and their Responsible Party were fully informed about the medication, including its dosage, frequency, and behavioral manifestations. The facility's policy required informed consent to be obtained prior to medication use, but the documentation was incomplete. This oversight meant that the resident and their Responsible Party might not have been fully informed about the treatment, potentially affecting their ability to make an informed decision regarding the resident's care.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, leading to potential negative impacts on their care plans and delivery of necessary services. For Resident 32, the MDS did not include a diagnosis of major depressive disorder, despite the resident receiving antidepressant medication and having been diagnosed by a psychiatrist. Similarly, Resident 3's MDS omitted a diagnosis of major depressive disorder, even though the resident had a long-term history of depression and was on antidepressant medication. Resident 9's MDS inaccurately reported no significant weight loss, although the resident experienced a 5% weight loss over one month. This omission could hinder the monitoring of the resident's nutritional status and the implementation of appropriate interventions to prevent further weight loss. Additionally, Resident 253's MDS failed to include a diagnosis of seizure disorder, despite the resident being readmitted to the facility with this primary diagnosis after a hospital stay. Interviews with the MDS Coordinator and the Director of Nursing highlighted the importance of accurate MDS assessments for developing patient-centered care plans. The facility's policy emphasized comprehensive and accurate assessments, yet the deficiencies in the MDS entries for these residents indicate a failure to adhere to this policy, potentially affecting the residents' care and treatment.
Failure to Develop Timely Care Plans for Residents
Penalty
Summary
The facility failed to develop timely, person-centered care plans for three residents, leading to deficiencies in their care. Resident 153, who was admitted with kidney failure and congestive heart failure, was diagnosed with cancer of the left eye and skin. Despite this diagnosis, no care plan was developed to address these new health issues. Interviews with Resident 153 and staff revealed that the resident was not informed about her dermatologist appointment, and no new treatments were provided for her skin or vision issues. The lack of a care plan meant there was no structured follow-up or interventions for her cancer diagnosis. Resident 42, who was admitted with peritonitis, intestinal obstruction, and deep vein thrombosis, was prescribed a nicotine patch for smoking cessation. However, a care plan to monitor the effectiveness and side effects of the nicotine patch was not developed until several months after the initial prescription. The delay in care planning resulted in a missed opportunity to monitor and support Resident 42's smoking cessation efforts, as evidenced by the resident being seen smoking a cigarette months after starting the nicotine patch. Resident 21, admitted with an infection of the ileostomy surgical site and acute kidney failure, also lacked a specific care plan for the care and monitoring of the ileostomy and stoma. The absence of a care plan meant there were no documented interventions for monitoring the stoma for bleeding or infection, changing the ileostomy bag, or cleaning the stoma and surrounding skin. This oversight left the nursing staff without a clear guide for providing necessary care to Resident 21, potentially compromising the resident's health and well-being.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The licensed nurses at the facility failed to review, update, and revise the care plan for Resident 21 to reflect attempts to prevent future falls. Resident 21, who has a history of falls and dementia, was admitted to the facility and had experienced multiple falls on specific dates. Despite these incidents, the care plan, which initially included interventions such as anticipating needs, placing the call light within reach, maintaining the bed in the lowest position, and encouraging appropriate footwear, was not revised after the falls on 8/9/2024 and 9/16/2024. Interviews with RN 3 and the Director of Nursing (DON) revealed that the care plan should have been revised after each fall to introduce new interventions to prevent further falls. The facility's policy and procedure on fall management emphasized the importance of updating care plans after every fall to provide appropriate assessment and interventions. However, the care plan for Resident 21 remained unchanged, resulting in a lack of interventions to prevent further falls, as evidenced by the resident's subsequent fall on 10/4/2024.
Failure to Conduct IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting following a fall experienced by Resident 21 on 9/16/2024. This oversight was identified through observation, interviews, and record reviews. Resident 21, who has a history of falls and dementia, was admitted to the facility with severely impaired cognitive skills and required moderate assistance for daily activities. Despite having falls on 8/9/2024, 9/16/2024, and 10/4/2024, the IDT notes were missing for the fall on 9/16/2024, indicating that no meeting was held to address this incident. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed that an IDT meeting is required after every fall to develop a care plan and prevent future incidents. The facility's policy mandates collaboration with the attending physician and documentation of the meeting in the electronic medical record (EMR). The absence of an IDT meeting for the fall on 9/16/2024 delayed the implementation of fall prevention interventions, potentially increasing the risk of subsequent falls for Resident 21.
Failure to Prevent Accidents and Conduct IDT Review
Penalty
Summary
The facility failed to ensure that Resident 253 was free from accident hazards by not utilizing floor mats as ordered. Resident 253, who has severe cognitive impairment and is dependent on staff for daily activities, was observed without a floor mat on the left side of the bed, despite having a physician's order for floor mats on both sides as a precaution against seizures. This oversight was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the risk of injury if the resident were to have a seizure and fall. Additionally, the facility did not conduct an interdisciplinary team (IDT) review for Resident 21 after a fall, which is a required procedure following such incidents. Resident 21, who has a history of falls and dementia, experienced a fall on 9/16/2024, but no IDT notes were found in the electronic medical record for this incident. Interviews with a Registered Nurse and the Director of Nursing confirmed that an IDT meeting should have been held to develop a plan to prevent future falls, as falls are considered a change of condition. The facility's policies and procedures, including the Fall Management System and Significant Change of Conditions, emphasize the importance of maintaining an environment free of accident hazards and conducting IDT meetings after falls. These deficiencies highlight the facility's failure to adhere to its own policies, potentially compromising resident safety.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure safe and effective medication administration practices for four out of five sampled residents. Registered Nurse (RN 2) did not administer medication to Resident 19 in a timely manner, resulting in the resident expressing concern about not receiving her medications for blood pressure and blood sugar. Additionally, RN 2 left medications at Resident 19's bedside for self-administration, which is not an acceptable practice as it could lead to medication errors. Resident 25 experienced a delay in receiving medications due to Licensed Vocational Nurse (LVN 2) running late with the medication pass. Furthermore, RN 3 left medications at Resident 25's bedside for self-administration, despite the resident having severely impaired cognitive skills. This practice was acknowledged by RN 3 as unacceptable, as it could not be confirmed whether the resident took the medication or experienced any adverse reactions. Resident 48 also faced a delay in medication administration due to LVN 2 being sidetracked. Additionally, LVN 1 incorrectly documented administering pain medication to Resident 49, when it was actually administered by another nurse. The Director of Nursing (DON) confirmed that these practices were not acceptable, emphasizing the importance of timely medication administration to avoid negative health effects.
Failure to Identify Duplicate Drug Therapy in Resident's Medication Regimen
Penalty
Summary
The facility failed to identify a drug irregularity during the Monthly Regimen Review (MRR) for a resident receiving duplicate drug therapy. The resident was prescribed two orally inhaled medications, Serevent Diskus and Advair Diskus, both containing salmeterol, a long-acting bronchodilator. This oversight occurred between September 13, 2024, and October 15, 2024, and was not identified during the MRR, as indicated by the unmarked sections for Drug-Drug Interactions and Drug Duplications on the review form. The resident's medical history included asthma and chronic obstructive pulmonary disease (COPD), and the resident had intact cognition as per the Minimum Data Set (MDS) dated September 17, 2024. Interviews with the facility's Consultant Pharmacist and Dispensing Pharmacist revealed that neither had identified the duplicate therapy. The Consultant Pharmacist admitted to not reviewing the resident's medications and stated that he would have questioned the physician about the duplicate therapy had he noticed it. The Dispensing Pharmacist confirmed the duplicate therapy and acknowledged that it should have been flagged during the medication order review. The facility's policy on Medication Regimen Review, dated December 2023, requires the identification and documentation of drug irregularities, including duplicate drug therapy, which was not adhered to in this case.
Failure to Label Inhalers with Open Dates
Penalty
Summary
The facility failed to ensure that opened boxes of oral inhalation medications were labeled with an open date, as required by the manufacturers' guidelines. This deficiency was observed for three residents who were using inhalers for conditions such as asthma, COPD, and other respiratory issues. The medications involved included Advair Diskus, Serevent Diskus, and Arnuity Ellipta, which were found in the MedCart without the necessary open dates. During an observation, it was noted that the inhalers for three residents were opened but lacked the required open date labeling. This oversight was confirmed by an LVN, who acknowledged that the absence of an open date could lead to the use of expired medications, potentially resulting in ineffective treatment for the residents. The Director of Nursing also confirmed that the inhalers should have been labeled with an open date to ensure their effectiveness and prevent respiratory complications. The facility's policy and procedures, as well as the manufacturers' labeling instructions, clearly stated the requirement for labeling opened inhalers with an open date. The failure to adhere to these guidelines increased the risk of administering expired medications to residents, which could compromise their respiratory health. The report highlights the importance of following proper medication labeling practices to ensure the safety and well-being of residents.
Incomplete Assessment and Documentation of Itchy Area
Penalty
Summary
The facility failed to ensure that a resident's itchy area was properly assessed and documented, and that the physician's order for treatment included the specific site of administration. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was prescribed Triamcinolone Acetonide Ointment 0.1% to be applied to areas of itching twice daily. However, the Medication Administration Record did not specify the location of the itching, and the progress notes lacked documentation of the site under the integumentary system assessment. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's condition. A Licensed Vocational Nurse admitted that they should have assessed the resident's skin and informed the physician. A Registered Nurse was unsure of the cause of the resident's itching. The Director of Nursing acknowledged that the physician's order was incomplete, as it did not specify the site of application, which could lead to incorrect administration of the medication.
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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