Casitas Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Granada Hills, California.
- Location
- 10626 Balboa Blvd., Granada Hills, California 91344
- CMS Provider Number
- 056148
- Inspections on file
- 57
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Casitas Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to accurately measure and document PU/I wounds for two residents, instead relying on a photo device’s automatic measurements, including recording a depth of 0 cm. One resident with an unstageable sacrococcygeal ulcer later assessed as a large stage IV PU/I had initial measurements that did not reflect the actual size and depth, and manual measurements were not taken until a surgical consult. Another resident with a sacral PU/I had very small dimensions documented from device-generated readings, while a later surgical consult measured a significantly larger stage II PU/I extending to both buttocks. The treatment nurse acknowledged not manually measuring either resident’s wounds despite knowing the device could be inaccurate, and the DON confirmed that wound sizes and depths were documented incorrectly, contrary to facility policies requiring complete and accurate skin assessment documentation.
A resident with dementia, impaired cognition, and a documented fall risk experienced an unwitnessed fall and was found on the floor. A 72-hour neuro check protocol was initiated, but multiple required Q30-minute and Q1-hour neurological assessments were not completed or documented by the responsible charge nurse. This failure occurred despite facility policies requiring routine neurological assessments and comprehensive documentation of all assessment data and changes in condition.
The facility did not ensure that two residents and their representatives were informed of their right to rescind the arbitration agreement within 30 days of signing, as the Admission Coordinator was unaware of this requirement and did not communicate it during the admission process.
A resident was not informed, nor was the physician notified, when a scheduled dose of levothyroxine was missed due to pharmacy delay. Additionally, the physician was not notified when the same resident refused body weight monitoring for nearly two months, despite orders for weekly weights. Facility staff confirmed the lack of documentation and notification in both cases, contrary to facility policy.
A resident with multiple chronic conditions repeatedly refused body weight monitoring, but staff did not document this refusal in the care plan, notify the physician, or implement interventions as required by facility policy. The lack of communication and care planning was confirmed through record review and staff interviews.
A resident with multiple chronic conditions was admitted without a nutritional assessment being completed by the RD as required by facility policy. Weight records showed inconsistencies and refusals, and the assessment was only performed after a hospital readmission, well past the expected timeframe. Staff interviews confirmed the assessment was missed due to a transition between dietitians.
The facility did not ensure that on-coming nurses signed the narcotic count sheet after counting controlled medications with out-going nurses, resulting in incomplete documentation. Additionally, a resident with multiple health conditions did not receive a scheduled dose of levothyroxine because the medication was not delivered, and there was no documentation of physician notification or administration upon receipt.
A resident's MDS assessment was completed with inaccurate information when the MDS nurse entered an outdated weight from several months prior, rather than using the most recent weight within the required 30-day period or the appropriate 'no information' code. The resident, who had multiple chronic conditions and had refused to be weighed, was incorrectly assessed for weight loss due to this error, contrary to facility policy and CMS guidelines.
A resident with confusion and agitation, admitted with diabetes and asthma, was observed wandering and later left the facility unsupervised at night. A CNA saw the resident exit but did not intervene or identify them, as the resident was in street clothes and appeared normal. Facility policy requiring staff to prevent elopement and notify nursing leadership was not followed, resulting in the resident being found offsite by law enforcement and taken to a hospital.
A resident's family member reported concerns about nursing care to the Social Services Director, but the grievance was not documented or followed up by staff, including the DON and Administrator. The facility's required grievance process was not initiated, and the family member did not receive a response regarding the concerns raised.
A resident with severe cognitive impairment and multiple medical conditions received IV hydration without required monitoring of intake and output or assessment of lung, heart status, and vital signs before administration. Facility staff did not follow policy for documentation and assessment during IV therapy, as confirmed by interviews and record review.
Staff did not assist three residents with severe cognitive impairment and high care needs to get out of bed or participate in activities, despite medical orders allowing participation. CNAs did not routinely offer or provide assistance due to lack of instruction, time constraints, or assumptions about residents' abilities. Facility leadership confirmed that this practice did not align with the facility's policy on promoting quality of life and resident dignity.
The facility did not schedule any outside or evening activities for its residents during two sampled months, contrary to its policy requiring monthly outings and weekly evening events. The Activities Director confirmed that these activities were not planned or provided for 93 residents during this period.
A resident with multiple serious diagnoses experienced hematuria, prompting a physician to order STAT laboratory tests. Despite facility policy and staff expectations that STAT labs be collected within four hours, the tests were not collected until the next day, resulting in a delay of necessary care and services.
The facility failed to ensure call lights were within reach for three residents, potentially delaying services and leaving needs unmet. A resident with acute respiratory failure and another with metabolic encephalopathy were found with call lights on the floor, while a resident with Parkinsonism had the call light hanging behind the bed. Staff acknowledged the oversight, and the facility's policy mandates call lights be within reach.
A facility failed to create comprehensive care plans for four residents, leading to potential inadequate care. One resident with an IV infusion lacked a care plan for site monitoring, another on antibiotics had no plan for administration, a third using an electric kettle was not assessed for safety, and a fourth with a language barrier had no communication plan. These deficiencies were confirmed by staff reviews and interviews.
The facility failed to ensure a safe environment for two residents by not following care plans and safety protocols. A resident at risk for falls did not have a landing mat placed as required, and another resident was allowed to use an electric tea kettle without assessment or care planning. These actions were contrary to the facility's policies on fall risk management and electrical appliance use.
Two residents in an LTC facility did not receive continuous oxygen as ordered by their physicians. One resident with COPD was observed without a nasal cannula multiple times, and staff misunderstood the oxygen order. Another resident with pneumonitis received oxygen at an incorrect flow rate and without a humidifier. The DON confirmed that oxygen should have been administered according to the orders to prevent complications.
A facility failed to ensure proper medication administration practices. A resident was left with medications unattended at the bedside without a self-administration assessment, and another resident experienced a delay in receiving the first dose of an antibiotic for a UTI. The facility's policies for medication administration and timely availability were not followed, leading to these deficiencies.
The facility failed to label leftover food brought by family and visitors with a resident identifier and use-by date in the residents' refrigerator. During an observation, two plastic bags of undetermined food were found without proper labeling. A registered nurse confirmed the requirement for labeling and discarding food older than three days to prevent contamination. The facility's policy mandates labeling and timely disposal of perishable foods.
The facility failed to ensure hospice services for a resident with COPD, as the contracted hospice agency did not provide required staff training, and there was no designated hospice coordinator. Additionally, there was no documentation of hospice staff presence in the facility, leading to a deficiency in hospice care delivery.
The facility failed to maintain proper infection control practices for two residents using nasal cannulas. A resident's oxygen tubing was found on the floor, risking contamination, while another resident's cannula was not labeled with the last change date, contrary to orders. These lapses in protocol could lead to increased infection risk.
A resident's dignity was compromised when their urinary catheter collection bag was left uncovered, contrary to facility policy. The resident, admitted with a urinary catheter infection and bladder neoplasm, had an order for catheter care every shift. A nurse and the DON confirmed the oversight, acknowledging the requirement for privacy bags to promote dignity.
The facility failed to develop baseline care plans within 48 hours for three residents upon admission or readmission, which included addressing antibiotic use for two residents and insulin use for another. This oversight could lead to staff being unaware of necessary monitoring for adverse reactions and the inability to meet residents' immediate care needs.
A facility failed to update a resident's care plan after the discontinuation of Januvia, a diabetes medication. Despite the physician's order to stop the medication, the care plan still indicated its use. The resident, with conditions including dementia and diabetes, had their care plan reviewed by the Infection Preventionist, who noted the discrepancy. The DON confirmed that the care plan was not revised as required by facility policy, potentially leading to confusion in care.
A resident with dementia and limited English proficiency was not provided with a communication board, hindering effective communication with staff. Despite facility policies requiring such support, the board was removed, leaving the resident unable to express needs adequately.
A resident with hypertension and anemia was not provided access to religious services, despite expressing the importance of such activities. The facility's Activity Director confirmed the lack of participation and documentation of religious services for the resident, violating her right to practice her religion.
A facility failed to monitor and document catheter care and UTI symptoms for a resident with an indwelling catheter, as required by the care plan. Despite the resident's conditions and cognitive impairment, there was no evidence of monitoring for pain or infection signs in the Treatment Administration Record. Interviews with staff confirmed the lack of documentation, highlighting a failure to follow the facility's catheter care policy.
The facility did not discard two opened eye drop bottles, Alpheagan and Latanoprost, after 28 days as recommended by the pharmacy. This was observed during a shift, and the RN confirmed the oversight, acknowledging the potential for bacterial growth. The DON stated that licensed nurses should have followed the pharmacy's recommendation to ensure resident safety.
A facility failed to accurately complete an MDS assessment for a resident with type 2 diabetes, omitting the administration of insulin since admission. Despite receiving insulin lispro as ordered, the MDS did not reflect this, potentially affecting the resident's care plan. The MDS Coordinator acknowledged the error, and the Director of Nursing confirmed the inaccuracy, highlighting the importance of accurate assessments for care planning.
Inaccurate Pressure Ulcer Measurement and Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately measure and document pressure ulcer/injury (PU/I) wound dimensions for two residents, relying instead on automatically generated measurements from a photo device. One resident was admitted with an unstageable pressure ulcer on the sacrococcyx and diagnoses including osteomyelitis, spina bifida, and abnormal posture. An early progress note documented the sacrococcyx wound as 7.66 cm in length, 10.87 cm in width, 0 cm in depth, and 67.66 sq. cm in area, based on a photo taken by the treatment nurse. However, a subsequent surgical consult described the same wound, now characterized as a stage IV PU/I extending to bilateral buttocks, as 11.5 cm in length, 15.0 cm in width, 2.5 cm in depth, and 172.50 sq. cm in area, indicating that the earlier measurements did not reflect the actual wound size and depth. In interviews, the treatment nurse acknowledged that on the date of the initial photo for this resident, she did not manually measure the wound and instead accepted the device’s automatic readings, including a depth of 0 cm. She further stated that actual wound measurements were not obtained until the surgical consult several days later and that she relied on serial photos taken upon admission or the following day and then weekly to assess wound progress. The DON later confirmed that the treatment nurse documented this resident’s wound measurements incorrectly and did not manually verify or correct the automatically generated measurements. A second resident was admitted with diagnoses including acute kidney failure and a disorder of the skin and subcutaneous tissue and was identified on the MDS as having one or more unhealed PU/Is and being at risk for pressure ulcers. A progress note documented a sacral PU/I present on admission with measurements of 1.14 cm in length, 0.57 cm in width, 0 cm in depth, and 0.43 sq. cm in area, again based on a photo taken by the treatment nurse. A later surgical consult described a coccyx wound extending to the right and left buttock, staged as a stage II PU/I, with measurements of 7.0 cm in length, 3.0 cm in width, 0.1 cm in depth, and 21 sq. cm in area. The treatment nurse stated that the admitting nurse had only marked skin sites without measurements on arrival, and that she took photos and obtained measurements the following day using the device’s automatic readings, without manual measurement, despite knowing that the device’s measurements were sometimes inaccurate. The DON confirmed that the treatment nurse did not manually measure these PU/I sizes to correct the automatically generated measurements, contrary to facility policies requiring complete and accurate documentation of skin condition, including size and location of affected areas.
Failure to Complete and Document 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete ordered 72-hour neurological checks following an unwitnessed fall for one resident. The resident was admitted with diagnoses including type 2 diabetes, abnormal posture, unspecified fall, and vascular dementia, and had moderately impaired cognition per the MDS. The resident required assistance with activities of daily living and was care planned as being at risk for falls with injury due to limited mobility, dementia, history of falls, unsteady gait, and weakness. On the date of the incident, a Change in Condition Evaluation documented that the resident experienced a fall and was found sitting on the floor. Following this unwitnessed fall, a 72-hour neuro check protocol was initiated, but the corresponding neuro check flowsheets showed that multiple required assessments were not completed. Specifically, the Infection Preventionist confirmed that several Q30-minute and Q1-hour neurological checks were missing and that the charge nurse responsible for the resident’s care was responsible for performing and documenting these assessments. Facility policies on neurological assessment required routine neuro exams to evaluate for small changes over time and mandated documentation of the date and time of the procedure, the person performing it, all assessment data, how the resident tolerated the procedure, any refusals and reasons, and the signature and title of the recorder. The facility’s charting and documentation policy further required that all services provided and any changes in the resident’s condition be documented in the medical record to facilitate communication among the interdisciplinary team, but this was not done for the missed neuro checks.
Failure to Inform Residents of Right to Rescind Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Admission Coordinator (AC) was aware that residents and their representatives have the right to rescind the facility's arbitration agreement within 30 days of signing. This deficiency was identified for two of three sampled residents. For one resident, the admission record showed the resident had the capacity to understand and make decisions, and the arbitration agreement was signed by the resident's representative. For the second resident, records indicated severe cognitive impairment, and the arbitration agreement was also signed by a representative. During interviews, the AC stated she was unaware that residents or their representatives could rescind their signature on the arbitration agreement after signing. The Administrator confirmed that residents and their representatives do have this right and that the AC is responsible for informing them. Review of the facility's policy and procedure confirmed that residents and their representatives must be advised of their right to rescind the agreement within 30 days, but this was not communicated by the AC as required.
Failure to Notify Physician and Resident of Missed Medication Dose and Refusal of Weight Monitoring
Penalty
Summary
The facility failed to notify a resident and the resident's physician regarding a missed dose of levothyroxine, a medication prescribed for hypothyroidism. The medication was scheduled to be administered in the morning, but was not available due to a delay in pharmacy delivery. Documentation showed that the dose was not given as scheduled, and there was no evidence that the physician or the resident was informed of the missed dose. Interviews with the Director of Nursing and the Director of Staff Development confirmed that the physician should have been notified and that this was not documented in the clinical record. The resident also stated she was not informed about the missed dose. Additionally, the facility failed to notify the physician when a resident refused body weight monitoring for an extended period of 58 days. Physician orders required weekly weights, but after the last recorded weight, the resident declined further monitoring. There was no documentation of the resident's refusal or of any notification to the physician regarding this ongoing refusal. Staff interviews confirmed that there was no record of the refusals or physician notification in the progress notes or care plans. The facility's policies required prompt notification of the resident, physician, and representative of changes in the resident's condition or status, including refusals of care. Despite these policies, the required notifications and documentation were not completed in both instances involving the missed medication dose and the refusal of weight monitoring.
Failure to Develop and Implement Care Plan for Refusal of Weight Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's ongoing refusal to allow body weight monitoring. Despite physician orders for weekly weights and documentation in the nutrition/dietary progress notes that the resident was refusing to be weighed, there was no evidence in the resident's care plan or progress notes that this refusal was addressed. The resident had multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity, and required varying levels of staff assistance for daily activities, but was cognitively intact. Interviews with nursing staff revealed that the refusal to be weighed was not communicated among the care team, and the physician was not notified of the resident's ongoing refusals. Facility policy required that a care plan be developed and revised as resident conditions changed, but no such care plan or interventions were documented for the resident's refusal to allow body weight monitoring. The lack of documentation and care planning had the potential to negatively affect the delivery of care and services for the resident.
Failure to Complete Timely Nutritional Assessment on Admission
Penalty
Summary
The facility failed to conduct a nutritional assessment upon admission for one of four sampled residents, as required by its own policy and procedure. The resident in question was originally admitted with multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. Despite these significant health conditions, there was no documented evidence that a nutritional assessment was completed by the dietitian at the time of admission. Record reviews showed that the resident's weight was documented at various points, both in the hospital and at the facility, but there were inconsistencies and strikethrough entries in the weight records. The resident had been refusing to be weighed since January, and the last recorded weight was from that time. The dietitian only completed the nutritional assessment after the resident returned from a hospital stay in April, well beyond the required timeframe for an initial assessment. Interviews with facility staff confirmed that the initial nutritional assessment was not completed as required. The Director of Staff Development acknowledged the absence of documentation for the assessment at admission, and the Registered Dietitian stated she was unaware that the assessment had not been done, attributing the oversight to a transition between dietitians. The facility's policy clearly states that a nutritional assessment should be conducted upon admission, but this was not followed in this case.
Failure to Document Controlled Medication Counts and Missed Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed regarding the handling of controlled medications. On two separate occasions, the on-coming nurses did not sign the Narcotic Count Sheet (NCS) after counting controlled medications with the out-going nurses. Specifically, one nurse forgot to sign the NCS after the count, and another instance showed a blank NCS, making it unclear if the count was performed according to facility protocol. The Director of Nursing confirmed that both nurses should have signed the NCS immediately after the count, as per facility policy, to confirm the accuracy of the controlled medication inventory. Additionally, the facility did not administer a prescribed dose of levothyroxine to a resident with hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The medication was scheduled to be given in the morning, but documentation showed it was not administered because the medication had not yet been delivered from the pharmacy. There was no evidence that the medication was given upon receipt, nor was there documentation that the resident's physician was notified about the missed dose. The facility's policies require that controlled medications be counted and documented by both the on-coming and out-going nurses at each shift change, and that medications be administered as prescribed, with proper documentation if a dose is missed or delayed. In these instances, the required procedures were not followed, resulting in incomplete records and a missed medication dose for a resident.
Inaccurate MDS Assessment Due to Incorrect Weight Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident by entering incorrect information in Section K0200 (weight) and Section K0300 (weight loss). The MDS nurse used a weight measurement of 265 lbs. from January, which was not within the required 30-day window of the assessment reference date in April. This led to an inaccurate entry for the resident's current weight and, subsequently, an incorrect assessment of weight loss status. The resident in question had a medical history that included hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The resident had been refusing to be weighed, and the last recorded weight was from January, as noted in the dietary progress notes. Despite this, the MDS nurse did not use the appropriate 'no information' code as instructed by the facility's policy and the CMS Resident Assessment Instrument (RAI) manual. Instead, the nurse entered the outdated weight to proceed with the MDS process, resulting in inaccurate data being recorded. Interviews and record reviews revealed that the MDS nurse was unaware of the resident's refusal to be weighed and acknowledged confusion regarding which weight to use. The nurse admitted to entering the outdated weight and recognized that this led to an inaccurate assessment of the resident's nutritional status. Facility policy and the RAI manual both require the use of the most recent weight within 30 days or, if unavailable, the use of a specific code with documentation, which was not followed in this case.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
The facility failed to implement its policy and procedure regarding wandering and elopement, resulting in a resident with a history of confusion and agitation leaving the premises unsupervised. The resident, who had been admitted with diagnoses including type 2 diabetes mellitus and asthma, was observed wandering and entering other resident rooms earlier in the evening. Despite these behaviors, a Certified Nursing Assistant (CNA) observed the resident leaving the facility late at night but did not intervene or attempt to identify the individual, as the resident was wearing street clothes and appeared to be walking normally. The CNA later acknowledged that he did not recognize the person leaving and did not stop to verify their identity or purpose for leaving, only realizing after being informed that a resident was missing that the individual was likely the resident in question. The facility's policy required staff to attempt to prevent residents from leaving, seek assistance from other staff, and notify nursing leadership if a resident was observed leaving the premises. These steps were not followed in this instance. The resident was subsequently found by local law enforcement and taken to a hospital for evaluation. Interviews with facility staff, including the Director of Nursing, confirmed that the CNA should have stopped and identified the individual leaving the building, especially given the time of night and the resident's lack of reflective clothing. The failure to follow established procedures resulted in the resident leaving the facility unsupervised.
Failure to Promptly Address and Document Resident Grievance
Penalty
Summary
The facility failed to promptly address and resolve a grievance raised by the family member of a resident with severely impaired cognition and multiple medical conditions, including pneumonitis, UTI, and gastrostomy status. The family member contacted the Social Services Director (SSD) to express concerns about the nursing care provided to the resident. Although the SSD informed the Administrator (ADM) of these concerns, there was no documentation of the grievance in the facility's Concern/Grievance Log for the relevant months, and no formal grievance process was initiated. Interviews with facility staff revealed that both the SSD and the Director of Nursing (DON) did not follow up with the family member regarding the reported concerns. The SSD admitted to being too busy to follow up or complete the necessary grievance documentation, and the DON stated she forgot to address the concerns after being informed. The facility's policy requires prompt investigation and written response to grievances, but this process was not followed, resulting in the resident's grievance not being addressed as required.
Failure to Monitor and Assess Resident During IV Fluid Administration
Penalty
Summary
The facility failed to implement its intravenous (IV) administration policy for a resident receiving IV hydration therapy. Specifically, staff did not monitor or document the resident's intake and output (I&O) as required by facility policy, despite an active physician's order for IV fluids. Interviews with nursing and medical records staff confirmed that there was no evidence of I&O monitoring for the resident, and the nurse stated that monitoring was discontinued after 30 days, even though the resident continued to receive IV hydration. The facility's policy required documentation of I&O in the medical record for residents receiving IV fluids. Additionally, the nurse did not assess the resident's lung and heart status or vital signs prior to administering IV fluids, contrary to facility policy, which mandates such assessments before and during IV therapy to monitor for complications like fluid overload. The nurse acknowledged the importance of these assessments but stated they were not performed because there was no specific physician order for them. The resident involved had severely impaired cognition, was dependent on staff for personal care, and had multiple diagnoses including pneumonitis, UTI, and gastrostomy status.
Failure to Assist Residents with Participation in Activities
Penalty
Summary
Facility staff failed to implement the policy on quality of life by not assisting three out of four sampled residents to participate in activities. These residents had significant cognitive impairments and were dependent on staff for daily care, including oral hygiene, toileting, and personal hygiene. Medical records indicated that each resident was permitted to participate in activities as long as it did not conflict with their treatment plan. Despite this, repeated observations throughout the day showed that these residents remained in bed and were not offered the opportunity to get out of bed or attend activities. Interviews with staff revealed that certified nursing assistants (CNAs) did not routinely offer or assist these residents to get out of bed or participate in activities. Reasons given included lack of instruction from licensed nursing staff, time constraints, and assumptions about the residents' ability to participate due to medical devices or communication barriers. For example, one CNA stated that a resident with a gastrostomy tube was not brought to activities because of the tube, and another CNA indicated that a nonverbal resident was not offered the opportunity to get out of bed because of her communication limitations. Further interviews with the registered nurse, activities director, director of staff development, director of nursing, and administrator confirmed that the facility's policy required staff to assist residents in getting out of bed and participating in activities to promote quality of life. These staff members acknowledged that the policy was not being followed and that residents were not being provided with opportunities for stimulation and social interaction as required.
Failure to Provide Required Outings and Evening Activities
Penalty
Summary
The facility failed to implement its policy and procedure regarding activity programs by not incorporating at least one activity per month held away from the facility and not offering at least one evening activity per week for 93 residents during two of the three sampled months (January and February 2025). During an interview and record review with the Activities Director, it was confirmed that no outside activities or evening activities were scheduled for these months, despite the facility's policy requiring such activities. The activity calendar for the specified months lacked both outings and evening events, and the Activities Director acknowledged responsibility for scheduling these activities and confirmed their absence.
Delay in STAT Laboratory Testing for Resident with Change in Condition
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who was admitted with diagnoses including acute respiratory failure with hypoxia, urinary tract infection, and chronic obstructive pulmonary disease. The resident experienced a change in condition, specifically hematuria, and the physician ordered STAT laboratory tests, including a CBC with differential and a comprehensive metabolic panel. According to facility staff, STAT labs are expected to be collected within four hours of the order. However, the laboratory tests were not collected until the following day, well beyond the expected timeframe for STAT orders. Record review and staff interviews confirmed that the delay in obtaining the STAT laboratory tests was due to the laboratory company not arriving within the required four-hour window. The facility's policy states that clinical laboratory services should be provided to meet the needs of residents, but in this instance, the delay resulted in a failure to provide necessary and timely care and services for the resident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, potentially delaying the provision of services and leaving residents' needs unmet. Resident 5, who was readmitted with acute respiratory failure, hemiplegia, and moderately impaired cognitive skills, was observed with the call light on the floor, out of reach. The MDS Nurse confirmed this observation and repositioned the call light within reach. Similarly, Resident 44, admitted with metabolic encephalopathy and severely impaired cognitive skills, was found with the call light on the floor, not within reach, during an observation. Certified Nursing Assistant 2 acknowledged the oversight and the importance of having the call light within reach for safety. Resident 45, who was readmitted with Parkinsonism and severely impaired cognitive skills, was observed with the call light hanging behind the head of the bed, out of reach. Certified Nursing Assistant 3 admitted to forgetting to place the call light back within reach after providing care. The Director of Nursing confirmed that call lights should always be within reach for resident safety. The facility's policy, reviewed in January 2025, mandates that residents have a means to call staff for assistance, and the call light should be within reach upon admission and as needed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential inadequate care. Resident 287, who was readmitted with several diagnoses including pneumonitis and type 2 diabetes, had a physician order for IV infusion of D5W. However, the facility did not create a care plan with specific interventions for monitoring the IV site, which could result in inadequate care of the IV site. This oversight was confirmed during a review and interview with the MDS Coordinator. Resident 36, who was readmitted with diagnoses such as dislocation of an internal joint prosthesis and essential hypertension, was receiving Ceftriaxone Sodium intravenously for a urinary tract infection. Despite this, the facility did not develop a care plan with person-centered interventions for the antibiotic administration, potentially leading to complications from the antibiotic use. This deficiency was acknowledged by the MDS Coordinator during a review of the resident's physician orders and care plans. Resident 37, who had intact cognition and was capable of making decisions, was using an electric kettle in his room without a care plan assessing his ability to do so safely. The Director of Nursing admitted that the resident should have been assessed and a care plan developed to ensure safety. Additionally, Resident 20, who primarily spoke Korean and had severely impaired cognitive skills, did not have a care plan addressing the language barrier, which could hinder effective communication and care. The Infection Preventionist confirmed the absence of a care plan for communication needs during a review of the resident's records.
Failure to Ensure Resident Safety and Adherence to Care Plans
Penalty
Summary
The facility failed to provide a safe environment for Resident 70 by not placing a landing mat on the right side of the bed as indicated in the care plan and physician's order. Resident 70, who was admitted with diagnoses including chronic obstructive pulmonary disease, palliative care needs, and cerebral infarction, was identified as being at risk for falls. Despite the physician's order and care plan intervention specifying the use of a right-side landing mat to minimize injury from falls, the mat was found under the bed during an observation. The Registered Nurse confirmed that the mat should have been placed on the right side, and the Director of Nursing acknowledged the oversight. The facility also failed to ensure the safety of Resident 37 by allowing the resident to keep an electric tea kettle in the room without proper assessment or care planning. Resident 37, who had intact cognition and was capable of making decisions, was observed using the kettle to boil water. The Director of Nursing admitted that there was no assessment or care plan addressing the use of the kettle, which posed a potential risk for accidents. The Maintenance Director was unaware of the kettle's presence and stated that electrical appliances should not be in resident rooms without approval. The facility's policies on falls and fall risk management, as well as safety and supervision of residents, were not adhered to in these cases. The policy required interventions to prevent falls and minimize complications, and the electrical appliances policy mandated written approval for such items in resident rooms. These deficiencies highlight lapses in following established protocols to ensure resident safety.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that two residents received continuous oxygen as ordered by their physicians. Resident 70, who was admitted with chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen, was observed multiple times without wearing the nasal cannula despite the oxygen concentrator being on. Registered Nurse 2 incorrectly stated that the oxygen order was as needed, not continuous, and Licensed Vocational Nurse 2 acknowledged that the resident often removed the nasal cannula but did not ensure it was worn continuously as ordered. Resident 287, who was readmitted with diagnoses including pneumonitis and had a care plan indicating the need for continuous oxygen, was observed receiving oxygen at a higher flow rate than ordered and without a humidifier. Licensed Vocational Nurse 1 confirmed that the oxygen was not administered according to the physician's order, which specified a lower flow rate and the use of a humidifier. The Director of Nursing acknowledged that both residents should have received oxygen as per their physician's orders to prevent complications. The facility's policies on oxygen administration and physician services were not adhered to, leading to the deficiencies observed in the care of these residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that licensed nurses did not leave medications unattended at a resident's bedside. Resident 57, who was readmitted with chronic hematogenous osteomyelitis, type 2 diabetes mellitus with a foot ulcer, and a non-pressure chronic ulcer, was observed with two pills in an unlabeled medication cup on his bedside table. The resident stated that the nurse left the medications for him to take later, a practice that was confirmed by Registered Nurse 2. The nurse justified this by stating that the medications were only vitamins and that the resident was trustworthy. However, there was no documented evidence of a Medication Self Administration Assessment, which is required to ensure the resident can safely self-administer medications. Additionally, the facility failed to administer the first dose of an antibiotic timely to Resident 60, who was readmitted with a urinary tract infection. The physician's order for Cipro was received at 3:22 a.m., but the first dose was not administered until 9:00 a.m., exceeding the four-hour window for timely administration. The MDS Nurse confirmed that the antibiotic was available in the facility's pharmacy e-kit, and the Director of Nursing acknowledged that the delay was inexcusable. The facility's policies and procedures for medication administration and provider pharmacy requirements were not followed in these instances. Medications are to be administered as prescribed and promptly available, especially anti-infectives, which should be available within four hours. The failure to adhere to these guidelines resulted in deficiencies in the pharmaceutical services provided to the residents.
Improper Labeling of Leftover Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that leftover food brought by residents' family and visitors was properly labeled with a resident identifier and use-by date in the residents' refrigerator. During an observation and interview with a registered nurse, it was noted that two plastic bags containing undetermined leftover food were found in the refrigerator. One bag had a room number but no name or date, while the other had no resident's name or date. The registered nurse acknowledged that the refrigerator is used to store residents' food and confirmed that all items should be labeled with an identifier and date. The nurse also stated that any leftover food older than three days should be discarded to prevent contamination and potential foodborne illness. The facility's policy, last reviewed in January 2025, requires perishable foods to be stored in re-sealable containers with tightly fitting lids and labeled with the resident's name, item, and use-by date. Nursing staff are responsible for discarding perishable foods on or before the use-by date. The failure to adhere to this policy had the potential to result in foodborne illness for the residents.
Failure to Ensure Provision of Hospice Services
Penalty
Summary
The facility failed to ensure the provision of hospice services for Resident 70, who was admitted with chronic obstructive pulmonary disease and was dependent on supplemental oxygen. The facility did not ensure that the contracted hospice agency provided training programs to the facility staff as per the contractual agreement. Interviews with various staff members, including a registered nurse, a certified nursing assistant, and the MDS nurse, revealed that none had received in-service training from the hospice agency. The facility's administrator and director of nursing were unaware of the training requirements outlined in the hospice contract. Additionally, the facility did not have a designated staff member to coordinate care and services provided by hospice and the facility. Interviews with the MDS nurse, registered nurse, social services director, administrator, and director of nursing indicated confusion and lack of clarity regarding who was responsible for coordinating hospice care. The facility's policy and procedure required a designated coordinator, but this role was not filled, leading to a lack of coordination in hospice care services. Furthermore, there was no documented evidence that hospice staff was physically present in the facility to provide hospice-related services to Resident 70. The MDS nurse and the director of staff development confirmed the absence of a sign-in sheet for hospice staff, which was necessary to document their presence and services provided. The facility's policy required documentation of all services provided to residents, but this was not adhered to, resulting in a deficiency in ensuring hospice care was delivered as required.
Infection Control Lapses in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents using nasal cannulas for oxygen therapy. For Resident 137, the nasal cannula oxygen tubing was observed touching the floor, which the Director of Nursing (DON) acknowledged as contaminated and a potential source of infection. The facility's infection control policy, as well as CDC guidelines, emphasize the importance of maintaining a sanitary environment to prevent the transmission of infections, which was not adhered to in this instance. For Resident 287, the nasal cannula was not labeled with the date it was last changed, contrary to the physician's orders and facility policy that require weekly changes and proper labeling to prevent respiratory infections. The Licensed Vocational Nurse (LVN) and the DON confirmed the oversight, and the Infection Preventionist reiterated the importance of labeling to prevent infection. Both deficiencies highlight lapses in following established infection control protocols, potentially increasing the risk of infection for the residents involved.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the resident's indwelling urinary catheter collection bag was covered with a privacy bag. This oversight was observed during a room visit, where the urinary catheter bag was found uncovered. The resident, who was admitted with diagnoses including an infection due to a urinary catheter and a malignant neoplasm of the bladder, had an order for catheter care every shift. However, the staff did not adhere to the facility's policy requiring catheter bags to be covered to promote dignity. During an interview, a registered nurse confirmed the absence of a privacy bag on the resident's catheter collection bag and acknowledged the requirement for such a cover to promote dignity. The Director of Nursing also confirmed that the catheter bags should be covered and admitted that the staff had forgotten to do so for this resident. The facility's policy clearly states that residents should be treated with dignity and respect, and that practices compromising dignity, such as leaving catheter bags uncovered, are prohibited.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission or readmission for three residents, which is a requirement to ensure that residents' immediate needs are met. Resident 21 was readmitted with diagnoses including chronic obstructive pulmonary disease and gastro-esophageal reflux disease, and had a physician order for ertapenem sodium injection for a urinary tract infection. However, a baseline care plan addressing the antibiotic use was not created, which could lead to staff being unaware of what to monitor for potential adverse reactions. Similarly, Resident 59, who was readmitted with a diagnosis of urinary tract infection and gastro-esophageal reflux disease, had physician orders for antibiotics cefdinir and sulfamethoxazole-trimethoprim to treat G-tube site cellulitis. Despite these orders, a baseline care plan was not developed to monitor the resident during antibiotic therapy, potentially preventing staff from identifying adverse reactions and intervening promptly. Resident 62 was admitted with diagnoses including benign prostatic hypertension, a history of falling, and type 2 diabetes mellitus. The resident had an order for insulin lispro to be administered per sliding scale, but the baseline care plan did not reflect the insulin use. This oversight was acknowledged by the MDS Coordinator, who admitted the mistake. The lack of a thorough baseline care plan could result in the inability to meet the resident's immediate care needs and deliver necessary services.
Failure to Update Resident's Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to update and revise a resident's care plan after the resident's physician discontinued the administration of Januvia, a medication for controlling blood sugar levels. This oversight involved a resident who was originally admitted on October 25, 2024, and readmitted on November 19, 2024, with diagnoses including unspecified dementia, major depressive disorder, type two diabetes mellitus, and cerebral infarction. Despite the physician's order to discontinue Januvia on October 25, 2024, the resident's care plan, initiated on October 26, 2024, still indicated that the resident was taking Januvia. This discrepancy was identified during a review of the resident's care plan and physician orders by the Infection Preventionist on March 8, 2025. The Director of Nursing confirmed that the licensed nurses did not review or revise the resident's care plan following the discontinuation of Januvia. The facility's policy requires that care plans be reviewed and revised when there are changes in a resident's medication. The failure to update the care plan could lead to confusion regarding the care and services provided to the resident. The facility's policy on comprehensive person-centered care plans emphasizes the importance of revising care plans as information about residents and their conditions change.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board for a resident whose primary language was Korean, which hindered the resident's ability to communicate effectively with staff. The resident, who was admitted and readmitted with diagnoses including unspecified dementia, major depressive disorder, type two diabetes mellitus, and cerebral infarction, had severely impaired cognitive skills and required assistance with activities of daily living. Despite the resident's need for a communication board to express needs, it was not available at the bedside, as observed during an interaction with a Certified Nursing Assistant (CNA) who relied on hand gestures to communicate. Interviews with the Director of Social Services (DSS) and the Director of Nursing (DON) revealed that the facility's policy required the provision of communication devices for residents who do not speak English. The DSS confirmed that a communication board was initially placed but was later removed for unknown reasons. The absence of the communication board was acknowledged by the DON, who stated that it was necessary for accurate communication and understanding of the resident's needs. The facility's policies on translation and activities of daily living support emphasized the importance of providing appropriate communication support for residents with limited English proficiency.
Failure to Provide Religious Services to a Resident
Penalty
Summary
The facility failed to provide religious services to a resident, identified as Resident 10, which violated the resident's right to access and receive religious services. Resident 10 was admitted to the facility with diagnoses of hypertension and anemia. The resident's Annual Minimum Data Set (MDS) indicated that participating in religious services was somewhat important to her. However, during an observation and interview, Resident 10 expressed that she had not attended a church service in a long time and that the facility did not offer any religious services. She also mentioned that no pastor or priest had visited her room, and she resorted to conducting her own bible study. The Activity Director (AD) confirmed that Resident 10 had not participated in any religious activities for the months reviewed and there was no documentation of her being offered or invited to attend any religious service. The AD acknowledged the importance of addressing the spiritual needs of residents and recognized the resident's right to practice their religion. Despite the facility's policy indicating that activity goals should be individualized to match residents' preferences, there was a lack of documented attendance or invitation for Resident 10 to participate in religious services, leading to the deficiency.
Failure to Monitor Catheter Care and UTI Symptoms
Penalty
Summary
The facility failed to provide proper care and monitoring for a resident with an indwelling catheter, as outlined in the resident's care plan. The resident, who was admitted with conditions such as benign prostatic hypertension, obstructive uropathy, and reflux uropathy, required substantial assistance with daily activities and had a moderately impaired cognitive function. The care plan specified that the resident should be monitored for signs and symptoms of urinary tract infections (UTIs) and pain associated with the catheter, but there was no documented evidence of such monitoring in the Treatment Administration Record for the specified period. Interviews with the MDS Coordinator and the Director of Nursing revealed that the licensed staff did not document the required monitoring for pain and signs of infection as per the care plan. The MDS Coordinator confirmed the absence of documentation regarding the monitoring of the resident's indwelling catheter, which was a necessary intervention to provide appropriate care. The Director of Nursing reiterated the requirement for licensed staff to monitor and document any complications associated with urinary catheters, including signs of UTIs and catheter-related pain. The facility's policy on catheter care emphasized the importance of preventing catheter-associated UTIs and required staff to observe residents for complications and report any issues to a physician or supervisor. However, the lack of documentation and monitoring for the resident's catheter care indicated a failure to adhere to these procedures, potentially leading to inadequate care and monitoring for the resident.
Failure to Discard Eye Drops After 28 Days
Penalty
Summary
The facility failed to adhere to the pharmacy's medication recommendation label by not discarding two opened eye drop bottles after 28 days of opening. This was observed during a concurrent observation and interview with a registered nurse, who confirmed that the eye drops, Alpheagan and Latanoprost, should have been discarded on specific dates to prevent bacterial growth. The eye drops were found on a medication cart used during the 3-11 shift, and the registered nurse acknowledged the oversight, stating that the eye drops should have been discarded to ensure resident safety. The Pharmacist Consultant clarified that the discard label on the eye drops is a pharmacy recommendation rather than a regulation. However, the Director of Nursing emphasized that licensed nurses are responsible for reading medication labels before administration and should have discarded the eye drops as per the pharmacy's recommendation. The facility's policy on medication procedures, reviewed earlier in the year, also indicated the importance of administering medications safely and effectively, which includes reading medication labels before administration.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to conduct an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 62, by not indicating that the resident was receiving insulin since his admission. Resident 62 was admitted with diagnoses including benign prostatic hypertension, a history of falling, and type 2 diabetes mellitus. Despite having an order for insulin lispro to be administered per sliding scale and receiving it from February 13 to February 17, 2025, the MDS dated [DATE] did not reflect this insulin administration. This oversight was acknowledged by the MDS Coordinator, who admitted to the mistake and recognized the need for correction. The Director of Nursing confirmed that the MDS assessment did not accurately reflect the resident's status, as it failed to indicate insulin use. The facility's policy requires the MDS Coordinator to ensure accurate completion of the MDS assessment, which is used to develop the resident's care plan. The inaccurate MDS assessment had the potential to negatively affect the resident's plan of care and the delivery of necessary services. The facility's policy emphasizes the importance of accurate assessments to inform the resident's comprehensive care plan.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
