Capistrano Beach Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dana Point, California.
- Location
- 35410 Del Rey, Dana Point, California 92624
- CMS Provider Number
- 055585
- Inspections on file
- 46
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Capistrano Beach Care Center during CMS and state inspections, most recent first.
A resident with moderately impaired cognition experienced a dislodged nephrostomy tube and was transferred to a hospital for re-insertion. Upon return, facility staff did not develop a care plan to address the resident's needs related to the dislodged and replaced nephrostomy tube, as confirmed by medical record review and staff interviews.
A resident with advanced dementia was not properly represented in care planning when the responsible party was not informed in advance about psychological testing, psychiatric visits, or a new order for buspar following a behavioral incident. Facility staff and the psychiatrist confirmed that the responsible party was not notified as required by policy, resulting in a lack of informed consent for the resident's psychiatric care.
A resident with moderately impaired cognition did not receive timely blood pressure monitoring for hypotension, as required by facility policy, with BPs checked only twice per day despite low readings. Abnormal CBC results indicating infection were not promptly reported to the physician, with a delay of over three hours. Additionally, a stat order for a urine sample was not acted upon immediately, with collection occurring several hours after the order was placed.
A resident with confusion and no capacity experienced a change of condition, developing a cough. The physician ordered Tamiflu, but the medication was not transcribed into the medical record or administered. The IP admitted to the oversight, and the DON acknowledged the miscommunication between staff.
A facility failed to report an abuse allegation in a timely manner, as required by their policies and section 1150B of the Act. An LVN witnessed a resident with pillows over her face, allegedly placed by another resident. The incident was reported to the Administrator and other authorities, but the CDPH, L&C Program was not notified until seven days later. This delay was confirmed by interviews with the RN and Administrator, highlighting a deviation from the facility's protocol.
A facility failed to provide a resident with quarterly trust fund statements, as required by policy. The resident, who was cognitively intact, reported not receiving statements for years. The BOM claimed to have handed the statement in November but did not document the transaction. The Administrator could not provide evidence of the statement's delivery, indicating a deficiency in managing residents' personal funds.
The facility failed to follow food safety and sanitation guidelines, with undated and expired food items in the refrigerator, improper hair restraints worn by staff, and poor condition of kitchen equipment. A cleaning chemical was stored next to food items, and a handwashing sink was obstructed, posing contamination risks.
A facility failed to update informed consent for a resident's use of risperidone when the indication changed from suicidal ideation to racing thoughts. Despite the resident's capacity to understand and make decisions, the informed consent form was not updated, as confirmed by an LVN and an RN during interviews and record reviews.
A facility failed to assess a resident's ability to self-administer tetrahydrozoline eye drops, which were found at the resident's bedside without a physician's order. The resident lacked the capacity to make medical decisions and had not been approved for self-administration, contrary to facility policy.
The facility failed to ensure call lights were accessible for two residents, impacting their ability to request assistance. One resident's call light was placed out of reach on the bed, while another's was found on the floor. CNAs confirmed the call lights were not accessible and repositioned them.
The facility failed to address concerns from resident council meetings, including incomplete follow-up on OCTA Access forms and CNA mannerisms. The Resident Council Response Form was not properly utilized, leading to unresolved issues. Interviews revealed communication lapses and incomplete documentation, resulting in unaddressed resident concerns.
The facility failed to document and offer advance directive information to several residents, as required by policy. Medical records for multiple residents lacked evidence of being asked about advance directives or provided information on formulating one. Interviews with the SSD confirmed these documentation gaps, and the DON acknowledged the findings.
The facility failed to protect the confidentiality of two residents' medical records when computer monitors displaying sensitive information were left unattended at a nursing station. An LVN confirmed the oversight, and a CNA admitted to leaving a monitor unattended while assisting a resident, violating the facility's policy on safeguarding resident information.
A facility failed to provide written notification to a resident's representatives about a hospital transfer, as required by policy. The resident, who lacked decision-making capacity, was transferred without a signed Notice of Transfer/Discharge Form or documented written notification. The SSD confirmed that verbal notification was typical, but written notice was not given, risking the representatives' awareness of appeal rights.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled in hospice services. The resident was admitted to hospice on July 29, 2024, but no comprehensive assessment or SCSA was completed within the required timeframe. This was confirmed by the MDS Coordinator during an interview.
The facility failed to develop comprehensive care plans for three residents who experienced falls, resulting in deficiencies in addressing their specific needs. A resident had an unwitnessed fall and significant weight loss without a care plan to address these issues. Another resident slipped off the bed, and a third resident fell while transferring from a wheelchair, both without care plans. Interviews with staff confirmed the lack of appropriate care planning, indicating a failure to provide individualized care.
A resident with a cervical fracture was observed without a required cervical collar, contrary to a physician's order. The resident had stopped wearing the collar after a neurosurgeon appointment, but there was no documentation of order discontinuation. An LVN confirmed the order was still active, highlighting a failure in follow-up care.
A resident at high risk for pressure ulcers was found on a low air loss mattress set incorrectly to 250 pounds instead of their actual weight of 103 pounds. The resident was unable to communicate comfort levels due to cognitive impairment, and staff interviews confirmed the mattress should have been set according to weight. The MDS Coordinator adjusted the setting after the discrepancy was identified.
The facility failed to investigate and document the cause of a skin tear for a resident and did not ensure another resident wore a WanderGuard as ordered. Staff interviews revealed inconsistencies in reporting and documentation, and the WanderGuard was never applied despite the resident's risk for wandering. These deficiencies indicate non-compliance with facility policies and physician's orders.
The facility failed to monitor and address significant weight loss in three residents. A resident experienced severe weight loss without timely notification to their physician or an IDT evaluation. Two other residents did not receive weekly weight monitoring as ordered, leading to untracked weight changes. The DON confirmed communication lapses in implementing RD recommendations and physician orders.
The facility failed to provide necessary respiratory care for several residents, including improper oxygen administration and lack of adherence to physician orders. A resident received oxygen without a physician's order, while another had their oxygen tubing compressed by a door. Additionally, a resident was found on room air despite needing continuous oxygen, and another's oxygen titration order lacked specific parameters. Improper storage of a suction machine was also noted.
A resident with severe cognitive impairment received inadequate pain management due to unclear medication orders. The resident had overlapping orders for acetaminophen and hydrocodone-acetaminophen, leading to the administration of acetaminophen for a pain level of 5, when hydrocodone-acetaminophen was more appropriate. An LVN confirmed the lack of clear indications for use in the medication orders.
A facility failed to follow its protocol for administering medications through a G-tube for a resident. The policy required flushing the G-tube with water before and between medications, but an LVN used a syringe and plunger without flushing. The resident had a G-tube placement and an order to flush with 30 ml of water before and after medications.
The facility failed to monitor the behavior and side effects of a resident on risperidone and did not limit another resident's PRN lorazepam order to 14 days, as required by policy. Staff confirmed the lack of monitoring and documentation for extending medication use.
The facility failed to provide appropriate dietary accommodations for three residents. A resident with a non-gluten diet did not receive gluten-free pasta, another resident requiring double portions received single portions, and a third resident did not consistently receive Ensure with meals as ordered. These deficiencies risked not meeting the residents' nutritional needs.
A resident with severe cognitive impairment signed a binding arbitration agreement at the facility. Despite having a BIMS score indicating severe cognitive impairment and a health examination confirming the lack of capacity to make medical decisions, the resident signed the agreement. The Admissions Director admitted to explaining the agreement but was unsure of the resident's understanding, acknowledging the resident should not have signed it.
The facility failed to notify hospice of significant weight loss for two residents and did not ensure hospice nursing visits occurred as per the care plan. This lack of communication and coordination posed a risk to resident care.
The facility failed to maintain essential equipment safely, with ice buildup in medication refrigerators and residue in an ice machine. Two RNs confirmed the ice buildup, and the Maintenance and Corporate Dietary Supervisors identified residue and improper repairs on the ice machine.
The facility failed to maintain a pest-free environment, with flies observed in a resident's room and the kitchen. In the resident's room, a fly landed on an uncovered cup of milk and an insulated water mug, with an open window lacking a screen. In the kitchen, flies were seen near the coffee machine, puree food preparation, and tray line areas, with one landing on a covered loaf of bread. These observations indicate a failure to prevent pests, potentially leading to foodborne illness transmission.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks in continuity of care. One resident's gender was incorrectly recorded, while another's hospice services and significant weight loss were not documented. These errors were confirmed by the MDS coordinator.
The facility failed to dispose and store trash in a sanitary manner, posing a threat for pest contamination. Observations revealed that the recycling bin had cardboard boxes piled above the rim, and two trash dumpsters had black trash bags preventing the lids from closing properly. The Maintenance Supervisor confirmed that lids should be fully closed to prevent pest access.
A resident's representative requested a copy of the resident's medical record, but the facility failed to provide it, potentially violating the resident's rights. The facility's P&P required written consent for releasing medical records and allowed access within 48 hours of a request. Despite receiving the request, the Medical Records Director and Administrator confirmed that the records were not sent.
A broken shower bench in Shower Room C was not removed, posing a safety risk to residents. The facility's maintenance policy requires equipment to be safe and operable, but the bench had uneven legs and a hanging metal piece. A CNA confirmed the bench was broken and stated that broken equipment should be reported to maintenance. The Maintenance Director verified the issue, noting missing and broken parts, and emphasized the need for removal to ensure resident safety. The Administrator and DON acknowledged the findings.
A resident's evening medications were not administered on the admission day because they were not delivered by the pharmacy. The LVN did not call the pharmacy or notify the physician after the expected delivery window had passed. The DON confirmed that the physician should have been notified, and the Administrator acknowledged that increased monitoring could have been ordered.
Failure to Develop Care Plan for Dislodged Nephrostomy Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the needs of a resident who experienced a dislodged nephrostomy tube. According to the facility's policy, a person-centered care plan with measurable objectives and timetables should be developed and implemented for each resident, including after a change in condition. Medical record review showed that the resident, who had moderately impaired cognition, had a nephrostomy tube dislodged and was transferred to an acute care hospital for re-insertion. Upon return to the facility with the tube replaced, there was no evidence that a care plan was created to address the dislodged and replaced nephrostomy tube. Interviews with facility staff, including an LVN and the DON, confirmed that no care plan was developed for the resident's nephrostomy tube incident. The staff acknowledged that a care plan should have been initiated following the change in condition, including interventions such as transfer to the hospital and care of the nephrostomy tube site. The absence of a care plan meant the resident's specific needs related to the nephrostomy tube were not formally addressed in the care planning process.
Failure to Inform Responsible Party of Psychiatric Care and Medication Changes
Penalty
Summary
The facility failed to ensure that the responsible party for one of six sampled residents was informed in advance about the care to be furnished and the type of provider who would be delivering that care. Specifically, the responsible party was not notified prior to psychological tests, psychiatric visits, or the prescription of buspar by the psychiatrist following a resident-to-resident altercation. The facility's policies require that residents and their responsible parties be included in care planning and notified of changes in care or treatment, but these procedures were not followed in this instance. The resident involved had advanced dementia and was readmitted to the facility prior to the incident. Documentation from a care conference with the responsible party did not mention upcoming psychiatric interventions or medication changes. Interviews with facility staff and the psychiatrist confirmed that the responsible party was not informed in advance about the psychiatric evaluation, follow-up visits, or the new medication order. The psychiatrist indicated that he believed it was the facility's responsibility to obtain informed consent, and the responsible party expressed concerns about not being notified about these aspects of the resident's care.
Failure to Monitor Hypotension, Delay in Reporting Lab Results, and Delay in Stat Urine Collection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident as required by physician orders, resident preferences, and established policies and procedures. Specifically, the facility did not adequately monitor the resident's blood pressure for hypotension, despite multiple readings below the defined threshold of 100/60 mmHg. Blood pressure measurements were only taken twice per day over two days, and staff interviews confirmed that more frequent monitoring was warranted but not performed. Additionally, the facility did not promptly report abnormal laboratory results to the resident's physician. A CBC test revealed an elevated white blood cell count, which was received by the facility at 1256 hours but not communicated to the physician until over three hours later. Both nursing staff interviewed acknowledged that the results, indicating a possible infection, should have been reported immediately upon receipt. The facility also failed to collect a stat urine sample in a timely manner after a physician's order was placed. The order for a UA with C&S stat was entered at 1747 hours, but the urine sample was not collected until 2218 hours the same day. Staff interviews confirmed that the sample should have been collected immediately following the order. These failures were verified through observation, interviews, and medical record review.
Failure to Administer Tamiflu as Ordered
Penalty
Summary
The facility failed to administer Tamiflu to Resident 2 as ordered by the physician, which was necessary to address a change in the resident's condition. Resident 2, who was admitted to the facility with confusion and no capacity, experienced a change of condition on January 22, 2025, when they developed a cough. The physician ordered Tamiflu 75 mg to be administered daily for seven days. However, the order was not transcribed into the resident's medical record, and the medication was not administered as required. Interviews and medical record reviews revealed that the Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP) were aware of the physician's order but failed to ensure it was documented and executed. The IP admitted to receiving the order but did not transcribe it into the medical record, acknowledging it as a mistake. The Director of Nursing (DON) confirmed the expectation for licensed nurses to notify physicians and family members of any changes in condition and to carry out physician orders, acknowledging the miscommunication between the charge nurse and the IP regarding the Tamiflu order.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner, as required by their policies and procedures and section 1150B of the Act. The incident involved two residents, where one resident alleged that another resident placed pillows over her face and told her to be quiet. This incident was witnessed by an LVN who responded to calls for help and removed the pillows from the resident's face. The LVN reported the incident to the RN, who then informed the Administrator and other relevant authorities, but failed to notify the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program immediately as required. The facility's policy mandates that any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the Administrator and other officials according to state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations. Despite this, the facility did not contact the CDPH, L&C Program until seven days after the incident, which was a clear deviation from the established protocol. Interviews conducted with the RN and the Administrator confirmed the failure to report the incident to the CDPH, L&C Program in a timely manner. The RN acknowledged the oversight, and the Administrator verified the lack of documentation regarding the immediate notification to the CDPH, L&C Program. This delay in reporting had the potential to leave the abuse allegation unreported and uninvestigated, contrary to the facility's policy and regulatory requirements.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly trust fund statements to a resident, identified as Resident 5, which is a requirement for managing residents' personal funds. The facility's policy, revised in March 2021, mandates that if the facility is appointed as the resident's representative payee, it must manage the funds in accordance with established policies and federal/state requirements. However, during an interview on January 2, 2025, Resident 5 stated she did not remember receiving any quarterly trust fund statements from the Business Office Manager (BOM) and mentioned not having received any statements for years, except possibly at the time of admission. The medical record review indicated that Resident 5 was cognitively intact and had the capacity to make medical decisions. Despite this, there was no documented evidence that Resident 5 received the quarterly trust fund statement for November 2024. The Account Receivable Consultant, who managed the resident's trust account offsite, confirmed that the statement was printed on October 31, 2024, but could not verify if it was handed to the resident. The BOM claimed to have personally handed the statement to Resident 5 in November 2024 but admitted to not keeping a copy or documenting the transaction. The Administrator, during an interview on January 3, 2025, was unable to provide documented evidence that Resident 5 received the quarterly statement in November 2024. The lack of documentation and verification of the delivery of the trust fund statement to Resident 5 highlights a deficiency in the facility's management of residents' personal funds, potentially leading to the loss and misuse of the resident's personal funds.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations during a survey. In the walk-in refrigerator, food items such as beef and chicken were found undated and unlabeled, and other items like gelatin and grape juice were not discarded by their use-by dates. This lack of proper labeling and disposal could lead to foodborne illnesses. Additionally, staff in the kitchen, including the Dietary Services Supervisor (DSS) and cooks, were observed not wearing appropriate hair restraints, which is a violation of the USDA Food Code. Further inspection revealed that a bucket of cleaning chemical was stored next to food items, which poses a risk of contamination. The kitchen equipment and utensils were found to be in poor condition, with melted handles on spoons and spatulas, and baking sheets and cutting boards with residues and markings. These conditions make it difficult to maintain cleanliness and could harbor pathogens. The facility also failed to label a dry goods bin containing a white granulated powder, identified as a thickener, which is a breach of proper food storage protocols. The handwashing sink was obstructed by a trash can lid, making it inaccessible for staff use, which is against the FDA Food Code. This obstruction could prevent proper hand hygiene, increasing the risk of contamination. The facility's failure to maintain clean and properly labeled equipment, ensure staff wear appropriate hair restraints, and keep handwashing facilities accessible, highlights significant lapses in maintaining food safety and sanitation standards.
Failure to Obtain Updated Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the use of psychotropic medication, specifically risperidone, when the indication for its use was changed. The resident, who had the capacity to understand and make decisions, was initially prescribed risperidone for schizoaffective disorder manifested by suicidal ideation. However, the indication was later changed to address racing thoughts, and the facility did not obtain informed consent for this new indication. Interviews and medical record reviews confirmed that the informed consent form on file did not reflect the updated indication for the medication. Both an LVN and an RN verified that the informed consent should have been updated to include the new manifestation of racing thoughts as per the physician's order. This oversight had the potential to leave the resident uninformed about the medication and its effects.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for their ability to self-administer medications, specifically tetrahydrozoline eye drops. The facility's policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, but this assessment was not documented for the resident in question. The resident was observed with the eye drop medication at their bedside, which they had been self-administering without a physician's order or documented approval for self-administration. The resident's medical records indicated they lacked the capacity to understand and make medical decisions, and they had previously expressed a desire not to self-administer medications. Despite this, the eye drops were found at the resident's bedside, and a Licensed Vocational Nurse confirmed there was no physician's order for the medication to be self-administered or stored at the bedside. The Director of Nursing was informed and acknowledged these findings.
Inaccessible Call Lights for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, specifically regarding the accessibility of their call lights. For Resident 4, who had impairments in mobility of both upper extremities and one lower extremity, the call light was not within reach. On a specific observation, the call light was placed by the resident's left knee, making it difficult for the resident to reach the juice on the meal tray. A CNA later confirmed the call light was not accessible and assisted the resident by repositioning the call light and the juice. Similarly, Resident 72's call light was found on the floor, out of reach. When asked, the resident was unaware of the call light's location. A CNA verified the call light's position on the floor and subsequently sanitized and repositioned it within the resident's reach. The CNA acknowledged that the call light should not have been on the floor and should have been accessible to the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and follow through with concerns raised during resident council meetings, specifically regarding the completion of OCTA Access forms and the mannerisms of CNAs when interacting with residents. The facility's policy and procedure for Resident Council, revised in February 2021, mandates the use of a Resident Council Response Form to track issues and their resolution. However, the facility did not adhere to this policy, resulting in unresolved issues. In the first instance, the Resident Council Minutes from a meeting held in June 2024 indicated a request for OCTA Access forms, which are necessary for residents to obtain transportation access for outings. The Department Response Form noted a delay in addressing this concern due to a change in the Social Services Director. Although the form indicated the issue was resolved to the residents' satisfaction, there was no documentation of follow-up efforts to obtain the forms. Interviews with the Assistant Director (AD) and the new Social Services Director (SSD) revealed a lack of communication and awareness about the concern, leading to the forms remaining unprocessed. In another instance, the Resident Council Minutes from August 2024 highlighted concerns from residents in specific rooms about the CNAs' mannerisms. The Department Response Form documented investigations for some residents but failed to address all the concerns raised. The AD admitted to forgetting to follow through with two residents, and the Director of Staff Development (DSD) confirmed incomplete documentation and follow-up. The section of the form regarding resolution to the residents' satisfaction was left blank, indicating an incomplete investigation and lack of resolution for the concerns raised.
Failure to Document and Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that advance directive information was documented and offered to residents, as required by their policy and procedure. This deficiency was identified through interviews, medical record reviews, and facility policy reviews. Specifically, the facility did not document whether residents were asked about having an advance directive or if they were provided information on formulating one. This issue affected seven sampled residents and one non-sampled resident. For several residents, including Residents 4, 18, 35, and 72, their medical records lacked evidence that they were asked about having an advance directive or offered information on formulating one. Residents 2 and 19's records indicated they did not have an advance directive, but there was no documentation showing they were provided with information on how to create one. Resident 27's records did not indicate whether they had an advance directive, and Resident 76's advance directive was not available in their medical record. Interviews with the Social Services Director (SSD) confirmed these documentation gaps. The SSD acknowledged that the forms were incomplete or blank and should have been filled out to reflect whether residents had advance directives or were offered information. The Director of Nursing (DON) was informed of these findings and acknowledged the issues. These failures had the potential to impact the residents' ability to have their healthcare and treatment decisions honored.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of residents' medical records, specifically for two nonsampled residents, Residents 56 and 59. This deficiency was identified during an observation at Nursing Station A, where three computer monitors were left turned on and unattended. One monitor displayed the physician's orders for Resident 59, while another showed the care tracker/dashboard for Resident 56. These monitors were accessible to unauthorized users, compromising the residents' personal and health information. During an interview, LVN 6 confirmed that the monitors were unattended and acknowledged that they should not have been left in such a state. Additionally, CNA 6 admitted to leaving one of the monitors unattended to assist a resident, indicating a lapse in following the facility's policy on safeguarding resident information.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to the resident's representatives regarding the transfer of a resident to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews. The facility's policy on transfer or discharge, dated October 2022, requires that resident or representative notification and documentation be completed for facility-initiated transfers. However, in the case of Resident 2, who lacked the capacity to understand and make decisions, there was no written notification provided to the resident's representative when the resident was transferred to the hospital on July 27, 2024. The medical record review revealed that the Notice of Transfer/Discharge Form for Resident 2 was not signed by the resident or their representative, and the progress notes did not document any written notification being given. During an interview, the Social Services Director (SSD) indicated that nurses typically inform the resident or their representative of such transfers verbally, but acknowledged that no written notice was provided in this instance. This oversight posed a risk of the resident's representatives being unaware of their appeal rights regarding the transfer.
Failure to Complete Timely SCSA for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled in hospice services. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a SCSA must be completed within 14 days when a resident enrolls in a hospice program. The medical record review for the resident, who was admitted to hospice services on July 29, 2024, showed that no comprehensive assessment or SCSA was completed within the required timeframe. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the assessment should have been completed within the specified period.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, which resulted in deficiencies in addressing their specific needs. Resident 13 experienced an unwitnessed fall on 7/27/24, and despite the incident being documented, no care plan was developed to address the fall. Additionally, Resident 13 experienced significant weight loss over a period of months, yet the care plan did not reflect any measures to address this issue. Interviews with the IP and DON confirmed these findings, indicating a lack of appropriate care planning for Resident 13's fall and weight loss. Resident 43 also experienced a fall on 7/29/24, where the resident was found sitting on the floor after slipping off the bed. Despite the incident being recorded in the progress notes, there was no care plan developed to address this fall. Interviews with the resident, LVN 7, and the DON confirmed that a care plan should have been initiated but was not, highlighting a failure to provide individualized care for Resident 43. Similarly, Resident 72 experienced a fall on 5/29/24 while transferring from a wheelchair to a couch. The incident was documented, but the care plan did not include any measures to address the fall. An interview with RN 1 confirmed the absence of a care plan for this incident, indicating a failure to develop a comprehensive care plan for Resident 72. These deficiencies suggest a pattern of inadequate care planning for residents who experienced falls, potentially compromising their well-being.
Failure to Follow Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to adhere to a physician's order for a resident who was required to wear a cervical collar at all times. The resident, who had a cervical fracture, was observed without the cervical collar during an interview and observation conducted on 09/18/24. The resident mentioned that she stopped wearing the collar after an appointment with her neurosurgeon on 9/6/24 and had given it to a friend for safekeeping. Despite this, there was no documentation in the medical records indicating that the order for the cervical collar had been discontinued. A Licensed Vocational Nurse (LVN) confirmed that the physician's order for the cervical collar was still active and that the care plan also required the collar to be worn at all times. The LVN acknowledged that there should have been a follow-up by the nursing staff after the resident's neurosurgeon appointment to verify any changes in the treatment plan. The lack of adherence to the physician's order posed a risk to the resident's well-being, as it was crucial for the resident's overall health and recovery.
Improper Mattress Setting for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set appropriately according to the resident's weight, which is crucial for preventing pressure ulcers. The resident, identified as being at high risk for developing pressure ulcers, was observed on two occasions lying on a mattress set to 250 pounds, despite the resident's actual weight being 103 pounds. The medical records indicated that the resident was totally dependent on staff for bed mobility and had severely impaired cognitive skills, making it impossible for them to communicate their comfort level. Interviews with the MDS Coordinator and LVN revealed that the mattress should have been set according to the resident's weight, as the resident could not verbalize comfort levels. The MDS Coordinator confirmed the incorrect setting and adjusted it to the correct weight. The DON acknowledged the findings, indicating a lapse in monitoring and adjusting the mattress settings as per the physician's order, which required checking the settings every shift.
Failure to Investigate Accident and Implement Safety Measures
Penalty
Summary
The facility failed to ensure adequate investigation and documentation of an accident involving a resident, identified as Resident 2, who sustained a skin tear on the right buttock. Despite the presence of a facility policy requiring thorough investigation and reporting of accidents, there was no documentation of the cause of the skin tear. Interviews with staff, including LVN 9, CNA 7, and LVN 3, revealed inconsistencies in the reporting and documentation process. LVN 9 was informed by CNA 7 about a fall incident involving Resident 2, but the focus remained on treating the skin tear rather than investigating the fall. The Director of Nursing (DON) and RN 1 confirmed the lack of documentation regarding the investigation of the skin tear's cause. The facility also failed to comply with a physician's order for Resident 86, who was at risk for wandering and elopement, to wear a WanderGuard on the left wrist. Observations and interviews with LVN 7 and RN 1 confirmed that Resident 86 was not wearing the WanderGuard as prescribed. Despite the care plan and physician's order indicating the need for the WanderGuard, it was never applied to Resident 86, leaving the resident without the necessary safety measure. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding accident investigation and the implementation of physician's orders. The lack of proper documentation and follow-through on safety measures had the potential to negatively impact the well-being of the residents involved.
Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional services to three residents, resulting in significant weight loss and lack of proper monitoring. Resident 13 experienced severe weight loss, with a 12% reduction in weight over three months and 11.2% over six months. Despite these alarming changes, the facility did not notify the resident's physician or responsible party in a timely manner, nor did they conduct an interdisciplinary team (IDT) evaluation to address the weight loss. This oversight was confirmed by both RN 1 and the Director of Nursing (DON), who acknowledged the failure to implement necessary interventions. For Resident 35, the facility did not adhere to the physician's order for weekly weight monitoring, which was recommended by the Registered Dietitian (RD) due to the resident's steady weight loss. The resident's weight decreased from 101 pounds to 95 pounds over a two-month period, yet no weekly weights were recorded after the initial order. The DON confirmed that the RD's recommendations were not effectively communicated to the nursing staff, resulting in the failure to monitor the resident's weight as ordered. Similarly, Resident 4's weight monitoring was not conducted as per the physician's order following an IDT meeting that recommended weekly weights. Although the resident's weight fluctuated, the facility did not perform weekly weigh-ins until a month after the order was given. The DON verified that the communication breakdown led to missed weight checks, which were crucial for monitoring the resident's nutritional status. This lapse in following the prescribed weight monitoring protocol was acknowledged during the review of the resident's medical records.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, as evidenced by multiple deficiencies in following physician orders and ensuring proper oxygen administration. Resident 442 was observed receiving oxygen at 4 liters per minute, but there was no documented evidence of the need for titration or the parameters for how high the oxygen could be titrated. The MDS Coordinator and DON confirmed the lack of documentation and the need for clarification of the physician's order. Resident 12's oxygen concentrator was found in the hallway with the door compressing the oxygen tubing, posing a risk of not receiving the necessary oxygen. Despite having a physician's order for continuous oxygen, the setup was not properly maintained, as verified by LVN 3. Similarly, Resident 27 was not receiving continuous oxygen as ordered, and was found on room air with a low oxygen saturation level of 84%. LVN 5 had not checked the resident's oxygen status that day, leading to a delay in administering the required oxygen. Additional deficiencies were noted for Resident 2, who was receiving oxygen without a physician's order, and Resident 72, whose oxygen titration order lacked specific parameters. Resident 4's suction machine and canisters were improperly stored on the floor, which could negatively affect the resident's medical condition. These observations highlight the facility's failure to adhere to physician orders and maintain proper respiratory care protocols, as outlined in their policy and procedure for oxygen administration.
Inadequate Pain Management Due to Unclear Medication Orders
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident with severe cognitive impairment. The medical record review revealed that the resident had orders for both acetaminophen and hydrocodone-acetaminophen, with overlapping indications for use based on pain levels. Specifically, acetaminophen was ordered for pain levels ranging from mild to severe (1-10 on a pain scale), while hydrocodone-acetaminophen was ordered for moderate to severe pain (4-10). On a specific occasion, the resident experienced a pain level of 5 and was administered acetaminophen instead of hydrocodone-acetaminophen, which was more appropriate for that level of pain. The Licensed Vocational Nurse (LVN) confirmed that the medication orders lacked clear indications for use, leading to the inappropriate administration of pain medication.
Failure to Follow G-tube Medication Administration Protocol
Penalty
Summary
The facility failed to administer medications according to its policy and procedure (P&P) for a nonsampled resident, identified as Resident 59. The P&P for administering medications through an enteral tube, revised in November 2018, required the removal of the plunger from the syringe before pouring medications into the syringe barrel and flushing the G-tube with water before and between administering medications. On September 19, 2024, during a medication administration observation, LVN 3 was seen using the syringe and plunger to push medications into Resident 59's G-tube without flushing it with 50 ml of water before and between the medications. LVN 3 acknowledged the failure to follow the procedure. Resident 59 had been readmitted to the facility with a post-status G-tube placement, and their September 2024 Medication Administration Record (MAR) included an order to flush the G-tube with 30 ml of water before and after medication administration.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as identified during a survey. For one resident, the facility did not accurately monitor behavior manifestations and side effects associated with the use of risperidone, an antipsychotic medication prescribed for schizoaffective disorder. Despite physician orders to monitor behaviors such as racing thoughts and side effects, the Medication Administration Records (MARs) for June, July, August, and September 2024 did not reflect any monitoring. Interviews with facility staff confirmed the lack of monitoring, which was required for residents receiving antipsychotic medications. Another resident was affected by the facility's failure to limit the PRN order for lorazepam, an antianxiety medication, to 14 days as per the facility's policy. The medical record review showed an ongoing PRN order for lorazepam without an end date or documented rationale for extending its use beyond 14 days. The Director of Nursing (DON) confirmed these findings and acknowledged the absence of documentation justifying the extended use of lorazepam. These deficiencies indicate a failure to adhere to the facility's policies regarding the use and monitoring of psychotropic medications, posing a risk of unnecessary medication use and potential negative impacts on the residents' health and well-being.
Failure to Meet Residents' Nutritional and Dietary Needs
Penalty
Summary
The facility failed to meet the daily nutritional and special dietary needs of three residents, as observed during a survey. Resident 592, who had a physician's order for a non-gluten diet, did not receive gluten-free pasta with their lunch tray. The Corporate Dietary Supervisor acknowledged that the staff forgot to include the gluten-free pasta on the tray. Similarly, Resident 593, who had a physician's order for double portions, received only single portions during lunch. The Corporate Dietary Supervisor confirmed that the tray should have contained double portions as per the resident's dietary requirements. Additionally, Resident 62, who had a physician's order to receive Ensure with meals to aid in weight gain, did not have Ensure included with their lunch tray. The resident confirmed that they only received Ensure sometimes, not with every meal as prescribed. The IP verified the absence of Ensure on the lunch tray and acknowledged the physician's order for Ensure with every meal. These deficiencies posed a risk to the residents' nutritional needs not being met.
Resident with Cognitive Impairment Signed Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment did not sign a binding arbitration agreement. Resident 45, who had a BIMS score of 6 indicating severe cognitive impairment, was admitted and readmitted to the facility. Despite the resident's lack of mental capacity to understand the terms of the arbitration agreement, as confirmed by a health and physical examination, the resident signed the agreement. The Admissions Director admitted to explaining the agreement to the resident but was unsure if the resident comprehended it, acknowledging that the resident should not have signed the agreement.
Failure to Coordinate Hospice Care and Notify of Significant Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services for two residents who were receiving hospice care. For Resident 13, the facility did not notify the hospice provider about significant weight loss, which was documented as a 12% loss over three months and an 11.2% loss over six months. Despite being admitted to hospice services, there was no record of communication with the hospice regarding these changes. Interviews with the RN and DON confirmed the oversight in notifying the hospice of the resident's condition change. Similarly, Resident 2 experienced a significant weight loss of 5.45% in one month and 23.5% over six months, yet there was no documented evidence that the hospice was informed. The DON stated that the nursing supervisor was responsible for notifying the hospice of any changes, but could not provide documentation to support that this was done for Resident 2's weight loss. Additionally, the facility did not adhere to the hospice care plan for Resident 2, which required hospice nursing visits twice a week. The records showed that the visits were not conducted at the specified frequency, as confirmed by a review of the hospice's staff sign-in sheet and an interview with an LVN. This lack of coordination and communication between the facility and hospice services posed a risk to the residents' care.
Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, which could potentially affect residents' health and well-being. During an inspection, it was observed that the freezer compartments of two medication refrigerators had ice buildup. This was verified by two registered nurses during separate observations and interviews. Additionally, an inspection of the ice machine revealed black duct tape on the plastic ice harvester curtain and reddish-brown residue on a gray water pipe and a white insulated wire. The Maintenance Supervisor confirmed that the black tape was applied approximately a year ago by an outside vendor to repair a crack in the plastic. The Corporate Dietary Supervisor verified the presence of residue by wiping the wire with a clean paper towel, which transferred some of the residue onto the towel, and acknowledged that the ice machine needed cleaning.
Pest Control Deficiency: Flies in Resident's Room and Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies in both a resident's room and the kitchen. In the resident's room, a fly was observed landing on an uncovered cup of milk and the opening of an insulated water mug. The room's window was open without a screen, allowing the fly to enter. A Certified Nursing Assistant (CNA) verified the presence of the fly and the open window, subsequently closing it. In the kitchen, flies were observed on multiple occasions over two days. A fly was seen near the coffee machine, puree food preparation, and tray line areas. During a lunch tray line observation, a fly landed on a covered loaf of bread. The Corporate Dietary Supervisor confirmed the presence of the fly. These observations indicate a failure to ensure the facility was free of pests, potentially leading to the transmission of foodborne illness to residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to potential risks in continuity of care. For one resident, the MDS inaccurately recorded the resident's gender as female, despite medical records indicating the resident was male. This discrepancy was confirmed during an interview with the MDS coordinator, who acknowledged the error in the MDS coding for multiple dates. Another resident's MDS assessment failed to reflect their admission to hospice services and significant weight loss. The resident had a physician's order for hospice services, which was not documented in the MDS. Additionally, the resident experienced a 9% weight loss in one month and a 20% weight loss over six months, yet the MDS inaccurately indicated no significant weight loss. These inaccuracies were verified by the MDS coordinator during a review of the resident's medical records.
Improper Trash Disposal and Storage
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner, which posed a threat for pest contamination. During an observation conducted with the Maintenance Supervisor, it was noted that the facility's trash dumpsters and recycling bin were not properly covered. Specifically, the recycling bin had flattened cardboard boxes piled above the rim, preventing the lids from closing properly. Additionally, two trash dumpsters were observed with black trash bags that also prevented the lids from closing fully. The Maintenance Supervisor acknowledged that the lids should be closed fully to prevent pests from accessing the bins.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide the requested medical and billing records for a resident, which had the potential to violate the resident's rights. The facility's policy and procedure (P&P) on the release of information, revised in November 2009, stated that all information in a resident's medical record is confidential and can only be released with written consent from the resident or their legal representative. A resident may access their records within 48 hours of a written or oral request. In this case, the resident's representative requested a copy of the medical record on July 2, 2024, using an Authorization for the Release of Medical Information form. However, the Medical Records Director confirmed receiving the request by mail on July 8, 2024, and the Administrator acknowledged that the records had not been sent as requested by the representative.
Broken Shower Bench Not Removed
Penalty
Summary
The facility failed to ensure a safe environment for residents by not removing a broken shower bench in Shower Room C. The maintenance policy, revised in December 2009, requires that all building areas, grounds, and equipment be maintained in a safe and operable manner. During an observation on July 1, 2024, a broken shower bench was found in the shower room, with uneven legs and a hanging metal piece. CNA 1 confirmed the bench was broken and mentioned that typically, a rolling shower chair is used for residents, and any broken equipment should be reported to maintenance. On July 3, 2024, the Maintenance Director confirmed the findings, noting that two flat plastic saucers on the bench's legs were broken, and a metal piece was missing. The Maintenance Director stated that any broken shower chair should be removed for resident safety. The Administrator and DON were informed of these findings and acknowledged the deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident. On the admission day, the resident's evening medications were not administered because they were not delivered by the pharmacy. The medications included treatments for hyperlipidemia, glaucoma, high blood pressure, diabetes, nerve pain, and bowel management. The orders for these medications were entered in the system, but the nursing progress notes indicated that the medications had not been delivered by the pharmacy, and there was no documented evidence that the physician was notified or that follow-up with the pharmacy occurred. Interviews with the MDS Coordinator, LVN, and DON confirmed that the pharmacy was expected to deliver medications within four to six hours of the resident's arrival. The LVN admitted to not calling the pharmacy or notifying the physician after the six-hour window had passed. The DON confirmed that the physician should have been notified and that the resident had the potential for high blood pressure and increased blood sugar levels due to not receiving the medications as ordered. The Administrator also acknowledged that notifying the physician could have led to increased monitoring of the resident's condition.
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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