Buena Park Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Buena Park, California.
- Location
- 8520 Western Avenue, Buena Park, California 90620
- CMS Provider Number
- 055571
- Inspections on file
- 26
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 48
Citation history
Health deficiencies cited at Buena Park Nursing Center during CMS and state inspections, most recent first.
A resident with a left hand mitten restraint ordered to prevent pulling out a GT had a care plan and facility policy requiring the mitten to be released every two hours for circulation, comfort, and exercise. Record review showed only shift-level monitoring of mitten placement, with no documentation that the mitten was released every two hours as care-planned. An RN confirmed the protocol to remove the mitten every two hours and assess circulation and skin, but acknowledged there was no corresponding order or documentation showing these checks were performed.
A resident with glaucoma and no decision-making capacity had multiple missed doses of ordered ophthalmic medications, including Refresh Plus, Timoptic, and Lumify. MAR review showed numerous administrations not given, some coded as held or to see progress notes without clear reasons, and others marked as awaiting pharmacy delivery or out of stock. Nursing documentation reflected calls to the pharmacy but did not show that the physician was notified of the repeated missed doses. During interviews, RN staff acknowledged that charge nurses were responsible for timely refill requests and that the physician should have been informed when medications were not administered as ordered.
A resident who lacked decision-making capacity experienced a fall, but staff did not update the care plan to address this incident. Review of the medical record and interviews with an RN and the DON confirmed that no care plan problem or intervention was developed for the fall, despite facility policy requiring care plan updates after such events.
Two residents did not receive necessary care and monitoring as required by physician recommendations and facility policy. One resident did not have a recommended medication initiated, did not receive neurological checks after a fall, and was not monitored for orthostatic hypotension while on Seroquel. Another resident did not receive neurological checks after an unwitnessed fall, despite documentation indicating they should have. These deficiencies were confirmed by staff interviews and record reviews.
A resident who lacked decision-making capacity was administered Ativan for anxiety without documented informed consent, as required by facility policy. Staff confirmed that when the medication was reordered after an initial period, the necessary informed consent process was not completed, and this was acknowledged by the DON.
The facility did not ensure consistent and accurate posting of Enhanced Barrier Precaution (EBP) signs for multiple residents colonized with MDROs, leading to staff confusion about required PPE. Staff interviews revealed uncertainty about the meaning of different colored isolation signs and the appropriate use of masks and gowns, while training records lacked evidence of specific instruction on these distinctions. These failures resulted in improper infection control practices for residents on EBP.
A resident with complex medical needs, including diabetes and gastroparesis, did not receive enteral feeding and medication through the correct ports of a GJ tube as ordered by the physician. Facility staff were unable to identify the G and J ports, did not notify the physician when unable to verify port placement, and had not received in-service training on GJ tube care. Additionally, there was no physician's order for the maintenance or discontinuation of the G tube drainage bag, resulting in the resident's transfer to an acute care hospital after the J tube became clogged and the resident experienced severe hypoglycemia.
A facility failed to ensure a POLST was signed and dated by a physician for a resident who lacked decision-making capacity. The POLST was incomplete, missing the healthcare provider's signature and date. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, as confirmed by staff interviews and medical record reviews.
The facility failed to complete PASRR screenings for two residents, leading to potential gaps in care. A resident readmitted after a hospital stay did not receive a new Level 1 PASRR screening, despite a recent depression diagnosis. Another resident, diagnosed with mild depression and prescribed mirtazapine, did not have a PASRR Level 1 Screening Resident Review Status Change performed. Staff confirmed these oversights, acknowledging the need for updated screenings to ensure appropriate care and resources.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks. One resident did not have a care plan for the use of elevated side rails, despite a physician's order. Another resident's care plan did not address their preference for a high bed, which increased the risk of falls. Staff confirmed the lack of appropriate care plans and interventions for these issues.
The facility failed to prevent pressure ulcers and ensure proper care for several residents. A resident developed a new blister that was not assessed or treated appropriately. Additionally, the facility did not consistently monitor and adjust the settings of low air loss (LAL) mattresses according to residents' weights, leading to incorrect settings for three residents. These deficiencies were confirmed by staff observations and interviews.
A facility failed to ensure a resident's GT feeding was properly connected, resulting in the feeding dripping onto the floor. The resident had a physician's order for continuous enteral feeding, but during an observation, it was found disconnected. Staff suggested the disconnection might have occurred after dialysis or during a shower. The issue was verified by RN and LVN, and the Administrator and DON were informed.
The facility failed to provide appropriate respiratory care for several residents, including incorrect oxygen administration, lack of required signage, and improper storage of respiratory equipment. These deficiencies were confirmed through observations and staff interviews.
A facility failed to provide appropriate dialysis care for a resident with ESRD by not completing required dialysis communication forms. The facility's P&P required pre- and post-dialysis checklists to be completed, but multiple entries were left blank. An LVN confirmed the oversight, acknowledging the forms should have been filled out.
The facility failed to ensure resident safety by not attempting alternatives or obtaining informed consent before using bed rails for two residents. One resident with impaired cognition used grab bars without documented consent or alternatives, while another with seizures had no assessment for entrapment risk or informed consent. Staff confirmed these omissions, posing potential entrapment risks.
A facility failed to administer medications via GT by gravity as per policy and did not check a resident's bowel pattern before giving a stool softener. An LVN used a syringe to push medication through the GT and relied on inaccurate verbal reports instead of reviewing the resident's documented history of loose stools.
A facility failed to monitor a resident's blood pressure and heart rate before administering amlodipine and losartan, as prescribed. The resident's physician orders required holding the medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm. From November 1 to 19, there was no documented evidence of these checks, confirmed by an RN during a review.
The facility failed to ensure that two residents were free from unnecessary medications. A resident was prescribed zolpidem without a 14-day stop date, and another was given quetiapine fumarate without a documented diagnosis or clinical rationale. These issues were confirmed by facility staff during interviews.
The facility failed to ensure safe storage and management of medications, with expired medications found in a medication room and carts, unauthorized bedside storage of antifungal cream, and improper disposal of controlled substances. Additionally, medication carts contained expired supplies and improper storage of items, risking cross-contamination and unsafe administration.
The facility failed to follow food safety and sanitation guidelines, including improper air-drying of a blender, use of corroded frying pans, and staff's lack of knowledge on proper food cooling procedures. Additionally, the storage area for water pitchers and cups was unsanitary. These issues were acknowledged by staff and reported to the DON and administrator.
The facility failed to label and date food items in a resident refrigerator, as required by their policy. During an observation, an RN and an LVN found several unlabeled and undated food items, including yogurts, cookies, kimbap, soy milk, a dirty Tupperware, and a jar of chia seeds. The RN confirmed that food should be labeled and dated, and noted that staff should not store their food in the resident's refrigerator. The refrigerator was also found to be dirty and sticky.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in health care directives and assessments. A resident's POLST was not updated to reflect their advance directive, another resident's record contained conflicting information about an advance directive, and a third resident's smoking assessment and care plan were incomplete and inaccurate. These issues were confirmed by facility staff.
An LVN failed to change gloves and PPE between administering medications to two residents on enhanced barrier precautions, risking infection transmission. The residents had conditions requiring specific precautions, and the LVN acknowledged the oversight.
The facility failed to notify physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection. This oversight involved multiple residents over several months, despite the facility's policy to promote appropriate antibiotic use. The Infection Preventionist confirmed that physicians were not informed, potentially leading to unnecessary antibiotic use and associated risks.
The facility failed to ensure proper calibration and quality control of glucometers, with missing entries and discrepancies in records for devices in Medication Carts A, F, and D. These lapses were confirmed by LVNs and the DON, potentially leading to inaccurate blood glucose readings for residents.
A resident's call light was found out of reach, contrary to the facility's policy requiring it to be easily accessible. The resident, who was dependent on staff for care due to medical conditions, was unable to summon help when needed. An LVN confirmed the call light's inaccessibility, acknowledging the resident's occasional use of it for assistance.
The facility failed to maintain a clean and homelike environment, as observed in several resident rooms. In one room, the door frame casings were in disrepair, with cracks, scratches, and missing paint, which the DON acknowledged might have been caused by resident beds. Additionally, curtains in four other rooms were found to be yellowish stained and dirty, a condition confirmed by an LVN who noted they needed changing. These issues posed a risk for unsanitary and unsightly conditions, potentially affecting residents' quality of life.
A resident on anticoagulant medication was not properly assessed or monitored for bruises reported by a CNA. Despite the facility's policy requiring assessment and physician notification for changes in condition, there was no documentation or care plan developed for the bruises. The DON and ADON confirmed the lack of adherence to the facility's policy.
A resident was subjected to the use of hand mittens as physical restraints without obtaining informed consent or a physician's order, and without a care plan addressing their use. The facility's policy requires informed consent and a physician's order for restraints, which were not documented in this case. The resident had severely impaired cognitive skills, and the deficiency was confirmed by an RN during an interview.
A resident's room was found with a disconnected portable AC unit tubing lying on the floor, covered in dust, during a survey. The Maintenance Assistant was unaware of the disconnection and admitted to not cleaning the unit per guidelines. The facility's policy requires maintaining a clean environment, which was not followed.
A resident's sexual abuse allegation against a CNA was not reported to the appropriate authorities in a timely manner, as required by the facility's policy. The incident was reported to RN 1 on a specific date, but the Administrator and DON were not informed until three days later, resulting in a delay in notifying the CDPH L&C Program, Ombudsman office, and law enforcement.
A resident reported a sexual abuse allegation against a CNA, but the facility failed to investigate the claim promptly. The incident was reported to an RN, who did not notify the Administrator or DON as per policy, resulting in the CNA continuing to work and interact with the resident until the investigation began three days later. This delay potentially increased the risk of further abuse.
Failure to Follow Care Plan for Hand Mitten Restraint Use
Penalty
Summary
Surveyors identified that the facility did not follow the care plan and policy for restraint use for one resident who had a physician’s order for a left hand mitten due to persistent pulling out of a gastrostomy tube (GT). The facility’s Physical Restraints policy, revised 1/2017, required that when restraints are used, the resident must be provided with motion and exercise for at least 10 minutes during each two-hour period. The resident’s care plan for use of the left hand mitten, initiated on 3/10/25 and revised on 11/9/25, included an intervention to apply the left hand mitten to prevent pulling out the tube and to release it every two hours for 15 minutes for circulation and comfort. Review of the resident’s medical record, including the MAR for March 2025, showed that the left hand mitten placement was monitored every shift from 3/10 to 3/31/25, but there was no documented evidence that the mitten was released every two hours as required by the care plan. During an interview and concurrent record review, an RN stated that the facility protocol for hand mitten restraints was to remove them every two hours and check circulation and skin condition, but confirmed that there was no physician order to monitor circulation and skin condition every two hours and no documentation that the mitten was released every two hours for circulation and comfort. The Administrator was informed of and acknowledged these findings.
Failure to Provide and Document Ordered Ophthalmic Medications
Penalty
Summary
The facility failed to provide ordered ophthalmic medications for a resident and did not ensure timely administration or appropriate documentation when doses were missed. The resident, who had glaucoma and no capacity to understand or make decisions, had physician orders for Refresh Plus eye lubricant every two hours for dry eyes and ocular surface irritation, Timoptic (timolol) twice daily for uncontrolled primary open angle glaucoma, and Lumify (brimonidine tartrate) twice daily for ocular hyperemia. Review of the MAR showed multiple missed doses of these medications. On one date, Refresh Plus was coded as held and as not given due to vitals being outside parameters, but the progress notes did not document the reason or specify what parameters were not met. On subsequent dates, Refresh Plus was not administered numerous times over two days, with MAR notes indicating the facility was awaiting medication from the pharmacy. Further review showed that Timoptic was not administered at scheduled times on two separate dates, with one entry lacking any documented reason and another indicating the facility was awaiting delivery. Lumify was also not administered at a scheduled time, and nursing notes documented multiple follow-up calls to the pharmacy, which reported it did not have Lumify in stock. There was no documentation that the physician was notified of the multiple missed doses of these ordered medications. During interviews, RN 1 confirmed that charge nurses were responsible for requesting refills five days before medications ran out and acknowledged that the physician should have been informed when medications were not administered as ordered. The DON and Administrator were informed of and acknowledged these findings.
Failure to Develop Individualized Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop an individualized care plan to address a resident's actual fall incident that occurred on 11/22/24. Review of the resident's medical record showed that the resident was found on the floor on the right side of the bed in a side-lying position. The resident's history and physical examination indicated that the resident lacked the capacity to understand and make decisions. Despite this incident, the resident's plan of care did not include a problem or intervention related to the fall. Interviews with facility staff, including an RN and the DON, confirmed that there was no care plan developed to address the resident's fall. The facility's policy on comprehensive care planning requires that the plan of care include measurable objectives and timeframes and describe the services to be provided to maintain the resident's highest practicable level of well-being. The DON acknowledged that it was the responsibility of the licensed nurse to update the care plan with each change of condition, which was not done in this case.
Failure to Follow Physician Orders and Complete Required Monitoring After Falls
Penalty
Summary
The facility failed to provide necessary care and services for two residents by not following physician recommendations and not completing required monitoring after incidents. For one resident, a psychiatric evaluation recommended starting Depakote for poor impulse control, but there was no documentation that this recommendation was communicated to or obtained from the physician, and the medication was not initiated. Additionally, after this resident experienced a fall, the medical record did not show evidence that neurological checks were performed as documented in the progress note, despite facility policy and staff statements indicating that such checks should be completed for 72 hours post-fall. The same resident was later prescribed Seroquel for mood disturbance, with informed consent obtained from the responsible party. However, there was no documented evidence that orthostatic hypotension monitoring was implemented, even though this is a known side effect of Seroquel and was acknowledged as necessary by the DON. The lack of monitoring for orthostatic hypotension was verified during interviews and record reviews with facility staff. For a second resident, after an unwitnessed fall, the progress note and IDT recommendation indicated that neurological checks should be performed for 72 hours. However, the medical record did not contain documentation that these checks were initiated. Both RN 1 and the DON confirmed that neurological checks were not completed as required, despite the resident's lack of capacity to make decisions and the facility's policy to monitor for changes in neurological status after a fall.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for one resident. According to the facility's policy and procedure on psychotherapeutic drug treatment, informed consent must be obtained from the resident or their representative prior to the use of such medications, including providing information about the need for the medication, its desired effects, and potential side effects. The resident in question was determined to lack capacity to make decisions, and a physician's order was given to administer Ativan for anxiety. However, a review of the resident's medical record did not show any documented evidence that informed consent was obtained for the use of Ativan as ordered. Interviews with facility staff, including an RN and the DON, confirmed that a new informed consent was not obtained when the Ativan medication was ordered. The Ativan prescription was not renewed after an initial 14-day period, and when it was reordered, the required informed consent process was not completed. This failure was acknowledged and verified by the DON during the survey.
Failure to Implement Consistent Enhanced Barrier Precautions and Staff Training
Penalty
Summary
The facility failed to implement effective infection control practices for seven non-sampled residents who were under Enhanced Barrier Precautions (EBP) due to colonization with multidrug-resistant organisms (MDROs) such as CRE, C. auris, and CRAB. Observations revealed that EBP signs posted outside resident rooms were inconsistent and, in some cases, incorrect. For example, one room displayed a red sign requiring staff to wear an N-95 mask for a resident with CRE, which was not necessary according to facility policy. Other rooms had both standard EBP signs and additional colored signs (red or pink), each listing different PPE requirements, leading to confusion among staff. Interviews with staff, including LVNs, CNAs, RNs, and the Infection Preventionist (IP), demonstrated a lack of understanding regarding the meaning and requirements of the different colored isolation signs. Some staff incorrectly believed that an N-95 mask was required for EBP precautions, while others could not distinguish between the red and pink signs or their associated PPE protocols. The IP confirmed that the red and pink signs were intended to indicate additional infections and PPE needs but acknowledged that the signage was not always accurate and that staff training on the distinction between the signs was insufficient. Further review of training records showed that while staff had received general in-service training on EBP precautions, there was no documentation of specific training on the differences between the red and pink isolation signs. The lack of clear, consistent signage and inadequate staff training on EBP protocols resulted in improper implementation of infection control measures for residents colonized with MDROs.
Failure to Provide Appropriate GJ Tube Care and Adhere to Physician Orders
Penalty
Summary
The facility failed to provide necessary enteral care and services to a resident with a GJ tube, resulting in the resident receiving enteral feeding through the incorrect port. Staff were unable to accurately identify the G and J ports of the GJ tube, and as a result, enteral feeding was administered through the G tube port instead of the J tube port as ordered by the physician. Additionally, medications were administered through the incorrect port, and staff did not notify the physician when they were unable to verify the correct ports. The staff also did not receive in-service training on the care and management of a resident with a GJ tube prior to being assigned to the resident. The resident in question had significant medical needs, including diabetes, gastroparesis, ventilator-dependent respiratory failure, and was dependent on staff for activities of daily living. The resident was admitted with a GJ tube, with physician orders specifying that enteral feeding should be administered through the J tube port and medications through the G tube port. Despite these orders, staff were unable to confirm the correct port for feeding and medication administration, and did not seek clarification from the physician or other clinical leaders. The ports on the GJ tube were not labeled, contributing to the confusion among staff. Furthermore, the facility failed to obtain a physician's order for the maintenance and discontinuation of the G tube drainage bag. The resident was admitted with a drainage bag attached to the G tube port, but there was no documentation of a physician's order for its use or discontinuation. These failures led to the resident's transfer to an acute care hospital for medical intervention after the J tube became clogged, and the resident experienced a critical drop in blood sugar level.
Incomplete POLST and Missing Advance Directive Acknowledgement
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) form was signed and dated by a physician, nurse practitioner (NP), or physician assistant (PA) for a resident who lacked the capacity to understand and make decisions. The POLST, dated 7/24/24, was incomplete in the Information and Signatures section, lacking the necessary documentation of the healthcare provider's name and date signed. This oversight was confirmed during an interview and medical record review with RN 1, who acknowledged the absence of the required signature and date on the POLST. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, which is used to offer information about advance directives. This was verified by both RN 1 and the Social Services Director (SSD), who confirmed the absence of the form in the resident's medical record. The Administrator and Director of Nursing (DON) also verified these findings during an interview, acknowledging the lack of documentation for both the POLST and the Advance Directive Acknowledgement form.
Failure to Complete PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure the completion of PASRR screenings for two residents, leading to potential gaps in care for mental illness or intellectual disabilities. Resident 76 was readmitted to the facility after a hospital stay exceeding 72 hours, which should have triggered a new Level 1 PASRR screening according to the facility's policy. However, the medical record showed no evidence of a PASRR being completed upon readmission, despite the resident's recent diagnosis of depression. Interviews with the LVN and ADON confirmed the oversight, acknowledging that the PASRR should have been updated to ensure appropriate care and resources were provided. Similarly, Resident 61 was diagnosed with mild depression and prescribed mirtazapine after the initial PASRR Level 1 screening indicated no serious mental illness or psychotropic medication use. Despite this change in mental health status, a PASRR Level 1 Screening Resident Review Status Change was not performed. The DON confirmed that the screening should have been updated to reflect the resident's new diagnosis and medication, which would have ensured the facility provided the necessary care for the resident's mental health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, which posed a risk for not providing appropriate and individualized care. For Resident 73, the facility did not create a care plan to address the use of elevated side rails, despite a physician's order for bilateral grab bars for bed mobility and repositioning. During an interview, RN 1 confirmed that a care plan specific to the use of side rails was not developed for Resident 73, even though the resident utilized the grab bars to get up in bed. For Resident 88, the care plan did not address the resident's preference for a high bed, which was contrary to the intervention of maintaining the bed in the lowest or locked position to prevent falls. Despite the resident's noncompliance and preference for a high bed, no interventions or alternatives were offered to mitigate the risk of falls. RN 3, LVN 7, and CNA 3 acknowledged the resident's preference and the absence of floor mats, confirming that no care plan was developed to address the resident's noncompliance and risk of falls.
Failure to Monitor and Adjust LAL Mattress Settings and Address Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcers for several residents, including Resident 334, who developed a new blister on the right great toe. The facility did not assess the skin, inform the physician of the new skin condition, or provide appropriate treatment. A family member had notified a nurse about the blister, but the dressing was incorrectly placed on the opposite side of the toe. LVN 3 later acknowledged the presence of the blister and confirmed it was a Stage 2 pressure injury, but no prior assessment or treatment had been conducted. For Resident 3, the facility did not consistently monitor the settings of the low air loss (LAL) mattress, which was set incorrectly for the resident's weight. Despite a physician's order to use the LAL mattress for skin maintenance and monitor its placement every shift, the mattress was set to less than 80 pounds, while the resident's weight was 119 pounds. LVN 9 confirmed the incorrect setting and acknowledged that the mattress should have been set between 100 - 120 pounds. Similarly, Resident 102 and Resident 103 also experienced issues with the LAL mattress settings. Resident 102's mattress was set to more than 150 pounds, while the resident weighed 100 pounds. LVN 4 verified the incorrect setting. For Resident 103, the mattress was set between 120 to 155 pounds, although the resident weighed 88 pounds. LVN 3 confirmed the discrepancy and stated that the mattress pressure setting should be based on the resident's weight to prevent skin breakdown or worsening of wounds.
Failure to Ensure Proper GT Feeding Connection
Penalty
Summary
The facility failed to provide the necessary gastrostomy tube (GT) care and services for a resident who was reviewed for tube feeding. The resident, who was readmitted to the facility, had a physician's order to receive Nepro 1.8 enteral feeding via an enteral pump at a rate of 50 ml per hour over 16 hours. However, during an observation, it was found that the GT feeding was not connected to the resident, and the feeding was dripping onto the floor instead. This oversight was verified by RN 4, who acknowledged the issue and stated the need to inform the charge nurse. Further investigation revealed that the disconnection might have occurred after the resident's dialysis session or during a shower given by the facility staff, as mentioned by LVN 10. The LVN confirmed that the GT feeding was not connected and indicated that the entire feeding setup needed to be changed. The facility's Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Inadequate Respiratory Care and Safety Measures
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by multiple observations and interviews. Resident 75 was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, there was no 'No Smoking/Oxygen in Use' sign outside the resident's room, and the suction machine at the bedside lacked a physician's order and care plan. The suction storage bag was also undated and unlabeled, which was confirmed by LVN 15 and LVN 4 during their interviews. Resident 8 was observed with oxygen at three liters per minute, but there was no 'No Smoking/Oxygen in Use' sign posted as required by the facility's policy. Furthermore, the nasal cannula attached to Resident 8's wheelchair was not stored in a sanitary manner, as it was hanging on the wheelchair without a clean bag. This was verified by RN 5 and LVN 6, who acknowledged the need for proper signage and infection control measures. Resident 58's CPAP mask was found on the floor, and there was no respiratory bag at the bedside for proper storage. The facility also failed to have a physician's order for the CPAP settings, which was confirmed by the DON. Resident 44 was observed receiving oxygen at a rate higher than prescribed, and Resident 29 did not have the required 'No Smoking/Oxygen in Use' sign posted. These deficiencies were acknowledged by the facility's staff, including the Administrator and DON, during interviews.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 82, who required such services. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P) regarding dialysis care. The facility's P&P, revised in January 2019, mandates that a pre-dialysis checklist be completed each time a resident is scheduled for dialysis, which includes assessing the type and condition of the access site and dressing. Additionally, a post-dialysis checklist is required to document similar information. However, the review of Resident 82's dialysis communication assessment forms revealed multiple instances of incomplete documentation, with blank entries on specific dates for both pre-dialysis and post-dialysis assessments. Resident 82, who was admitted to the facility with a diagnosis of end-stage renal disease (ESRD) and was dependent on renal dialysis, had no capacity to understand and make decisions, as noted in their health and physical examination. The resident's medical records showed a physician's order for hemodialysis three times a week. Despite this, the facility failed to complete the necessary dialysis communication forms on several occasions, as verified by LVN 12 during an interview. LVN 12 acknowledged that the forms should not have been left blank and should have been filled out as required, indicating a lapse in the facility's adherence to its own dialysis care policies.
Failure to Ensure Resident Safety with Bed Rail Use
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 46 and 73, remained free from accident hazards related to the use of bed rails. For Resident 73, the facility did not attempt alternatives or obtain informed consent before using side rails. The resident, who had moderately impaired cognition, was observed using the grab bars for bed mobility, but there was no documentation of informed consent or attempts at alternative measures in the medical record. RN 1 confirmed these omissions during a review of the resident's medical record. For Resident 46, the facility did not assess the risk of entrapment or attempt alternatives before using side rails, nor did they inform the responsible party about the use of side rails. The resident had a physician's order for bilateral padded side rails due to medical necessity for seizures, but there was no documented evidence of an assessment for bed zone entrapment. RN 5 and the Medical Record Assistant were unable to locate documentation for the assessment or informed consent, acknowledging that these were not completed. These failures had the potential to place the residents at risk for entrapment.
Improper Medication Administration via GT and Inadequate Bowel Pattern Check
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, specifically in the administration of medications via a gastrostomy tube (GT). The policy required medications to be administered by gravity, but during an observation, a Licensed Vocational Nurse (LVN) was seen using a syringe to push a crushed docusate sodium tablet through the resident's GT, contrary to the policy. This deviation from the policy was acknowledged by the LVN during a follow-up interview. Additionally, the facility did not ensure that the resident's bowel pattern was checked for loose stools or diarrhea before administering the stool softener, docusate sodium. The resident had a documented history of loose stools/diarrhea for several weeks, yet the LVN did not review this information before administering the medication. The LVN relied on a verbal endorsement from the previous nurse, which inaccurately reported the resident's bowel condition. This oversight was confirmed during an interview with the LVN, who admitted the medication should not have been given under the circumstances.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to adequately monitor a resident's blood pressure and heart rate before administering prescribed medications, leading to a deficiency. Resident 73, who was on amlodipine and losartan for hypertension, had specific physician orders to hold the medications if the systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. However, from November 1 to November 19, 2024, there was no documented evidence that the licensed staff checked these vital signs before administering the medications at the prescribed times of 0900 and 1700 hours. This oversight was confirmed during an interview and concurrent medical record review with RN 5 on November 20, 2024.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the prescription practices for psychotropic drugs. Resident 124 was prescribed zolpidem, a hypnotic medication, on an as-needed basis for insomnia without a 14-day stop date, contrary to the facility's policy. This oversight was confirmed during interviews with RN 2 and the Director of Nursing (DON), who acknowledged the absence of a stop date for the medication. Resident 86 was prescribed quetiapine fumarate, an antipsychotic medication, for intermittent explosive disorder without a documented diagnosis or clinical rationale at the time of prescription. The resident's medical records did not show a diagnosis of psychosis or intermittent explosive disorder prior to the continuation of the medication. This was verified by RN 1 and the Assistant Director of Nursing (ADON), who confirmed the lack of documentation supporting the prescription of quetiapine fumarate before the resident was seen by a psychiatrist.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and management of medications and supplies in one of its medication rooms and several medication carts. In Medication Room A, multiple expired medications were found, including acetaminophen, vitamin B6, and normal saline vials. This oversight had the potential to lead to the unsafe administration of medications. Additionally, the facility did not prevent the storage of antifungal cream at a resident's bedside, which could have allowed unauthorized access to the medication. The resident in question had moderate cognitive impairment and was not assessed as a candidate for self-administration of medications, and there was no physician's order for the cream. Medication carts also exhibited significant deficiencies. Medication Cart D contained a mix of external and internal medications alongside bleach germicidal wipes, posing a risk of unsafe administration. Medication Cart E was found to have expired vials of normal saline, and Medication Cart F had germicidal wipes, adult washcloths, and Povidone-Iodine swabsticks stored with nutritional supplements, risking cross-contamination. Additionally, albuterol inhalation solutions were not stored according to the manufacturer's recommendations, as they were found outside their foil pouches. The facility's procedures for the disposal of controlled medications were not followed correctly. The Director of Nursing (DON) did not sign the narcotic disposition log when controlled medications were disposed of, which could lead to drug diversion. Furthermore, several medication carts contained expired supplies, such as alcohol-free liquid skin prep, wound dressing supplies, and povidone-iodine prep pads. These expired items were not discarded as required, and opened sterile gloves were found, which compromised their sterility. The facility's failure to adhere to its policies and procedures for medication storage and disposal was verified by the DON and other staff members.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several deficiencies observed during the survey. The blender used for preparing pureed food was not allowed to air dry properly before use, which is against the facility's policy for maintaining food machines in a sanitary condition. Additionally, two frying pans in the kitchen were found to be corroded, with the potential for the black substance from the corrosion to come into contact with food. These observations were verified by the staff member involved in food preparation. Furthermore, staff members lacked knowledge of proper food cooling procedures. One staff member described an incorrect cooling method for roasted meats, which did not comply with the facility's policy or USDA guidelines. Another staff member admitted to not knowing how to perform the cooling process. Additionally, the storage area for water pitchers and cups was found to be unsanitary, with a dirty curtain stained with brown residue covering the cart. These failures were acknowledged by the staff and reported to the Director of Nursing and the administrator.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that food items in the residents' refrigerator were labeled and dated, as required by their policy and procedure (P&P) titled 'Bringing in Food for a Resident' dated 2023. This policy mandates that food or beverages should be labeled and dated to monitor for food safety, and any food in unmarked or unlabeled containers should be marked with the current date and the resident's name. During an observation and interview with an RN and an LVN, it was found that several food items in the resident refrigerator in Nursing Station 1 were unlabeled and undated, including yogurts, cookies, kimbap, soy milk, a dirty Tupperware, and a jar of chia seeds. The RN confirmed that food brought from outside should be labeled with the resident's name and dated, and noted that the jar belonged to the staff, who should not keep their food in the resident's refrigerator. Additionally, the bottom inner part of the refrigerator was observed to be dirty and sticky. These findings were verified by the RN and LVN, and later communicated to the DON and administrator.
Inaccurate Medical Records and Assessments for Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, leading to discrepancies in their health care directives and assessments. For Resident 73, the POLST was not updated to reflect the resident's advance directive, despite the resident having the capacity to make decisions and having signed an advance directive. This discrepancy was confirmed by both an LVN and the SSD, who acknowledged that the POLST should have been updated to reflect the resident's current health care directive. Resident 100's medical record contained conflicting information regarding the existence of an advance directive, with the POLST indicating both the presence and absence of such a directive. This inconsistency was verified by an RN, who noted the need for clarification. Additionally, Resident 124's smoking assessment and care plan were incomplete and inaccurate. The care plan incorrectly identified the resident as an independent smoker, despite the resident lacking the capacity to make decisions and requiring supervision while smoking. The Activities Director confirmed the absence of necessary entries in the smoking assessments, such as cognitive and visual function evaluations.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement a safe and sanitary environment to prevent the transmission of infections. During a medication observation, a Licensed Vocational Nurse (LVN) did not change gloves between administering medications through different routes. This oversight occurred while administering various medications, including oral tablets and a topical patch, to a resident who was under enhanced barrier precautions due to a colostomy diagnosis. The facility's policy requires adherence to infection control procedures, including glove changes between different routes of medication administration. Additionally, the LVN did not change personal protective equipment (PPE) between administering medications to two residents on enhanced barrier precautions. The same gown was used for both residents, one of whom had a colostomy and the other a gastrostomy tube. Both residents had physician orders for enhanced barrier precautions every shift. The LVN acknowledged the failure to change gloves and PPE, which posed a risk for the transmission of disease-causing microorganisms.
Failure to Notify Physicians of Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents who were prescribed antibiotics without meeting McGeer's Criteria for a true infection. This deficiency was identified for two of the 26 final sampled residents and five nonsampled residents. The facility's Infection Preventionist (IP) confirmed that the antibiotic stewardship program was designed to review prescribed antibiotics and notify physicians if residents did not meet the criteria for a true infection. However, the IP verified that the physicians were not notified for several residents across August, September, and October 2024, who did not meet McGeer's Criteria. The facility's policy on Infection Control - Antibiotic Stewardship, revised in January 2018, aimed to promote appropriate antibiotic use and monitor to improve resident outcomes and reduce antibiotic resistance. Despite this policy, the facility's monthly Infection Prevention and Control Surveillance Logs showed multiple instances where residents were prescribed antibiotics without meeting the necessary criteria, and their physicians were not informed. This oversight had the potential to lead to unnecessary antibiotic use, which could result in adverse reactions and the development of antibiotic-resistant bacteria.
Glucometer Calibration and Quality Control Failures
Penalty
Summary
The facility failed to ensure that glucometers used for blood glucose monitoring were properly calibrated and underwent quality control checks as per their policy and procedure. Specifically, the glucometer in Medication Cart A was not calibrated, and quality control was not performed on several dates in November 2024. Additionally, the glucometers in Medication Cart F were not calibrated or maintained in safe operating condition, with missing entries in the calibration log for October and November 2024. Similarly, the glucometer in Medication Cart D was not maintained in safe operating condition, with discrepancies between the documented quality control results and the actual quality control history. These failures were confirmed through observations, interviews with licensed vocational nurses (LVNs), and reviews of facility documents. The LVNs and the Director of Nursing (DON) verified the findings, acknowledging that the quality control records did not match the glucometer serial numbers and that the required nightly checks were not consistently documented. These lapses had the potential to result in inaccurate blood glucose readings for residents requiring such checks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 110, which had the potential to prevent the resident from summoning help when needed. The facility's policy and procedure, dated January 2017, required staff to ensure the call light was within easy reach of residents when they were in bed or seated in a wheelchair or chair. On November 18, 2024, during an observation at 0900 hours, Resident 110 was found awake with the call light hanging on the wall, out of reach. Later, at 1030 hours, a Licensed Vocational Nurse (LVN) confirmed the call light was not accessible to the resident. Resident 110's care plan, dated November 6, 2024, indicated the resident was totally dependent on staff for toileting and hygiene due to impaired self-care and functional mobility related to a history of acute renal failure, transient ischemic attack, and cerebrovascular accident. The LVN acknowledged that the resident sometimes used the call light to request assistance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. In Room E, where two residents resided, the door frame casings were found in disrepair, with cracks, scratches, and missing paint. The Director of Nursing (DON) acknowledged these findings and suggested that the damage might have been caused by resident beds hitting the door frame. Additionally, the facility was in the process of refurbishing resident rooms. In Rooms A, B, C, and D, the curtains were observed to be yellowish stained and dirty. These rooms housed four different residents. A Licensed Vocational Nurse (LVN) confirmed the condition of the curtains and acknowledged that they needed to be changed. These deficiencies posed a risk for unsanitary and unsightly conditions, potentially impacting the residents' quality of life.
Failure to Assess and Document Bruises in Resident on Anticoagulant
Penalty
Summary
The facility failed to provide necessary care and services to Resident 1, who was on anticoagulant medication, by not assessing and monitoring reported bruises on the resident's lower legs. Despite a CNA reporting the bruises to the charge nurse, there was no documented evidence of an assessment or notification to the physician or the resident's representative. The facility's policy required thorough assessment and physician notification for changes in a resident's condition, which was not followed in this case. Resident 1 was admitted with redness on the right cheek and forehead and was on Eliquis for atrial fibrillation. The facility's records showed no signs of bleeding or bruising documented from early June to late June, despite initial assessments noting skin discoloration. The DON and ADON confirmed the lack of documentation and care planning for the bruises, acknowledging that the facility's policy was not adhered to, which required documentation of such changes in condition.
Failure to Obtain Consent and Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically hand mittens, without obtaining informed consent or a physician's order. The facility's policy and procedure on physical restraints, revised in January 2017, mandates that restraints should only be used with informed consent from the resident, physician, and/or representatives, and that a written order specifying the use of restraints should be obtained. Additionally, an interdisciplinary assessment team should develop and maintain comprehensive care plans for residents, which should include the use of restraints if applicable. In the case of the resident in question, the medical record review revealed that hand mittens were applied on two consecutive days to prevent the resident from pulling out medical devices. However, there was no documented evidence of informed consent, a physician's order, or a care plan addressing the use of hand mittens. The resident's cognitive skills for daily decision-making were severely impaired, as noted in the Minimum Data Set (MDS). An interview with an RN confirmed these findings, indicating a failure to adhere to the facility's policies and procedures regarding the use of physical restraints.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, as observed during a survey. The portable air conditioning unit in the resident's room had its tubing disconnected and lying on the floor, with visible dust particles on both the tubing and the floor. This situation was identified during an observation and interview with the Maintenance Assistant, who was unaware of how the tubing became disconnected and admitted to not cleaning the unit according to the manufacturer's guidelines. The facility's policy, revised in January 2018, mandates maintaining a safe, clean, and comfortable environment for residents, which was not adhered to in this instance. The Administrator confirmed that the AC unit should be cleaned as per the manufacturer's instructions.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report a sexual abuse allegation made by Resident 1 against a Certified Nursing Assistant (CNA) to the California Department of Public Health Licensing and Certification (CDPH L&C) Program, Ombudsman office, and local law enforcement agency in a timely manner. According to the facility's policy and procedure (P&P) on abuse reporting and prevention, such allegations should be reported immediately or within two hours. However, the allegation, which was reported by Resident 1 to RN 1 on 5/25/24, was not communicated to the appropriate authorities until 5/28/24, three days later. Interviews conducted with facility staff revealed that RN 1, who was informed of the allegation by Resident 1, did not notify the Administrator or Director of Nursing (DON) as required by the facility's policy. RN 2, who was informed of the incident by RN 1, instructed RN 1 to write an incident report but did not take further action until she returned to work on 5/28/24. The DON confirmed that all staff are mandated reporters and acknowledged the delay in reporting the allegation to the necessary authorities, which was contrary to the facility's policy of immediate reporting upon awareness of such incidents.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility failed to investigate a reported allegation of sexual abuse in a timely manner, which involved a resident and a certified nursing assistant (CNA). The resident reported the incident to a registered nurse (RN) on 5/25/24, but the RN did not notify the facility's Administrator or Director of Nursing (DON) as required by the facility's policy. Consequently, the alleged abuser, CNA 1, continued to work and had access to the resident until 5/28/24, when the incident was finally reported to the Administrator and DON, and the investigation was initiated. The facility's policy mandates immediate action to ensure resident safety and the removal of the suspected abuser from resident care. However, the delay in reporting and initiating the investigation allowed CNA 1 to interact with the resident after the allegation was made. The DON confirmed that the investigation should have started on 5/25/24, the day the allegation was reported, but it was not initiated until three days later, on 5/28/24. This delay potentially exposed the resident and other vulnerable residents to further risk of abuse.
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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