California Home For The Aged
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 6720 E. Kings Canyon, Fresno, California 93727
- CMS Provider Number
- 055955
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at California Home For The Aged during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment contained hazards and supervision was insufficient to prevent incidents.
Surveyors found that the facility's sprinkler system was not properly maintained, with missing signage on inspector test valves, a dust-covered sprinkler, and a delayed waterflow alarm activation. Staff were unaware of these issues, which affected all residents in the building.
The facility did not conduct fire drills at varying times as required, instead holding drills at the same times for both AM and PM shifts. Staff were unaware that repeating drill times was not permitted, resulting in noncompliance with fire safety regulations affecting all residents.
A corridor door was found obstructed by a floor mat, preventing it from closing properly. This issue was observed during a facility tour and confirmed by staff, affecting multiple residents and a smoke compartment.
Surveyors found that two electrical panels in mechanical rooms had several circuits missing required identifiers, with staff either unaware of their purpose or identifying them as spares. This failure to label circuits affected a portion of the facility and did not comply with NFPA 70 standards.
Surveyors observed the use of extension cords in both a staff office and a resident room, with one cord powering a coffee machine and another used for phone charging. Staff were unaware of the prohibition on extension cords, and one cord had been brought in by a resident. These findings affected multiple residents and a smoke compartment.
A resident's care plan failed to include duloxetine hydrochloride, a psychotropic medication prescribed for anxiety disorder, despite being admitted with active orders for it. The care plan only addressed trazodone and buspirone, omitting duloxetine. Facility staff, including LVNs and the DON, confirmed the oversight, acknowledging that the IDT was responsible for ensuring all medications were included in the care plan.
A resident received medications not prescribed for her due to a failure by an LVN to verify the correct patient before administration. The LVN did not adhere to the facility's medication administration policy, which requires following the five rights of medication administration. The error was confirmed by the DON, who noted the LVN's failure to follow professional standards and facility procedures.
The facility failed to provide a comfortable homelike environment for three residents when the air vents in their rooms were observed to be covered with black and brown stains and dust. Residents and staff expressed discomfort and dissatisfaction with the cleanliness of the vents, and the Infection Preventionist highlighted the potential health risks for residents with respiratory issues. Despite facility policies emphasizing cleanliness, the air vents were not adequately maintained.
The facility failed to develop and implement comprehensive care plans for four residents, including the use of side rails, respiratory treatments, special mattresses, and urinary catheter monitoring. This lack of care planning placed the residents at risk of injury and infection.
The facility failed to meet professional standards for four residents. An RN signed the eMAR before administering medications and improperly applied a lidocaine patch. An LVN administered Potassium Chloride without food. Another resident received incorrect oxygen flow and had an unchanged humidifier bottle. A fourth resident's humidifier bottle was not changed as required, and their nasal cannula tubing was unlabeled.
The facility failed to ensure the medication error rate did not exceed five percent. An RN did not administer metoprolol to a resident due to unavailability, and an LVN did not follow instructions to administer potassium chloride with breakfast. These errors resulted in a calculated medication error rate of 7.69 percent.
The facility failed to ensure proper storage and labeling of medications. A resident's narcotics were repacked in unlabeled plastic bags, and two boxes of omeprazole lacked received and expiration dates. Staff were unaware of the proper procedures, and the DON confirmed these practices were against facility policy.
The facility failed to provide a well-balanced diet to several residents by continuing discontinued supplements and providing chopped diets without physician orders. This was due to poor communication between nursing staff and the kitchen, as evidenced by discrepancies in tray tickets and official dietary orders.
The facility failed to follow the prescribed small portion diet for two residents, using a #16 scoop instead of the required #12 scoop for Spanish rice. This discrepancy was confirmed by the Dietary Service Supervisor and the Registered Dietitian, potentially compromising the residents' caloric intake and medical status.
The facility failed to ensure food was prepared in accordance with professional standards for food service safety when a cook did not wear a beard restraint while preparing food, potentially leading to contamination.
The facility failed to ensure medical records were complete and accurately documented. One resident's humidifier bottle change was not recorded correctly, and four residents had incomplete POLST forms, lacking essential information such as the physician's phone number and license number. These deficiencies pose risks to residents' health and their ability to have their treatment preferences respected.
The facility failed to implement safe infection control measures for two residents, as their urinary catheter tubing and drainage bags were observed lying on the floor. Staff confirmed that this practice posed a risk of infection and did not adhere to the facility's policies on urinary catheter care and infection control.
The facility failed to ensure that LNs, CNAs, and ancillary support staff completed mandatory in-service training for dementia care, fall prevention, and abuse prevention. A significant portion of the staff did not attend these essential training sessions, potentially placing residents at risk for inadequate care.
The facility failed to ensure residents were treated with dignity and respect when two residents' urinary catheter bags were not placed in dignity bags, making them visible from the hall. Staff confirmed this was against the facility's policy, which requires catheter bags to be covered to protect residents' dignity.
The facility failed to ensure the MDS assessment accurately reflected a resident's health and functional status. The resident, with a history of hemiplegia and muscle weakness, was inaccurately coded as having no impairment in the upper extremity. Interviews confirmed the resident required assistance with ADLs due to limited mobility in the left arm. The MDSRN admitted to the error, and the DON confirmed the resident should have been coded for upper extremity weakness.
The facility failed to complete a PASRR assessment for a resident diagnosed with major depressive disorder, dementia, and psychotic disorder who was started on psychotropic medications. The admission coordinator and Director of Nursing acknowledged the oversight, and the facility lacked a specific PASRR policy.
The facility failed to validate the competency of the Infection Preventionist (IP) after hiring, as confirmed by the DON and DSD. The IP, responsible for infection prevention and control, did not have her nurse competency checked, contrary to facility policy, potentially risking infection spread among residents.
The facility failed to provide pharmaceutical services for a resident when their metoprolol medication was not available for administration. The resident's blood pressure was elevated, and the nurse had to notify the physician about the unavailability. Interviews revealed that licensed nurses are responsible for ensuring medication availability, and the facility's policies emphasize the importance of notifying the prescriber and following up with the pharmacy.
The facility failed to maintain adequate lighting in one of its medication rooms, where only one of four fluorescent lights was working. This issue persisted for at least two months, making it difficult for staff to read medication labels and increasing the risk of tripping. The Maintenance Facility Director was unaware of the problem until the survey, and the administrator did not consider it an immediate hazard.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision was not sufficient to prevent such incidents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of appropriate oversight in the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and interviews with staff, surveyors observed that inspector test valves (ITVs) in the medicine room by nurses station 3 and in the courtyard were missing required signage. Staff interviewed were unaware of the missing signs. Additionally, a sprinkler located in the storage closet next to nurses station 3 was found to be covered in dust, and staff were not aware of this condition. Further, when the waterflow was tested at the ITV in the medicine room by nurses station 3, it took 116 seconds for the alarm to initiate after the valve was fully opened, which exceeds the acceptable time for waterflow alarm activation. Staff interviewed were unaware of the reason for this delay. These deficiencies affected all 103 residents in the facility across five smoke compartments.
Plan Of Correction
K 353: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The facility has not identified any residents affected by the deficient practice but recognizes that all residents have the potential to be affected. The facility contracted with MS Fire, a qualified contractor, to inspect each identified area of deficiency, and to determine and obtain the necessary signage for each Inspector Test Valve and all Auxiliary Drain valves. During this inspection, the valve located in the medicine room by station 3 was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain valve was placed during the inspection done on 04/02/2025. As this was identified as an Auxiliary Drain valve and not an Inspector Test Valve, MS Fire has corroborated during their inspection that the water flow expected of this valve was in working order and it is not expected to perform as an Inspector Test Valve, alarming in no more than 90 seconds. This is because Auxiliary Drain valves do not have the restricted head on the discharge pipe to correctly stimulate a fire sprinkler activation as an Inspector Test Valve would, and therefore this is why it took longer than 90 seconds to alarm. During this same inspection, the valve located in the courtyard was properly identified as an Auxiliary Drain Valve and not an Inspector Test Valve. Signage indicating that this is an Auxiliary Drain Valve was placed during the inspection done on 04/02/2025. Two other correctly identified Inspector Test Valves were tested during the survey process and performed within regulatory requirements, alarming in less than 90 seconds. The sprinkler located in the storage closet next to Nurses Station 3 was cleaned of dust on 3/26/25 by the Maintenance Lead and reinspected by MS Fire on 04/02/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility recognizes that while no residents were identified to have been affected by the deficient practice, all residents have the potential to be affected. The same corrective actions as listed above are the corrective actions taken to eliminate the potential risk to the residents. 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 Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust. How does the facility plan to monitor its performance to make sure that the corrective actions are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integrations into the facility's Quality Assurance system? The Facility Maintenance Director shall review monthly in-house sprinkler inspection task reports for completion and findings. 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 Maintenance Director in-serviced all maintenance personnel on the locations and appropriate signage required for Inspector Test Valves and Auxiliary Drain valves. Also included in this same in-service was the importance of inspecting and cleaning sprinkler heads to keep them free of dust. The facility utilizes TELS Building Management System for all Maintenance related inspections or tasks. A monthly in-house fire sprinkler inspection task was added to the Maintenance TELS system to include checking fire sprinkler heads for dust and Auxiliary Drain Valves and Inspector Test Valves for appropriate signage. Any findings will be immediately corrected and reported by the Maintenance team member completing the task to the Maintenance Lead and/or Director. Housekeeping staff was in-serviced by the Hospitality Director/Environmental Services Director on how to clean fire sprinkler heads to keep them free of dust.
Failure to Conduct Fire Drills at Varying Times
Penalty
Summary
The facility failed to maintain proper fire drill procedures as required by NFPA 101. Record review and staff interviews revealed that fire drills were repeatedly conducted at the same times for both AM and PM shifts, rather than at varying times as required. Specifically, AM shift fire drills on three separate dates were all conducted at 10 a.m., and PM shift drills on two dates were both conducted at 3 p.m. Staff confirmed they were unaware that fire drill times could not be repeated. This deficiency affected all 103 residents across all five smoke compartments.
Plan Of Correction
K 712: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were identified to have been affected by the deficient practice. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were identified to have been affected by the deficient practice, but the facility recognizes that all residents have the potential to be affected by the deficient practice. To gain compliance, two fire drills were conducted on the AM and PM shifts at times different than previously completed. A fire drill was conducted on 04/03/2025 at 7:00 am and on 04/04/2025 at 6:30 pm. 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 Facilities Maintenance Director in-serviced all Maintenance staff that conduct fire drills of the requirements that such drills are to be held at expected and unexpected times, under varying conditions, at least quarterly on each shift. The Facilities Maintenance Director added a monthly fire drill task to the TELS system so that the Maintenance team can conduct such drills at unexpected and varying times on all shifts quarterly. The Maintenance Director and/or Maintenance Lead will be responsible for ensuring the time of the in-service is appropriate.
Corridor Door Obstructed by Floor Mat
Penalty
Summary
During a facility tour, surveyors observed that the corridor door to resident room 507 was obstructed by a brown floor mat placed by bed A. This obstruction prevented the door from closing properly. The presence of the mat was confirmed during an interview with a staff member, who acknowledged that the door mat was in the way. This deficiency affected 23 out of 103 residents and one of five smoke compartments in the facility. The failure to maintain the corridor doors in accordance with regulatory requirements was specifically evidenced by the inability of the door to close due to the obstruction, as directly observed and confirmed by staff.
Plan Of Correction
K 363 and/or findings shall be reported by the Maintenance Director to the Quality Assurance and Performance Improvement Committee monthly for integration and recommendations. K 363: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The mat that prevented the door of room 507 from closing was immediately relocated by the Maintenance Lead to allow the door to fully close. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility did not identify any other residents affected by the deficient practice but recognizes any resident in the first bed of the room with a floor mat has the potential to be affected by this same deficient practice. On 3/26/2025, all residents with floor mats were identified and all rooms were inspected to ensure that none of those mats impeded or obstructed the door from closing. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? An in-service by the Director of Staff Development was held for all staff about ensuring that nothing, including floor mats, can prevent the resident room door from closing. The facility's Maintenance Director added a monthly corridor door inspection task to the TELS system, so the maintenance department is instructed to inspect all corridor doors monthly for proper closing and to ensure they are free from obstruction. Any findings shall be corrected immediately. NEXT PAGE INTENTIONALLY BLANK DUE TO FORMATTING. THIS PAGE INTENTIONALLY LEFT BLANK DUE TO FORMATTING. How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, the solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly corridor door inspection reports in TELS and report compliance and any findings to the Quality Assurance Committee monthly for integration and recommendations.
Electrical Panel Circuits Missing Required Identification
Penalty
Summary
Surveyors observed that the facility failed to maintain proper identification of electrical circuits in two separate electrical panels located in mechanical rooms. Specifically, Panel A was found to have two out of forty-two circuits (circuits 13 and 27) missing identifiers, and Panel F had three out of forty-two circuits (circuits 26, 28, and 30) without labels. During interviews, staff indicated that the unlabeled circuits in Panel A were considered spares, while for Panel F, staff were unaware of the purpose of the unlabeled circuits. These deficiencies were identified during a facility tour and staff interviews, affecting 23 of 103 residents in one of five smoke compartments. The lack of proper labeling on the electrical panels was found to be non-compliant with NFPA 70 National Electrical Code requirements, which mandate that each circuit be clearly and legibly identified as to its specific purpose or use.
Plan Of Correction
How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly fire drill reports to ensure compliance with varying times and shift compliance. Any findings will be corrected within the month by way of a separate drill if required. The Facilities Maintenance Director will report compliance and findings of fire drills to the Quality Assurance Committee monthly for 12 months for integration and recommendations if indicated. K 919: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were found to be affected by the deficient practice in regard to the unlabeled circuits. The Maintenance Lead inspected and identified that circuits 13 and 27 in Panel A and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. The maintenance lead inspected and identified that circuits 26, 28, and 30 on Panel F and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were found to have been affected by the deficient practice and the corrective action taken above ensures that no residents will be affected. 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 Facilities Maintenance Director in-serviced all Maintenance Personnel in regard to the requirements of K919, specifically ensuring all circuit breakers are labeled. The Facility Maintenance Lead will inspect the electrical panels for proper circuit labeling monthly for three months. After this, the Facilities Maintenance Director added an annual "Inspect and Document the Main and Feeder Circuit Breakers" task to the TELS system to
Improper Use of Extension Cords in Staff and Resident Areas
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with regulatory requirements, as evidenced by the use of extension cords in both a staff area and a resident room. During a facility tour, surveyors observed an orange extension cord plugged into a coffee machine in the medical records office. Staff interviewed at the time indicated they were unaware that the use of extension cords was not permitted. Additionally, a brown extension cord was found in a resident room, being used to charge a phone. Staff reported that the extension cord had been brought in by the resident. These observations affected 23 of 103 residents and one of five smoke compartments within the facility.
Plan Of Correction
Ensure the Maintenance Department is inspecting all electrical breaker panels annually for appropriate and proper labeling. How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly inspections by the Facilities Maintenance lead and report findings and compliance to the Quality Assurance committee monthly for three months for integration and recommendations, and then annually thereafter. K 920: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? The extension cord in room 503 and in the Medical Records office were immediately removed by the Maintenance Lead. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility has not identified any other residents affected by the deficient practice. An inspection walk-through of all patient rooms and non-patient rooms was conducted on 03/27/2025 to ensure no other extension cords were in use. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? Maintenance staff were in-serviced by the Facilities Maintenance Director on 4/4/2025 to review K 920 findings and the acceptable and appropriate use of extension cords and/or power strips. An in-service for all staff was conducted by the Director of Staff Development and Maintenance Lead to educate staff that extension cords are not permitted to be used except for temporary purposes and must be removed immediately upon completion of the task for which it was used. Staff were educated to be observant for unauthorized use of extension cords and to remove them immediately, and to report any use of power strips to Maintenance so that Maintenance can ensure the power strip is compliant in its use and design. The Facilities Maintenance Director generated a monthly Room Safety Inspection task within the TELS system so that the Maintenance department can inspect all rooms for use of extension cords and/or power strips monthly. Findings shall be corrected immediately. The Facilities Maintenance Director will review the monthly Room Safety Inspection task reports from TELS for compliance and findings and shall report compliance and findings monthly for three months to the Quality Assurance Committee for integration and recommendations if indicated.
Omission of Psychotropic Medication in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a psychotropic medication, duloxetine hydrochloride, was addressed on the comprehensive care plan for a resident with a history of major depressive disorder, anxiety disorder, and insomnia. The resident was admitted to the facility with active orders for duloxetine hydrochloride for anxiety disorder and trazodone hydrochloride for major depressive disorder. However, the care plan only addressed trazodone and another anti-anxiety medication, buspirone, but omitted duloxetine. This oversight was identified during a review of the resident's care plan and confirmed by multiple staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON). Interviews with facility staff revealed that the responsibility for updating and revising care plans fell to the floor nurses, with the admission nurse responsible for ensuring new medication orders were addressed in the care plan. Despite this, duloxetine was not included in the care plan, which was acknowledged by the DON and the Director of Social Services (DSS). The Administrator also confirmed that the interdisciplinary team (IDT) was responsible for the comprehensive care plan and expected duloxetine to be included, given its classification and use. The omission of duloxetine from the care plan was a clear deficiency in the facility's adherence to its policy of developing comprehensive, person-centered care plans that include all prescribed medications.
Medication Administration Error Due to Non-Compliance with Verification Protocols
Penalty
Summary
The facility failed to ensure that licensed nurses administered medications in accordance with professional standards of practice, resulting in a medication error for one resident. The incident involved a resident who was administered medications that were not prescribed for her. The resident, who had no cognitive impairment as indicated by a Brief Interview for Mental Status score of 13, was given several medications not listed in her physician's orders, including pantoprazole, carvedilol, potassium phosphate, amlodipine, memantine, and pioglitazone. This error occurred because the Licensed Vocational Nurse (LVN) responsible for administering the medications did not verify the correct patient before administration, relying instead on a picture in the medication administration software. During the investigation, the LVN admitted to not following the facility's policies and procedures, which require verification of the correct patient and adherence to the five rights of medication administration: the right patient, the right drug, the right time, the right dose, and the right route. The Director of Nurses confirmed the error and stated that the LVN did not follow the facility's medication administration policy. The facility's policy, dated April 2019, emphasizes the importance of administering medications according to prescriber orders and documenting any medication errors. The report highlights the potential risk for adverse drug effects due to this medication error.
Failure to Maintain Clean Air Vents
Penalty
Summary
The facility failed to provide a comfortable homelike environment for three residents when the air vents in their rooms were observed to be covered with black and brown stains and dust. During observations and interviews, residents expressed discomfort and dissatisfaction with the cleanliness of the air vents, stating that they would not tolerate such conditions in their own homes. Certified Nursing Assistants (CNAs) and other staff members also acknowledged the dirty condition of the vents and agreed that they did not promote a homelike environment. The Infection Preventionist (IP) highlighted the importance of maintaining clean air vents, especially for residents with respiratory issues such as pneumonia, chronic obstructive pulmonary disease (COPD), and asthma. The IP stated that dirty air vents could lead to residents breathing in contaminated air, potentially causing respiratory distress. The Director of Hospitality (DOH) and the Maintenance Lead (ML) confirmed that housekeeping staff were responsible for cleaning the vents and that unclean vents should be either cleaned, repainted, or replaced to ensure a comfortable living environment for residents. The facility's policies and procedures emphasized the importance of providing a clean, sanitary, and homelike environment for residents. The Housekeeping Department was responsible for maintaining high infection control standards and ensuring that the facility complied with all relevant regulations. Despite these policies, the observations and interviews revealed that the air vents in the residents' rooms were not adequately cleaned, leading to an uncomfortable and potentially unhealthy living environment.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents. For Residents 49 and 80, there were no individualized care plans developed for the use of side rails, despite having signed consent forms and physician orders. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the care plans should have included interventions such as bed inspections and frequent visual checks to prevent risks of entrapment and injury. Resident 37 had an order for ipratropium bromide via a hand-held nebulizer for respiratory illness, but there was no care plan developed to educate the resident on its use. Additionally, Resident 37 was using a low air loss mattress to prevent skin breakdown, but again, no care plan was developed for this intervention. The Licensed Vocational Nurse (LVN) and the DON confirmed that care plans should have been initiated when the orders were received to guide the nursing staff in providing appropriate care. For Resident 4, the facility failed to implement a person-centered care plan for urinary catheter monitoring. The resident's catheter tubing was observed touching the floor, which could lead to infection. The ADON and other staff members confirmed that there were no documented orders for catheter monitoring, and the care plan did not include necessary interventions. This lack of documentation and monitoring placed Resident 4 at an increased risk of developing a urinary tract infection.
Failure to Adhere to Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to meet professional standards of practice for four of twelve sampled residents. For Resident 25, a Registered Nurse (RN) signed the electronic Medication Administration Record (eMAR) prior to administering medications, resulting in inaccurate charting. Additionally, the same RN did not follow medication administration directions when applying a lidocaine patch to Resident 25's left upper arm without cleaning the site, potentially affecting medication absorption and causing skin irritation. Resident 25 was admitted with diagnoses including hypertension, muscle weakness, and chronic pain. For Resident 55, a Licensed Vocational Nurse (LVN) administered Potassium Chloride without food, contrary to the medication's directions, which could lead to stomach upset and affect medication absorption. Resident 55 had diagnoses of hypokalemia, hypertension, and muscle weakness. In the case of Resident 52, the oxygen flow rate was set to 3 liters per minute (L/min) instead of the ordered 4 L/min, potentially causing shortness of breath and respiratory distress. Additionally, Resident 52's humidifier bottle was not changed for six days, risking bacterial growth and inadequate humidification of the oxygen being delivered. Resident 66's humidifier bottle was not changed every three days as required, which could lead to dry mucosal membranes and associated complications. Furthermore, the nasal cannula tubing for Resident 66 was not labeled with the date it was opened, risking contamination and infection. Resident 66 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). These deficiencies were observed through a combination of direct observation, interviews with staff, and record reviews, highlighting a failure to adhere to professional standards and facility policies for medication and treatment administration.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent. Registered Nurse (RN) 1 did not administer metoprolol to Resident 25 because it was not available. This medication was prescribed to manage Resident 25's high blood pressure and pulse. At the time of the observation, Resident 25's blood pressure was 150/85 and pulse was 85. The failure to administer the medication as prescribed had the potential to cause serious health conditions. The Director of Nursing (DON) confirmed that it was the responsibility of licensed nurses to ensure medications were available and administered as ordered. Licensed Vocational Nurse (LVN) 4 did not follow the medication label instructions to administer potassium chloride with breakfast for Resident 55. Instead, the medication was given while Resident 55 was lying in bed with eyes closed and breakfast untouched. This failure could lead to stomach irritation and affect the medication's effectiveness. The DON stated that medications with specific instructions to be taken with food should be administered while the resident is actively eating to prevent adverse effects. The facility's policies and procedures were reviewed, indicating that medication errors include omissions and failure to follow manufacturer's instructions. The calculated medication error rate was 7.69 percent, exceeding the acceptable threshold of five percent. Interviews with staff and the DON highlighted the importance of adhering to medication administration protocols to prevent serious health issues for residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. Specifically, Resident 5's hydromorphone, hydrocodone-acetaminophen, and lorazepam were found repacked in smaller plastic bags with no labels and placed back in the plastic medication container from the pharmacy. This practice was observed by LVN 4, who stated that it was done for faster counting, although she was unsure if the DON or ADON were aware of this practice. Further interviews with LVN 2 and RN 1 confirmed that repacking narcotics in smaller plastic bags was a common but unapproved practice, which could lead to infection control issues and drug diversion. The DON was unaware of this practice and confirmed that only pharmacists are authorized to repack narcotics, as per the facility's policy and procedure on medication labeling and storage. Additionally, the facility failed to ensure proper labeling and storage of omeprazole in medication cart three. Two boxes of omeprazole were found without received dates or expiration dates. LVN 1 confirmed the absence of these dates and acknowledged that residents could potentially receive expired medication, which could be less effective or have undesired side effects. The DON confirmed the lack of expiration dates on the boxes and stated that all medications in the carts are required to have expiration dates to prevent the administration of expired medications. The facility's policy and procedure on medication packaging, dated 10/2007, requires all unit dose medications to contain a lot number, expiration date, and product name. The observed deficiencies in medication storage and labeling practices indicate a failure to adhere to these policies, potentially compromising resident safety and care quality.
Failure to Provide Correct Dietary Supplements and Textures
Penalty
Summary
The facility failed to provide a well-balanced diet to meet the nutritional needs of several residents. Specifically, three residents continued to receive a nutritional supplement that had been discontinued by their physician. During observations and interviews, it was found that the kitchen staff was not properly informed of the discontinued supplements due to a lack of communication from the nursing staff. This resulted in residents receiving supplements that were no longer part of their prescribed diet, as evidenced by tray tickets and order audit reports that did not reflect the updated dietary orders. Additionally, two residents were given a chopped diet without a physician's order. The tray tickets for these residents indicated a chopped meat diet, while their official dietary orders specified a regular texture diet. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the residents' diets should have been regular texture as per the physician's orders. The discrepancy between the tray tickets and the official orders highlighted a failure in the communication process between the nursing staff and the kitchen. The facility's policy and procedure documents state that all diet orders and changes must be communicated to the kitchen staff using a Diet Communication Form. However, this protocol was not followed, leading to the dietary errors. The lack of proper communication and adherence to established procedures resulted in residents receiving incorrect dietary supplements and textures, potentially impacting their nutritional needs and overall health.
Failure to Follow Prescribed Small Portion Diet
Penalty
Summary
The facility failed to ensure that the small portion diet for two residents, Resident 13 and Resident 21, was followed according to their alternate menu for lunch on March 25, 2024. During an observation in the kitchen, Cook 1 was seen using a #16 scoop (1/4 cup) of Spanish rice instead of the prescribed #12 scoop (1/3 cup) for the small portion diet. This discrepancy was confirmed during a review of the lunch tray tickets and the Daily Spreadsheet, which indicated the correct scoop size should have been #12. Cook 1 and the Dietary Service Supervisor (DSS) acknowledged the error when questioned by the surveyor team. Further interviews and record reviews revealed that both residents were on a small portion diet as per their Order Summaries. The Registered Dietitian (RD) confirmed that the kitchen staff did not follow the Daily Spreadsheet, which could potentially lead to weight loss for the residents if the correct portion sizes are not provided. The facility's Policy and Procedure on Food Service, dated 2018, also emphasized the importance of portion control to meet nutritional specifications and ensure resident satisfaction. The failure to adhere to the prescribed portion sizes had the potential to compromise the residents' caloric intake and medical status.
Failure to Ensure Proper Beard Restraint During Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared in accordance with professional standards for food service safety when one of the kitchen staff, Cook 2, did not wear a beard restraint while preparing food. During an observation, Cook 2 was seen slicing and measuring roast beef with a surgical mask that only covered his mouth and nose, leaving his facial hair exposed. Later, Cook 2 was observed putting roast beef into a food processor without a beard restraint, which could potentially lead to hair falling into the food and causing contamination. Interviews with the Registered Dietitian (RD) and the Dietary Service Supervisor (DSS) confirmed that kitchen staff were expected to wear a snood or beard restraint during food preparation. The facility's policy and procedure, dated 2018, also indicated that all hair, including beards and mustaches, should be covered during meal preparation and service. Despite these guidelines, Cook 2 was not in compliance, leading to the observed deficiency.
Incomplete Medical Records and POLST Forms
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards. One resident's medical record did not reflect the timely change of the humidifier bottle and the accurate amount of oxygen administered. This discrepancy was observed during an interview and record review, where it was found that the humidifier bottle was not changed as required every three days, leading to potential risks for the resident, such as dry, cracked, and bleeding mucosal membranes. The Director of Nurses confirmed that the documentation was inaccurate and that the humidifier bottle had not been changed as indicated in the medical administration record. Additionally, the facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for four residents were complete. The POLST forms lacked essential information such as the physician's phone number and license number, which are crucial for honoring the residents' end-of-life wishes. During interviews and record reviews, it was revealed that the incomplete POLST forms could delay treatment and potentially violate the residents' or their families' wishes regarding life-sustaining measures. The facility's policy and procedure on charting and documentation emphasized the need for accurate and complete documentation. However, the observed deficiencies in both the humidifier bottle change records and the POLST forms indicate a failure to adhere to these standards. The incomplete documentation and inaccurate records pose significant risks to the residents' health and well-being, as well as their ability to have their treatment preferences respected in emergency situations.
Failure to Implement Safe Infection Control Measures
Penalty
Summary
The facility failed to implement safe infection control measures for two residents, Resident 2 and Resident 4, as observed by surveyors. Resident 4's urinary catheter tubing was found lying on the floor during an observation with the Director of Nursing (DON), who confirmed that the tubing should not be on the floor due to the risk of infection. Certified Nursing Assistant (CNA) 8 and Licensed Vocational Nurse (LVN) 6 also confirmed that catheter tubing should not be on the floor and should be covered to prevent contamination. Resident 4 had a history of obstructive and reflux uropathy, retention of urine, type II diabetes mellitus, and congestive heart failure, and was moderately cognitively impaired with a BIMS score of 12. Similarly, Resident 2's urinary catheter drainage bag was observed lying on the floor during the initial tour of the facility. LVN 8 and the Infection Preventionist (IP) verified that the catheter bag should not be on the floor, as it posed a risk of infection. Resident 2 had severe cognitive impairment with a BIMS score of 4 and was diagnosed with dementia, type 2 diabetes mellitus, anemia, neuromuscular dysfunction, hypertensive heart disease with heart failure, dysphagia, and benign prostatic hyperplasia without lower urinary tract symptoms. The facility's policy and procedure on urinary catheter care, dated August 2022, indicated that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. Additionally, the facility's infection control policy, dated October 2018, aimed to prevent, detect, investigate, and control infections within the facility. The failure to adhere to these policies was confirmed by multiple staff members, including the DON, CNA 8, LVN 6, LVN 8, the IP, and the Director of Staff Services (DSD).
Failure to Ensure Mandatory Staff Training
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), and ancillary support staff received and demonstrated competency in preventing and recognizing resident abuse and in caring for residents with dementia. Specifically, 36 of 67 CNAs did not complete the 2023 annual mandatory in-service training for Dementia Module 1, and 47 of 67 CNAs did not complete Dementia Module 4. Additionally, 22 of 120 facility staff did not complete the mandatory in-service training for Fall Prevention, and 50 of 120 facility staff did not complete the mandatory in-service training for Abuse Prevention. These training modules are essential for ensuring that staff have the necessary skills and knowledge to provide safe and competent care to residents, particularly those with dementia or at risk of abuse and falls. During interviews and record reviews, the Director of Staff Development (DSD) confirmed that the mandatory training sessions were not attended by a significant portion of the staff. The DSD acknowledged that the Dementia modules, Fall Prevention, and Abuse Prevention trainings are required annually for all relevant staff members. The Director of Nursing (DON) also confirmed that these trainings are mandatory and should be completed annually to ensure proper care for the residents. The facility's Resident matrix indicated that 27 of 87 residents were diagnosed with Alzheimer's disease or dementia, highlighting the critical need for staff to be adequately trained in dementia care. The facility's policies and procedures emphasize the importance of in-service training for staff to understand resident rights, recognize signs of abuse, and manage aggressive or catastrophic resident behavior. The failure to ensure that all staff completed the required training sessions potentially placed residents at risk for inadequate care. The professional reference documents reviewed also support the necessity of regular training for nurse aides on dementia care and abuse prevention, as mandated by the Affordable Care Act and CMS guidelines.
Failure to Maintain Resident Dignity by Not Using Dignity Bags for Catheter Bags
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when two residents' urinary catheter bags were not placed in dignity bags, making them visible from the hall outside the residents' rooms. Resident 2, who was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, Anemia, Neuromuscular Dysfunction, Hypertensive Heart Disease with Heart Failure, Dysphagia, and Benign Prostatic Hyperplasia, had a BIMS score of 4, indicating severe cognitive impairment. Resident 26, admitted with diagnoses including Multiple Sclerosis, Anemia, Major Depressive Disorder, Muscle Weakness, Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection, had a BIMS score of 9, indicating moderate cognitive impairment. During the initial tour, Resident 2's catheter bag was observed on the floor next to the bed, and Resident 26's catheter bag was attached to the wheelchair, both without dignity bags and visible from the hall. Interviews with staff, including an LVN, the Infection Preventionist, the Director of Staff Development, and the Director of Nursing, confirmed that the catheter bags were not in dignity bags, which was against the facility's policy. The facility's policy and procedure on dignity, dated February 2021, indicated that each resident should be cared for in a manner that promotes their sense of well-being and self-esteem, including keeping urinary catheter bags covered. The failure to follow this policy resulted in a violation of the residents' rights to dignity and respect.
Inaccurate MDS Assessment for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of Resident 65. Resident 65, who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and atherosclerotic heart disease, was observed with limited mobility in her left arm due to a previous stroke. Despite this, the MDS assessment inaccurately coded Resident 65 as having no impairment in the upper extremity. Interviews with the resident, a Certified Nurse Assistant (CNA), and a Licensed Vocational Nurse (LVN) confirmed that Resident 65 required assistance with activities of daily living (ADL) due to the weakness in her left arm. The Minimum Data Set Registered Nurse (MDSRN) admitted to making an error in the assessment, acknowledging that Resident 65's left upper extremity did not have the same range of motion as her right upper extremity. The Director of Nursing (DON) also confirmed that Resident 65 should have been coded as having weakness in the upper extremity. The facility follows the Long Term Care Facility Resident Assessment Instrument (RAI) guidelines, which were not adhered to in this case, leading to the inaccurate assessment of Resident 65's functional limitations.
Failure to Complete PASRR Assessment for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with major depressive disorder, dementia, and psychotic disorder. The resident, who had been in the facility for more than eight years, was started on psychotropic medications on 12/2/19. However, the facility did not complete a new PASRR assessment to reflect the resident's diagnosis and use of psychotropic medications. The admission coordinator acknowledged the absence of a PASRR assessment after 11/8/19 and admitted that there should have been one completed. The facility did not have a policy on PASRR and relied on current regulatory guidelines instead. During an interview, the Director of Nursing confirmed that a new PASRR assessment should have been completed when the resident was started on psychotropic medications. The failure to complete the necessary PASRR assessment had the potential to prevent the resident from receiving the appropriate psychiatric level of treatment and evaluation. The deficiency was identified during a survey that included observation, interview, and record review.
Failure to Validate Competency of Infection Preventionist
Penalty
Summary
The facility failed to provide sufficient staff with the appropriate competencies and skill sets to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the Infection Preventionist (IP) did not receive a competency skills check after being hired. The Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that the IP, who was responsible for the facility's infection prevention and control program, did not have her nurse competency validated. This oversight means the facility lacks proof that the IP can provide appropriate nursing care to residents, potentially placing them at risk of infection spread. The IP was hired and started her orientation but did not recall having her nurse competency checked by the DON or DSD. The facility's policy and procedure for newly hired employees require an in-depth orientation, including a review of infection control practices, but this was not completed for the IP. The facility's job description for the IP emphasizes the importance of maintaining current knowledge of regulations and performing duties related to infection prevention, yet the necessary competency validation was not conducted, leading to the identified deficiency.
Failure to Provide Metoprolol Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 25 when their metoprolol medication, used to treat high blood pressure, was not available for administration on 3/27/24. During a medication pass observation, RN 1 noted that Resident 25's blood pressure was 150/85 and pulse was 85, but the metoprolol was not available. RN 1 stated that she would call the physician to notify them of the unavailability of the medication. The facility's policy requires that the attending physician be notified and the pharmacy be contacted when a medication is not available, but it was unclear if these steps were followed prior to RN 1's shift. Interviews with LVN 2 and the Director of Nursing (DON) revealed that licensed nurses are responsible for ensuring medications are available for administration. LVN 2 confirmed that the facility's practice is to call the MD and follow up with the pharmacy when a medication is not available. The DON stated that the nurse who administered the last dose should have followed up with the pharmacy. The facility's policies on medication shortages and non-controlled medication orders emphasize the importance of making every effort to ensure medications are available and notifying the prescriber if there is a delay in delivery or unavailability of the medication.
Inadequate Lighting in Medication Room
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment in one of its medication rooms (Station 5), where only one of four fluorescent lights was working. This deficiency was observed during a survey on 3/26/24, at 3:50 p.m. with an LVN who noted the room was dark, making it difficult to read medication labels and increasing the risk of tripping and falling. The LVN was unaware if the issue had been reported to the maintenance department. An RN confirmed that the lights had been broken for at least two months and that no work order had been submitted to fix them. The RN also acknowledged the difficulty in reading medication labels and the potential for tripping due to the inadequate lighting. The Maintenance Facility Director (MFD) was unaware of the lighting issue until it was brought to his attention during the survey. He confirmed that the lighting situation was unsafe and that all lights should be functional. The facility's administrator stated that the lights were fixed on 3/26/24 but did not consider the lack of lighting an immediate health and safety hazard. The administrator mentioned that nurses could use alternative lighting methods, such as cell phone lights or flashlights, to read medication labels. The facility's policy and procedure on maintaining a homelike environment emphasized the importance of adequate lighting to promote safety and comfort, which was not adhered to in this case.
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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