Casa Bonita Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in San Dimas, California.
- Location
- 535 E Bonita Avenue, San Dimas, California 91773
- CMS Provider Number
- 056291
- Inspections on file
- 34
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Casa Bonita Convalescent Hospital during CMS and state inspections, most recent first.
A resident with a history of impulsive behavior and multiple falls was not provided with a resident-centered fall prevention plan, and the facility did not monitor or document the effectiveness of interventions. Despite repeated incidents and known high fall risk, only standard measures such as bed alarms and floor mats were used, without addressing the underlying causes of the resident's behavior. The resident sustained serious injuries after another fall, highlighting the facility's failure to individualize care and assess intervention effectiveness.
Two residents at high risk for pressure injuries were found with low air loss mattresses set incorrectly, contrary to physician orders and facility policy. One resident with quadriplegia had a mattress set higher than ordered, and another with a stage 4 pressure ulcer had a mattress set far above their actual weight. Staff interviews and record reviews confirmed the settings were not properly adjusted or monitored, leading to a failure in pressure ulcer prevention protocols.
Two residents received antibiotics without proper screening or documentation, as the facility failed to use the correct surveillance forms and did not follow established protocols for monitoring antibiotic use. The Infection Control Nurse acknowledged missing required reviews and using incorrect forms, resulting in antibiotics being administered without confirming the presence of true infections.
Two residents were not treated with dignity during meals: one with hemiplegia was left without a clothing protector, resulting in food and drink spills on her body and bedding, while another was fed by a nurse standing over her rather than sitting at eye level, making her feel rushed and uncomfortable. Staff and policy confirmed that these actions did not meet expectations for promoting resident dignity during care.
A resident with multiple complex conditions, including diabetes and severe cognitive impairment, experienced consistently high blood glucose levels and was transferred to a hospital for uncontrolled hyperglycemia. Despite facility policy requiring Interdisciplinary Team (IDT) review for significant changes in condition, staff confirmed that no IDT meeting or care plan revision was documented to address the resident's ongoing hyperglycemia.
A resident with multiple chronic conditions and moderate cognitive impairment was given a time-release antibiotic capsule that was improperly opened and mixed with applesauce by an LVN, contrary to facility policy and without pharmacist verification. This altered the medication's intended delivery, as confirmed by interviews and record review.
A CNA did not wear a gown while removing soiled linens from a resident with severe cognitive impairment and multiple medical conditions who was under Enhanced Barrier Precautions (EBP). Despite clear signage and an active EBP order, the CNA carried the soiled linens into the hallway without appropriate PPE, contrary to facility policy and infection control protocols.
A resident with cognitive impairments and multiple health conditions was mistakenly given another resident's unlabeled dentures, posing an infection risk. The dentures were found in a denture cup at the resident's bedside without proper labeling, contrary to the facility's infection control policies.
The facility failed to inform and provide written information about Advance Directives to several residents or their legal representatives, resulting in a lack of documentation in their medical records. This deficiency affected residents with severe cognitive impairments, preventing the facility from respecting their medical care preferences.
The facility failed to conduct comprehensive assessments for two residents, resulting in discrepancies between their medical records and care plans. One resident with dementia and anxiety received lorazepam, but the MDS did not reflect the anxiety disorder. Another resident was prescribed Ativan for anxiety, yet the MDS did not indicate anxiety or medication use. These inaccuracies were confirmed during reviews with nursing staff.
The facility failed to ensure proper management of GT feedings for three residents. A resident's head of bed was not elevated as required, increasing aspiration risk. Two residents experienced prolonged GT pump alarms without timely staff response, risking nutritional intake and tube complications. Staff interviews confirmed the importance of adhering to facility policies on GT feeding safety.
The facility failed to monitor and document the use of psychotropic medications for three residents. A resident on duloxetine did not have side effects monitored, another on PRN Ativan lacked documented rationale for extended use, and a third had a PRN Lorazepam order extended without proper documentation, all contrary to facility policy.
The facility failed to serve milk/mocha mix at the required temperature of 40 degrees Fahrenheit or lower, as per policy. During a kitchen observation, three glasses of milk were found to be above the safe temperature limit, with readings of 42 F, 44 F, and 51 F. Staff interviews confirmed the importance of maintaining temperatures below 41 F to prevent spoilage and bacterial growth.
A facility failed to develop and implement a resident-centered care plan for a resident on Depakote, with interventions for side effects not documented or implemented. The care plan inaccurately listed allergies, including insulin, despite active insulin orders. The DON stated interventions were unnecessary per the Facility Consultant Pharmacist, and the MDS Coordinator noted the care plan was not individualized.
A resident with severe dementia and communication difficulties did not receive necessary care when a CNA failed to use a communication board, as required by the facility's policy. The resident, who sometimes spoke a different language, was not effectively communicated with, leading to potential unmet needs.
A resident at high risk for pressure ulcers was found lying on a low air loss (LAL) mattress with multiple layers of material, including a sling, which contradicted facility policy. The CNA responsible left the sling under the resident, intending to use it again, but this practice was against guidelines. The DON confirmed the sling should have been removed to ensure the mattress's effectiveness in preventing pressure injuries.
A resident with limited ROM did not receive necessary rehabilitation services to maintain or prevent further decline in ROM. Despite recommendations for splints and passive ROM exercises, the facility failed to follow up on an occupational therapist's recommendation for evaluation and treatment. The resident's joint mobility screening showed a decline, but no physician's order for therapy was obtained, and the resident did not receive further occupational therapy.
A resident with respiratory failure and tracheostomy status did not receive the correct oxygen flow rate as per the physician's order, which was set at 2 LPM. Observations revealed the flow rate was below 1 LPM, contrary to the care plan and facility policy. Interviews with staff confirmed the importance of maintaining the correct flow rate to prevent respiratory distress.
A resident with multiple health issues, including impaired vision, did not receive eye drop medication properly due to a nurse's failure to follow the facility's policy. The nurse administered the drops consecutively without waiting the required five minutes between applications, as confirmed by the DON. This oversight could have affected the medication's effectiveness.
A facility failed to identify irregularities in the monthly Medication Regimen Review for a resident on psychotropic medications. The Consultant Pharmacist did not report inadequate monitoring of duloxetine, used for depression, potentially affecting the resident's well-being. Despite the administration of duloxetine, there was no documented evidence of side effect monitoring, as confirmed by staff interviews.
A resident with spinal stenosis, post laminectomy syndrome, and type 2 diabetes mellitus was not provided a snack at night despite requesting one, as per the facility's policy. Interviews revealed that the facility sometimes ran out of snacks, and the Dietary Supervisor was informed of the shortage. The resident's care plan indicated snacks should be offered, but this was not followed, resulting in a deficiency.
A Registered Dietician in the kitchen was observed without a beard cover while preparing food, contrary to the facility's sanitation policy. The RD's beard was partially exposed despite wearing a surgical mask, which could lead to food contamination. Interviews confirmed the requirement for beard nets, aligning with the facility's infection control policy.
A facility failed to implement Enhanced Standard Precautions (ESP) for a resident with a gastrostomy, leading to a CNA not wearing a gown during high-contact care. Staff interviews revealed a misunderstanding of the ESP policy, which requires gown and glove use for residents with indwelling devices to prevent infection transmission.
A resident with multiple diagnoses, including hemiplegia and respiratory failure, was not readmitted to the LTC facility after hospitalization due to a positive test for Candid Auris. Despite having an available room, the facility did not prepare an isolation room, leading to the resident overstaying at the hospital for 10 days. The facility's policies prioritize readmission, but the resident was not accommodated as required.
Failure to Implement Resident-Centered Fall Prevention and Monitor Effectiveness
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident with a known history of impulsive behavior and repeated attempts to get out of bed unassisted. Despite being identified as a high fall risk with multiple diagnoses, including encephalopathy and type 2 diabetes, the resident experienced several falls over a period of months. The care plan interventions primarily consisted of standard fall prevention measures such as low bed, floor mats, bed alarms, and placement near the nurse's station, but did not include a resident-centered approach or address the specific causative factors of the resident's behavior as required by the facility's policy. The facility did not consistently monitor or document the effectiveness of the fall prevention interventions. Although the care plan called for assessment and reduction of behavioral triggers, staff interviews and record reviews revealed that the facility did not investigate or document the underlying causes of the resident's repeated attempts to self-transfer. The interdisciplinary team conferences following each fall did not result in new or individualized interventions, and the facility continued to rely on the same standard measures despite ongoing incidents. Staff acknowledged the resident's impulsiveness and need for close monitoring, but the facility did not utilize sitters or other enhanced supervision strategies. On the date of the most serious incident, the resident was found on the floor mat after the bed alarm sounded, having sustained significant injuries including fractures to both hips. Documentation indicated that frequent rounding was being performed, but there was no evidence of a comprehensive evaluation of the effectiveness of interventions or of any changes made to address the resident's persistent fall risk. The facility's failure to implement a resident-centered fall prevention plan, monitor the response to interventions, and assess causative factors contributed to the resident's repeated falls and resulting injuries.
Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are pressure-reducing devices, were set at the correct settings for two residents at high risk for pressure injuries. For one resident with functional quadriplegia and severely impaired cognition, the LALM was observed to be set at 200, despite a physician's order specifying a setting of 160 based on the resident's weight. Staff interviews confirmed that the setting was incorrect and should have been checked during daily rounds, but the discrepancy was not identified or corrected at the time of observation. Another resident, who was dependent for all activities of daily living and had a history of chronic respiratory failure and a stage 4 sacral pressure ulcer, was found lying on a LALM set at 400 lbs, while the resident's actual weight was 107 lbs and the physician's order specified a setting of 80. Staff interviews indicated that the correct mattress setting is essential for effective pressure redistribution and prevention of further skin breakdown, and that the mattress should be set according to the resident's actual weight as per facility policy and manufacturer instructions. Record reviews, staff interviews, and direct observations confirmed that the facility did not follow its own policy and physician orders regarding the adjustment of LALM settings based on resident weight. The failure to maintain correct mattress settings was observed for both residents, and staff were unable to provide an explanation for the discrepancies at the time of the survey.
Failure to Implement Antibiotic Stewardship Program and Proper Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two of five sampled residents, resulting in the improper monitoring and documentation of antibiotic use. For one resident with vascular dementia and generalized weakness, a change in condition was noted with greenish vaginal discharge but no pain, discomfort, or fever. Despite these findings and a urine culture report indicating that antibiotic therapy was not recommended without localized urinary tract symptoms, the resident was prescribed and administered Diflucan. The Infection Control Nurse (ICN) acknowledged that the wrong surveillance form was used and that the appropriate McGreer's UTI criteria should have been applied to determine the necessity of antibiotics, but this review was missed for the month in question. Another resident with neuralgia and generalized weakness was prescribed Azithromycin for a tooth infection. The ICN stated that the incorrect antibiotic surveillance form was used for this resident as well, and the proper screening for skin/mucosal infection was not completed. The ICN did not follow up to verify if the correct antibiotic screening was performed, resulting in the resident receiving antibiotics without confirmation that the criteria for a true infection were met. Facility policy required the use of approved antibiotic surveillance tracking forms and regular review of antibiotic usage patterns by the leadership team. The Infection Preventionist was responsible for implementing the infection prevention and control program, including the collection and review of antibiotic use data. However, these protocols were not followed, and the required documentation and monitoring were not completed for the residents in question.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity during mealtimes. One resident with hemiplegia and hemiparesis, who was unable to use her left side and had severely impaired cognitive skills, was observed eating breakfast in bed without a clothing protector. This resulted in food and drink spilling onto her chest, neck, gown, tray, bedside table, and comforter. Staff interviews confirmed that a towel or similar item should have been placed to protect the resident and maintain her dignity during meals, but this was not done at the time of observation. Another resident, who had dementia, diabetes, and severe protein-calorie malnutrition, required substantial assistance with activities of daily living and was dependent for mobility. During a lunch meal, a treatment nurse was observed standing and leaning over the resident while providing feeding assistance, rather than sitting at eye level. The resident reported feeling rushed and uncomfortable when staff stood over her during meals, expressing a preference for staff to sit beside her, which made her feel more at ease. The nurse later acknowledged that sitting at eye level would have promoted dignity and comfort for the resident. Facility policy and staff interviews confirmed that the expectation was to uphold resident dignity during all aspects of care, including meal assistance. The policies reviewed emphasized providing a dignified dining experience and treating all residents with kindness, respect, and dignity. However, the observed actions did not align with these expectations, resulting in a failure to honor the residents' rights to a dignified existence and self-determination during mealtimes.
Failure to Conduct IDT Review for Persistent Hyperglycemia
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice by not conducting an Interdisciplinary Team (IDT) review for a resident who experienced continuous episodes of hyperglycemia. The resident, who had multiple complex diagnoses including type 2 diabetes mellitus, dementia, and a feeding tube, was admitted and later readmitted to the facility. Medical records indicated that the resident's cognitive status was severely impaired and that she was unable to make her own decisions. Blood glucose monitoring showed consistently high levels ranging from 306 mg/dL to 500 mg/dL over a ten-day period. Despite these findings and a subsequent transfer to an acute care hospital for uncontrolled hyperglycemia, there was no documentation of an IDT meeting to address the resident's condition. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that no IDT documentation existed for the resident's episodes of hyperglycemia. The facility's policy and procedure required that care plans be reviewed and revised by the IDT after each assessment or significant change in condition, including issues related to diagnosis or health condition. The lack of an IDT review and care plan revision in response to the resident's persistent hyperglycemia constituted a failure to follow established protocols and professional standards of care.
Significant Medication Error Due to Improper Administration of Time-Release Capsule
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) was observed opening a Macrobid (nitrofurantoin macrocrystals) 100 mg oral capsule, pouring its contents into a medication cup, and mixing it with applesauce prior to administration. This action disrupted the time-release mechanism of the medication, which was intended to be delivered in a specific manner for therapeutic effectiveness. The LVN acknowledged that opening capsules should only be done after verification with a pharmacist, as some capsules are not meant to be opened due to potential changes in drug efficacy and safety. The resident involved had multiple diagnoses, including rheumatoid arthritis, diabetes mellitus, and encephalopathy, and was assessed as having moderately impaired cognition. The resident required assistance with activities of daily living and supervision with mobility. The medication order for Macrobid specified administration by mouth, but did not indicate that the capsule should be opened or mixed with food. The Medication Administration Record confirmed that the resident received the medication in this altered form. Interviews with the LVN and the Director of Nursing (DON) confirmed that facility policy required clarification with a pharmacist before altering any capsule medication, especially antibiotics that are often time-released. The DON emphasized the importance of maintaining the intended formulation to ensure proper absorption and effectiveness. Review of facility policy and job descriptions further supported that medications were to be administered as prescribed and in accordance with regulatory guidelines.
Failure to Follow Enhanced Barrier Precautions During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) when handling soiled linens for a resident with multiple diagnoses, including peripheral vascular disease, COPD, and cellulitis. The resident had severe cognitive impairment and required partial to moderate assistance with activities of daily living and mobility. Despite signage indicating EBP outside the resident's room and an active order for EBP, the CNA was observed removing soiled linen from the resident's bed and carrying it into the hallway without wearing a gown, as required by facility policy and EBP protocols. Interviews with the CNA and the Infection Preventionist confirmed that staff were expected to wear gloves and gowns during high-contact care activities, such as changing soiled linens, to prevent the spread of infection. The facility's policy specified that gowns and gloves must be used during these activities, but the CNA did not adhere to these requirements during the observed incident. This lapse in infection control practices constituted a failure to maintain the facility's infection prevention and control program.
Infection Control Breach Due to Misidentified Dentures
Penalty
Summary
The facility failed to maintain and implement its Infection Control Program, leading to a potential risk of infection for a resident. The incident involved placing another resident's dentures into the mouth of a resident who was admitted with diagnoses including a urinary tract infection, dementia, and type 2 diabetes mellitus. The resident was severely impaired in cognitive skills and required substantial assistance for daily activities. The dentures, which were not labeled, were mistakenly identified as belonging to the resident and were placed in their mouth by a dentist. Interviews with family members and staff revealed that the dentures were found in a denture cup at the resident's bedside, but they were not labeled with any identifying information. The facility's policy required dentures to be stored in labeled containers to prevent such mix-ups. The Infection Preventionist confirmed that using the wrong dentures posed a risk of infection. The facility's policies on denture storage and infection control were not followed, leading to this deficiency.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that five of nine sampled residents and/or their legal representatives were informed and provided with written information about Advance Directives (AD). This deficiency was identified through interviews and record reviews, revealing that residents or their responsible parties were not adequately informed about their rights to formulate an AD, which is crucial for making medical care decisions when residents are unable to communicate their wishes. For Resident 41, the admission record indicated multiple diagnoses, including dementia and type 2 diabetes mellitus, and showed that the resident did not have the capacity to make decisions. The responsible party did not sign the Advance Directive Acknowledgment (ADA) form, and there was no documented evidence that information regarding AD was provided. Similarly, Resident 30, who had severe cognitive impairments, did not have an ADA or AD in their chart, and the facility staff acknowledged the absence of these documents, which are essential for respecting the resident's wishes. Residents 25 and 53 also lacked proper documentation of ADs in their medical records. Both residents had severe cognitive impairments and were dependent on others for decision-making. The facility's policy required that residents or their representatives be provided with written information about their rights concerning ADs, but this was not consistently implemented. The absence of ADs in the residents' charts meant that the facility staff could not be aware of or respect the residents' medical care preferences, especially in emergencies.
Inaccurate Resident Assessments Lead to Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure comprehensive assessments of disease diagnoses, health conditions, and medications for two residents, leading to potential inaccuracies in their care plans. Resident 27 was admitted with multiple diagnoses, including dementia and generalized anxiety disorder, but the Minimum Data Set (MDS) did not reflect the anxiety disorder, despite the resident receiving lorazepam for anxiety-related symptoms. The inconsistency between the MDS and the physician's orders highlighted a lack of accurate assessment, which was confirmed during a review with a registered nurse. Similarly, Resident 20, admitted with dementia, was prescribed Ativan for anxiety, yet the MDS did not indicate the presence of anxiety or the use of anti-anxiety medication. The resident received Ativan multiple times over several days, but the MDS assessments failed to capture this information. The Director of Nursing acknowledged the importance of thorough assessments, including physical evaluations and communication with staff and family, to ensure accurate MDS completion and appropriate care planning.
Deficiencies in GT Feeding Management
Penalty
Summary
The facility failed to provide appropriate treatment and services for three residents receiving gastrostomy tube (GT) feedings. Resident 36's head of bed (HOB) was not elevated to the required 30-45 degrees during GT feedings, as per the facility's policy and physician's orders, which is crucial to prevent aspiration. Observations revealed that Resident 36's HOB was only elevated to 20-25 degrees, and staff interviews confirmed the necessity of maintaining the correct elevation to avoid aspiration risks. For Residents 25 and 252, the facility did not respond timely to the GT pump alarms, which indicated a flow error and potential clogging in the feeding line. Resident 25, who was nonverbal and had multiple diagnoses including cerebral palsy and severe protein-calorie malnutrition, was observed with a beeping GT pump for an extended period. Similarly, Resident 252, who had a history of cerebral infarction and severe cognitive impairment, experienced prolonged GT pump alarms without timely intervention from the staff. The facility's policy on enteral feeding safety precautions and equipment checks was not adhered to, as evidenced by the delayed response to the GT pump alarms for Residents 25 and 252. Staff interviews highlighted the importance of addressing these alarms promptly to ensure the residents received their nutritional intake and to prevent complications such as GT clogging or the need for tube replacement.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents did not receive unnecessary psychotropic medications. For Resident 11, the facility did not monitor the side effects of duloxetine, a psychotropic drug used to treat major depressive disorder, from 5/1/2024 through 5/15/2024. Despite the resident's severe cognitive impairment and frailty, there was no documented evidence of side effect monitoring, which is crucial to prevent adverse effects. Resident 20 was administered Ativan, a medication for anxiety, on a PRN basis without documented rationale for its continuation beyond 14 days. The facility's policy requires that PRN orders for such medications be limited to 14 days unless a healthcare provider evaluates and documents the rationale for extension. However, there was no documentation from the prescribing healthcare provider justifying the extended use of Ativan for Resident 20, who also had severe cognitive impairment. For Resident 96, the facility did not adhere to its policy of limiting PRN orders for Lorazepam to 14 days. The resident's PRN order for Lorazepam was extended to 30 days without documented rationale from the primary care physician. This oversight occurred despite the resident's severe dementia and need for substantial assistance with daily activities. The facility's failure to document the rationale for extending the PRN order contravened its own policy and procedure guidelines.
Improper Milk Temperature in Meal Service
Penalty
Summary
The facility failed to ensure that three out of four sampled glasses of milk/mocha mix were served at the appropriate temperature of 40 degrees Fahrenheit or lower, as required by the facility's policy. During an observation in the facility kitchen, several 8-ounce glasses of milk were prepared on trays for residents' lunch. Upon random selection, three glasses were found to have temperatures exceeding the safe limit: one at 42 F, another at 44 F, and the last at 51 F. This was confirmed during interviews with Kitchen Aid 1 and the Dietary Supervisor, both of whom acknowledged that milk should be kept below 41 F to prevent bacterial growth and spoilage. The facility's policy, updated in March 2024, mandates that cold beverages and desserts be served at no more than 40 degrees F.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident, specifically regarding the risk of side effects from the medication Depakote and the resident's allergies. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, generalized anxiety disorder, and bipolar disorder, had severely impaired cognition and was dependent on staff for daily activities. The care plan for Depakote included interventions to monitor for cognitive impairment and other side effects, but these interventions were not documented in the Medication Administration Record (MAR) and were not being implemented. The Director of Nursing stated that these interventions were not needed, as advised by the Facility Consultant Pharmacist, because Depakote is not an antipsychotic medication and typically does not have these side effects. Additionally, the care plan inaccurately listed the resident's allergies, including insulin, despite the resident having active physician orders for insulin medications. The Minimum Data Set Coordinator acknowledged that the care plan was not individualized or person-centered, as evidenced by the inaccurate allergy information and the unimplemented interventions for Depakote. The facility's policy and procedure for comprehensive person-centered care plans require that interventions be derived from a thorough analysis of gathered information and reflect recognized standards of practice, which was not adhered to in this case.
Failure to Use Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with severe dementia, hypertension, and dysphagia, who was admitted with severe cognitive impairments and required substantial assistance for daily activities. The deficiency occurred when a Certified Nursing Assistant (CNA) did not utilize a communication board to communicate with the resident, as indicated in the facility's policy and procedure for accommodating communication needs. The resident, who sometimes spoke a different language and was confused, was not effectively communicated with, leading to potential unmet needs. Interviews with CNAs revealed that the resident often yelled and did not speak English when confused. One CNA admitted to not using a communication board, which was part of the resident's care plan, and was unaware of its availability. The facility's policy required the use of communication boards with written translations to ensure effective communication with residents. This oversight in following the care plan and facility policy resulted in a deficiency related to the resident's communication needs.
Failure to Prevent Pressure Ulcers Due to Improper Use of LAL Mattress
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for a resident identified as being at high risk. The resident, who was dependent on others for daily activities and had severe cognitive impairment, was observed lying on a low air loss (LAL) mattress with multiple layers of material between them and the mattress. This included a flat sheet, chux pad, cloth incontinence pad, adult diaper, and a sling, which contradicted the facility's policy for using LAL mattresses effectively. The certified nursing assistant (CNA) responsible for the resident admitted to leaving the sling under the resident after transferring them back to bed, intending to use it again shortly. However, this practice was against the facility's guidelines, which required the removal of the sling to ensure the LAL mattress could function properly in preventing pressure injuries. The CNA also acknowledged that having more than one sheet would hinder the mattress's effectiveness. The Director of Nursing (DON) confirmed that the sling should have been removed and that the resident should only have been lying on a flat sheet with an adult diaper or a chux pad. The DON and another CNA both recognized that the improper use of the LAL mattress could lead to the development of pressure injuries. The facility's policies and procedures, as well as the CNA job description, emphasized the importance of using appropriate linens and measures to prevent pressure injuries, which were not followed in this instance.
Failure to Provide Necessary Rehabilitation Services for ROM Maintenance
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received necessary rehabilitation services to maintain or prevent further decline in ROM. The resident, who was admitted with multiple diagnoses including dementia, osteoarthritis, and contractures, was discharged from skilled occupational therapy and placed on a Restorative ROM Program. Despite recommendations for the application of splints and passive ROM exercises, the facility did not follow up on the occupational therapist's recommendation for an evaluation and treatment order. The resident's joint mobility screening indicated a decline in ROM, particularly in the left upper extremities, from minimal to moderate loss. However, there was no documented evidence that the nursing staff obtained a physician's order for occupational therapy evaluation or treatment following this decline. Interviews with the Director of Rehabilitation and a registered nurse confirmed that no such order was made, and the resident did not receive occupational therapy in the facility after the initial period. The Director of Nursing acknowledged that nursing staff should consult with the rehabilitation department and obtain new orders if a resident experiences a decline in ROM. The facility's policies and procedures require regular assessments and updates to care plans to prevent deterioration of joint mobility, but these were not adhered to in this case, leading to the deficiency.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 61, who required oxygen therapy. The resident was admitted with multiple diagnoses, including respiratory failure, tracheostomy status, and anoxic brain damage. The care plan for the resident specified interventions such as maintaining an oxygen flow rate of 2 liters per minute (LPM) via a t-bar and monitoring oxygen saturation to keep it above 92%. However, during an observation, it was noted that the oxygen flow rate was below the 1-liter mark, which was not in accordance with the physician's order. Interviews with the Respiratory Therapist Supervisor and a Registered Nurse confirmed the importance of maintaining the correct oxygen flow rate to prevent respiratory distress. The facility's policy on oxygen administration required the proper flow of oxygen to be administered, but this was not adhered to in the case of Resident 61. The deficiency was identified through a review of the resident's records, care plans, and physician orders, which highlighted the discrepancy in the oxygen flow rate being provided.
Improper Administration of Eye Drops to Resident
Penalty
Summary
The facility failed to administer eye drop medication properly to a resident, identified as Resident 49, in accordance with its policy and procedure. Resident 49, who was admitted with multiple diagnoses including ventricular fibrillation, tracheostomy status, and gastrostomy, had a care plan addressing potential alteration in visual function due to eye dryness. The care plan included the administration of Visine Dry Eye Relief Ophthalmic Solution, with a specific order to instill two drops in both eyes three times a day. However, during a medication pass, a Licensed Vocational Nurse (LVN) administered the eye drops consecutively without waiting the required five minutes between applications, as per the facility's policy. The Director of Nursing (DON) confirmed that the facility's policy required a five-minute interval between eye drop applications to ensure optimal absorption and effectiveness. The LVN involved was unaware of this requirement, which was crucial for the resident to receive the full benefits of the medication. The facility's policy, dated 2008, clearly outlined the procedure for safe and accurate administration of ophthalmic solutions, emphasizing the importance of waiting between applications. This oversight had the potential to compromise the effectiveness of the treatment for Resident 49's eye dryness.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that irregularities in the monthly Medication Regimen Review (MRR) were identified for a resident who was on psychotropic medications. The Consultant Pharmacist (FCP) did not identify or report inadequate monitoring of duloxetine, a psychotropic medication used to treat depression, during the MRR conducted from May 14 to May 15, 2024. This oversight had the potential to affect the resident's physical and psychosocial well-being due to the administration of unnecessary psychotropic medications. The resident, admitted on April 27, 2024, had multiple diagnoses including Alzheimer's disease and depression, and was noted to have severe cognitive impairment. Despite the administration of duloxetine from May 1 to May 15, 2024, there was no documented evidence of monitoring for side effects. Interviews with the Registered Nurse and the Director of Nursing confirmed the lack of documentation and emphasized the importance of monitoring side effects to prevent adverse effects. The FCP acknowledged the oversight, stating that monitoring side effects is crucial to ensure appropriate medication dosing without adverse effects.
Failure to Provide Snacks to Resident
Penalty
Summary
The facility failed to provide a snack to a resident, identified as Resident 48, in accordance with its Policy and Procedure titled 'Frequency of Meals.' Resident 48, who was admitted with spinal stenosis, post laminectomy syndrome, and type 2 diabetes mellitus, reported feeling hungry at night and requested a snack from the facility staff. However, the staff did not provide a snack, which was contrary to the facility's policy that nourishing snacks should be available for residents who need or desire additional food between meals. During interviews, a Registered Nurse (RN) acknowledged that sometimes the facility ran out of snacks, and there was an instance when the RN could not provide a snack to Resident 48 during the night shift. The Dietary Supervisor confirmed that the kitchen staff provided snack trays to the facility units for distribution during the evening and night shifts, but nursing staff had informed the supervisor about a shortage of snacks available for residents during the night. The care plan for Resident 48 indicated that snacks should be offered, yet this was not adhered to, leading to the deficiency.
Sanitation Breach in Kitchen Due to Uncovered Beard
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during a survey. A Registered Dietician (RD) with a visible beard was seen in the kitchen food preparation area without a beard cover, which is against the facility's policy. The RD was observed moving from the cold drinks preparation area to the food assembly tray line while the residents' lunch was being prepared. Although the RD wore a surgical mask, the beard was not fully covered, with parts of it protruding from under the mask. Interviews with the Dietary Supervisor and the RD confirmed that kitchen staff are required to wear a beard net if they have facial hair, to prevent contamination of residents' food. The facility's policy on Sanitation and Infection Control, dated March 2024, mandates that beards and mustaches should be closely trimmed or covered at all times to ensure sanitary conditions. This oversight had the potential to lead to contamination of the food served to residents.
Failure to Implement Enhanced Standard Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, specifically the Enhanced Standard Precautions (ESP), for a resident with multiple medical conditions, including dementia, type 2 diabetes, and a gastrostomy. The resident, who was admitted on 9/29/2020, was dependent on staff for all self-care activities and had severely impaired cognitive skills. During an observation, a Certified Nursing Assistant (CNA) was seen changing the resident's adult brief while wearing gloves but not a gown, contrary to the facility's policy that requires both gown and gloves for high-contact care activities. Interviews with staff revealed a misunderstanding of the ESP policy. The CNA believed that the resident was not on ESP and therefore did not require a gown. However, a Registered Nurse and the Director of Nursing clarified that all residents, especially those with indwelling medical devices like a gastrostomy tube, should be on ESP to prevent infection transmission. The facility's policy mandates the use of gowns and gloves during high-contact activities for residents with wounds or indwelling devices, regardless of MDRO colonization.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident from the General Acute Care Hospital (GACH) after the resident was cleared to return. The resident, who had multiple diagnoses including hemiplegia, respiratory failure, and dysphagia, was initially admitted to the facility and later readmitted with severe cognitive impairment. The resident was dependent on staff for daily activities. After being transferred to the GACH, the resident tested positive for Candid Auris, a multidrug-resistant fungal infection, which required isolation upon return to the facility. The facility's administrator and admissions coordinator indicated that there was an empty room available when the GACH was ready to discharge the resident back to the facility. However, the facility was concerned about the potential spread of C. Auris and did not have an isolation room prepared for the resident. The admissions coordinator acknowledged that the facility could have accommodated the resident's readmission by making room changes, similar to those made previously for another resident. The facility's policy and procedure for readmission and bed-holds state that residents should be given priority for readmission following hospitalization, regardless of payer source, and should be allowed to return to their previous room or the first available bed in a semi-private room. Despite these policies, the facility did not readmit the resident, resulting in the resident overstaying at the GACH for 10 days. The infection preventionist noted that the resident was the fifth case of C. Auris at the facility.
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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