Catered Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 4010 N Virginia Rd., Long Beach, California 90807
- CMS Provider Number
- 056150
- Inspections on file
- 39
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Catered Manor Care Center during CMS and state inspections, most recent first.
A resident with multiple health conditions fell while transferring from bed to wheelchair after staff failed to lock the wheelchair and did not respond to a call for assistance. No fall risk assessment or comprehensive care plan was documented or implemented following the incident, despite facility policy requiring individualized safety interventions.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment contained hazards and lacked sufficient oversight, increasing the risk of accidents for residents.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
A resident with COPD and DM experienced increased confusion and poor food intake, leading to lab tests that revealed abnormal blood glucose, sodium, and chloride levels. Although earlier abnormal results were reported, the physician was not notified of subsequent abnormal findings, contrary to facility policy, resulting in a delay in care and treatment.
A resident with DM and COPD was given Prednisone without a care plan or interventions to monitor for hyperglycemia, despite the medication's known risk of raising blood sugar. The resident's b/s was not monitored, resulting in a critical hospitalization for DKA and HHS after presenting with altered consciousness, hypotension, and an unmeasurably high b/s level.
A resident with significant physical dependencies was not provided the required two-person assistance during incontinent care, as indicated in the MDS and facility policy. A CNA attempted to reposition the resident alone, resulting in the resident falling from the bed and sustaining severe neck and spinal injuries. The resident was hospitalized, placed on a ventilator, and later passed away due to complications from the injuries.
A resident with multiple medical conditions and mild cognitive impairment was assessed as fully dependent on staff for toileting hygiene and turning in bed, requiring a two-person assist. However, the care plans did not document this specific need, and interventions were limited to general safety measures. The MDS Nurse acknowledged the omission, stating she assumed CNAs would understand the resident's dependency without explicit instructions.
A resident with diabetes and hypoglycemia, who was cognitively intact and required assistance with daily activities, was not included—nor was their family—in the IDT care conference following a fall. Staff interviews and facility policy confirmed that the resident or family should have participated in the care planning process, but only staff attended the meeting.
A family member requested a resident's medical records, but the facility did not provide access within the required two-day timeframe as outlined in its policy. The resident had diabetes and hypoglycemia, with intact cognition and some assistance needs. The DON confirmed the delay in fulfilling the records request.
A resident with diabetes and hypoglycemia did not have their blood glucose rechecked after insulin administration, as required by their care plan. Nursing staff administered insulin on several occasions but did not perform the follow-up blood sugar checks specified in the care plan. This failure was confirmed by both the RN and DON, and was not in accordance with facility policy for comprehensive care planning.
A cook prepared pumpkin pie for a puree diet without following the required recipe, adding milk and resulting in a mixture that was too loose. The Dietary Manager and DON confirmed that recipes must be followed to ensure correct consistency, especially for residents on puree diets, as improper preparation can compromise food quality and safety.
Staff failed to follow the standardized recipe for a puree diet when a cook added milk to a pumpkin pie mixture, resulting in a consistency that did not meet dietary requirements. The Dietary Manager and DON confirmed that the correct procedure was not followed, and facility policies require adherence to recipes for resident safety.
A resident with diabetes, dementia, and moderate cognitive impairment was prescribed and administered topical bacitracin for a toe infection without the required assessment using McGeers criteria. Interviews with the IP and DON confirmed that the facility's antibiotic stewardship policy, which mandates use of McGeers criteria to define infections before starting antibiotics, was not followed.
A resident's MDS assessment was not accurately documented, with the middle initial entered in the wrong field and the assessment being 120 days overdue. The resident, who had multiple chronic conditions and required assistance with daily activities, was affected by this documentation error, which was identified during a record review and confirmed by the MDS Nurse.
A resident with schizophrenia and dementia was admitted without a properly documented Level 1 PASRR, despite exhibiting behavioral symptoms and a history of mental illness. The PASRR screening was incorrectly marked as negative, and no Level II PASRR was conducted, which was acknowledged by the case manager. The DON confirmed that inaccurate PASRR screening would lead to an incorrect care plan.
Two residents experienced significant changes in condition—one passing out and another developing a toe infection—without appropriate documentation of the events or development of care plans. Nursing staff did not complete required COC documentation or initiate care plans, despite facility policies mandating these actions for acute changes. This resulted in a lack of guidance for staff and insufficient monitoring of the residents' conditions.
A resident with diabetes, heart failure, and chronic kidney disease did not receive timely referral and follow-up for ophthalmology services as ordered, despite documented need for cataract management and further evaluation. The resident waited a year for new glasses and used inadequate over-the-counter glasses. Staff interviews and record reviews revealed a breakdown in communication and follow-through, with the social service director unaware of the eye doctor’s recommendations until the survey. Facility policy required prompt arrangement of such services, but this was not followed.
A resident with diabetes, dementia, and depression did not receive a timely podiatry consult for a left big toe infection as ordered by a PA. Although an appointment was initially scheduled, it was missed due to the resident having COVID-19 and was not rescheduled, resulting in a lack of appropriate foot care.
A resident with chronic respiratory and heart failure was ordered to receive continuous oxygen at 8 LPM via re-breathable mask, but was instead observed receiving 3 LPM via nasal cannula. An LVN admitted to not checking the physician's order, resulting in the resident not receiving the prescribed oxygen therapy.
The facility did not perform or document required annual competency and performance evaluations for a CNA working the night shift over multiple years, as confirmed by record review and staff interviews. This failure was attributed to oversight due to the CNA's shift schedule, and was not in accordance with facility policy requiring annual assessments and documentation.
The facility failed to ensure the Infection Preventionist (IP) had the required specialized training and certification in infection prevention and control. The IP, responsible for staff training on infection control practices, could not provide her IP certificate. Interviews with the Director of Staff Development, Registered Nurse Supervisor, and Administrator highlighted the importance of certification to prevent infection spread, as mandated by federal regulations.
A resident with a history of chest pain and hypertension experienced a significant change in condition, including low oxygen saturation and chest pain. Despite these symptoms, the resident was not transferred to a hospital for eight hours due to inadequate monitoring and communication by the nursing staff. The delay resulted in the resident's condition worsening, leading to their death after unsuccessful resuscitation efforts at the hospital.
The facility failed to provide recommended restorative nursing care for three residents with limited ROM and/or mobility. One resident did not receive the prescribed left-hand splint and RNA services, another received RNA services inconsistently, and a third had no documentation of RNA services or joint mobility assessments. The facility lacked a system to track and assess residents' progress.
The facility failed to ensure that two cartridges of morphine tablets were properly stored in the cubex machine after delivery by the pharmacy. The morphine tablets were found in unlabeled red containers with plastic locks in the medication storage room, leading to potential drug diversion and theft. Interviews and record reviews confirmed that the facility's policies for controlled substance storage were not followed.
The facility failed to ensure that the consultant pharmacist's recommendations were communicated to the physician for four residents, resulting in the administration of unnecessary medications. The recommendations included dose adjustments, taking medication with food, reassessing the need for a medication, and clarifying the indication for use. These recommendations were not followed up, leading to potential adverse effects for the residents.
The facility failed to ensure that over-the-counter medications were not expired in a medication storage room and that a resident's medications were not left unattended on a bedside table by an LVN. The expired medications included multivitamins, Vitamin B12, nasal decongestants, Aspirin, and Vitamin D. The LVN signed off on the medications as administered without waiting for the resident to take them, contrary to the facility's policy.
The facility failed to ensure safe and sanitary food storage practices, as expired banana puree, egg puree, lettuce, and eggs were found in the kitchen. Staff interviews revealed that cooks were responsible for labeling and dating food, while all kitchen staff were responsible for removing expired items. The facility's policy indicated that food should be stored to minimize contamination and bacterial growth, and expiration dates should be checked to ensure they are within acceptable parameters.
The facility failed to assess the mental capacity of two residents before having them sign arbitration agreements. Both residents, who were documented as unable to make decisions, signed the agreements without the signature of an authorized agent or a witness. The Admission Coordinator and her assistant were unsure about the requirements, and the facility's policy on informing residents about their rights was not followed.
The facility failed to observe proper infection control practices by allowing dietary staff to store personal food items in the kitchen refrigerator and by not ensuring proper use of PPE when providing care for a resident on Enhanced Standard Precaution. These actions had the potential to result in cross-contamination and the spread of infection.
The facility failed to inform five residents about their right to develop an advance directive, despite their various medical conditions and the facility's policy requiring such information to be provided upon admission and periodically thereafter.
The facility failed to ensure that two residents with mental illnesses had proper PASARR assessments prior to admission. Both residents were admitted with incorrect PASARR Level I screenings that did not reflect their diagnoses of schizophrenia, resulting in a lack of necessary mental health support and services.
The facility failed to accurately assess and code the MDS for a resident, leading to potential issues in care planning and service provision. The MDS did not reflect the resident's lower extremity impairments, including ankle contractures and footdrop, until after the deficiency was identified.
The facility failed to ensure that a resident and/or their responsible party were informed in advance of the risks and benefits of psychoactive medications. Despite the resident's moderately impaired cognitive skills and need for assistance with daily activities, informed consent was not obtained for the use of Ativan and ABHR cream. The consent was only obtained after the medications had already been administered, violating the resident's right to make an informed decision.
The facility failed to ensure that the call light was within reach for a resident with multiple medical conditions, leading to feelings of helplessness and incidents of falls. Despite care plan interventions and facility policies emphasizing the importance of call light accessibility, the call light was found placed out of reach, impacting the resident's dignity and ability to receive timely care.
Failure to Develop and Implement Comprehensive Fall Care Plan After Resident Fall
Penalty
Summary
A resident with a history of acute respiratory failure, muscle weakness, type 2 diabetes, and dependence on renal dialysis experienced a fall while attempting to transfer from bed to wheelchair after returning from dialysis. The resident, who had intact cognitive function and required moderate assistance for activities of daily living and transfers, reported that staff did not respond to her call for help because they were occupied elsewhere. The wheelchair had not been locked by staff, causing it to slide and resulting in the resident falling face down. The resident sustained a slight swelling on the right forehead, which later resolved. Upon review, there was no documentation of a fall risk assessment or a comprehensive, resident-centered care plan addressing falls in the resident's electronic health record following the incident. Staff interviews confirmed that neither a fall assessment nor appropriate care plan interventions were initiated after the fall. The facility's policy required individualized safety interventions and risk assessments, but these were not implemented or documented for the resident after the fall event.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents among residents. Specific actions or inactions leading to this deficiency include the presence of hazards and insufficient oversight in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. These actions resulted in noncompliance with regulations regarding pharmaceutical services and oversight.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician of abnormal laboratory results, specifically a high blood glucose level, low sodium, and low chloride, as indicated in lab results dated 5/22/2025. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM), was experiencing increased confusion and poor food intake, prompting the physician to order a series of lab tests. While the physician was notified of earlier abnormal results and ordered further testing, there was no documented evidence that the subsequent abnormal results were communicated to the physician. Interviews confirmed that the physician was not made aware of the abnormal lab findings from 5/22/2025, and the Director of Nursing acknowledged that the physician should have been notified. The facility's policy required prompt notification of lab results outside clinical reference ranges, but this was not followed in this instance, resulting in the physician being unaware of the resident's condition and a delay in care and treatment.
Failure to Develop and Implement Care Plan for Prednisone Use in Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of Prednisone for one resident with a history of diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD). Despite the known risk of Prednisone to increase blood sugar (b/s) levels and induce hyperglycemia, there was no care plan created to monitor for risk, side effects, or adverse reactions related to this medication. As a result, the resident's b/s levels were not monitored from 4/11/2025 through 5/16/2025, and no interventions were documented to ensure b/s remained within an acceptable range. This lack of monitoring and absence of a care plan led to the resident experiencing an altered level of consciousness, hypotension, high heart rate, and a b/s level too high to register on the facility's glucometer. The resident was subsequently transferred to a general acute care hospital, where she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), requiring admission to the intensive care unit in critical condition. Facility policy required comprehensive, person-centered care plans with measurable objectives and monitoring for medication effects, but these were not followed in this case.
Failure to Provide Required Two-Person Assistance During Incontinent Care Results in Resident Fall and Fatal Injuries
Penalty
Summary
A deficiency occurred when a resident, who was assessed as totally dependent on staff for toileting hygiene and for turning and repositioning in bed, was not provided the required two-person assistance during incontinent care. The resident's Minimum Data Set (MDS) indicated that he was unable to assist in turning himself and required two staff members for safe repositioning. Despite this, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without the help of another staff member, contrary to the resident's care plan and facility policy. During the incident, the CNA raised the resident's bed to her waist level and attempted to pull the resident towards her using a draw sheet. As she did so, the resident slid out of bed and landed face down on a floor mat. The CNA called for help, and a Licensed Vocational Nurse (LVN) responded, finding the resident unresponsive. The resident was subsequently transferred to a general acute care hospital, where he was diagnosed with multiple traumatic injuries to his neck and spine, including ligamentous injuries, spinal cord compression, hemorrhage, and suspected fractures. The resident's medical history included a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. Following the fall, the resident required intubation and mechanical ventilation, and after consultation with neurosurgery and the family, comfort care was initiated. The resident passed away as a result of sequelae from blunt traumatic injuries sustained in the fall. Interviews with facility staff confirmed that the CNA was not aware of the two-person assistance requirement, and the facility's policy required the appropriate number of staff for safe turning and repositioning.
Failure to Document Two-Person Assist for Dependent Resident in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to document necessary interventions to prevent falls and injuries for a resident with multiple medical conditions, including a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. The resident was assessed as having mild cognitive impairment and was dependent on nursing staff for toileting hygiene and for rolling to either side while lying in bed, requiring a two-person assist for these activities. Despite this, the care plans reviewed did not specify the resident's dependency or the need for two-person assistance for turning and repositioning. The care plans in place addressed impaired physical mobility and risk for falls, listing general interventions such as allowing adequate response time, assessing toileting needs, and encouraging use of the call light. However, they lacked documentation of the resident's specific need for two-person assistance during turning and repositioning. The MDS Nurse confirmed that this level of dependency was identified during assessment but was not included in the care plan, as she assumed that CNAs would understand the implications of the term "dependent" without explicit instructions.
Resident and Family Not Included in Post-Fall Care Planning
Penalty
Summary
The facility failed to involve a resident and/or their responsible party in the Interdisciplinary Team (IDT) conference following a fall incident. The resident, who had diagnoses including hypoglycemia and type 2 diabetes mellitus, was cognitively intact according to the Minimum Data Set (MDS) and required varying levels of assistance with daily activities. After the resident experienced a fall in front of the bathroom door, the IDT meeting was conducted with participation from nursing, rehabilitation, dietary, and activities staff, but without the involvement of the resident or their family. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed that the resident or family should have been included in the care conference. Review of facility policy also indicated that care plans are to be developed collaboratively with the resident and the IDT team. The omission of the resident and/or responsible party from the care planning process after the fall constituted a deficiency in person-centered care planning.
Delay in Providing Resident Medical Records to Family Member
Penalty
Summary
The facility failed to provide a family member with timely access to a resident's medical records as required by facility policy. The family member requested the records on 3/21/2025, but the records were not made available until 3/28/2025, exceeding the facility's policy of providing records within two calendar days of a valid request. The resident involved had diagnoses including hypoglycemia and type 2 diabetes mellitus, with intact cognition and requiring varying levels of assistance with daily activities. The Director of Nursing acknowledged that the records should have been provided sooner.
Failure to Recheck Blood Glucose After Insulin Administration
Penalty
Summary
The facility failed to follow the care plan for a resident with diabetes mellitus and hypoglycemia by not rechecking blood glucose levels after administering insulin, as required by the resident's care plan. The care plan specified that blood sugar should be rechecked 30 to 45 minutes after insulin administration to monitor for hypo- or hyperglycemia. Record review and interviews confirmed that on multiple occasions, insulin was administered to the resident for elevated blood sugar levels, but no subsequent blood glucose checks were performed as directed in the care plan. The resident had intact cognition and required assistance with daily activities, including eating, oral hygiene, toileting, and showering. The failure to recheck blood glucose was acknowledged by both the RN and the DON during interviews, and the facility's policy required comprehensive, person-centered care plans with measurable objectives to be implemented. The omission of post-insulin blood glucose monitoring was directly contrary to the established care plan and facility policy.
Failure to Follow Recipe Results in Improper Puree Food Consistency
Penalty
Summary
A deficiency occurred when a cook prepared pumpkin pie without following the prescribed recipe, specifically by adding milk to the mixture, resulting in a loose consistency. The cook acknowledged not following the recipe and recognized the importance of adhering to recipes, especially for residents on puree diets, as improper consistency could pose a risk. The Dietary Manager observed the incident, confirmed the mixture was too loose, and stated that cooks are responsible for reading and following recipes to ensure correct food preparation, particularly for puree diets. The Director of Nursing also confirmed the importance of following recipes, noting that improper preparation could compromise food quality and resident health. Review of the cook's job description indicated a requirement to prepare food according to planned menus, diet plans, recipes, and portions. Facility policy further stated that all special diets must be prepared and served as planned. The failure to follow the recipe had the potential to affect the quality and safety of meals, particularly for residents requiring puree diets.
Failure to Follow Puree Diet Recipe Results in Improper Food Consistency
Penalty
Summary
A deficiency occurred when staff failed to prepare a puree diet according to the facility's standardized recipes and menus. During an observation, a cook was seen adding milk directly to a pumpkin pie mixture in a food processor, resulting in a loose consistency. The cook confirmed that this action was not in accordance with the recipe, which did not call for milk to be added. The cook acknowledged the importance of following recipes, especially for residents on puree diets, as improper consistency could pose a risk to residents with swallowing difficulties. The Dietary Manager observed the incident and agreed that the mixture was too loose, stating that puree diets must have the correct consistency to prevent risks for residents. The Director of Nursing also emphasized the importance of following recipes, noting that improper preparation could compromise resident health. Review of the job description and facility policies confirmed that staff are required to prepare food according to planned menus, diet plans, and recipes. The facility's recipe for pumpkin pie specified the correct preparation method, which was not followed in this instance.
Failure to Use McGeers Criteria Before Initiating Topical Antibiotic
Penalty
Summary
The facility failed to ensure that McGeers criteria were used to assess a resident prior to the initiation of a topical antibiotic for a left big toe infection. The resident, who had diagnoses including type 2 diabetes mellitus, dementia, and depression, was admitted with moderate cognitive impairment and required substantial assistance with activities of daily living. Medical documentation showed that a physician assistant ordered bacitracin ointment to be applied to the resident's left big toe for a skin infection, and this order was carried out as documented in the Treatment Administration Record. Interviews with the Infection Preventionist and the Director of Nurses confirmed that McGeers criteria, which are required by facility policy to define infections and guide antibiotic use, were not utilized before starting the antibiotic treatment. The facility's policy on antibiotic stewardship specifies that nursing staff should assess residents using McGeers criteria prior to notifying the physician and that antibiotic orders should be reviewed for appropriateness. Despite these protocols, the required assessment was not performed in this case.
Inaccurate and Overdue MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately documented and completed in a timely manner. Specifically, the resident's middle initial was incorrectly entered in the section intended for the first name, and the middle initial field was left blank. This error was identified during a review of the resident's records and confirmed by the MDS Nurse, who acknowledged responsibility for providing accurate assessments. The MDS for this resident was also found to be 120 days overdue. The resident involved had a medical history including rheumatoid arthritis, diabetes, and a right artificial hip joint. The MDS indicated the resident was able to express ideas and understand others clearly, and required supervision or assistance with certain activities of daily living such as toileting, showering, and dressing. Facility policies reviewed stated that documentation must be complete and accurate, and that MDS coding should reflect an accurate assessment of each resident's functional capacity and health status.
Failure to Accurately Complete PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Level 1 Preadmission Screening and Resident Review (PASRR) for one resident was documented correctly. The resident was admitted with diagnoses including schizophrenia and dementia, and exhibited behavioral symptoms such as verbal outbursts, use of foul language, and physical aggression towards others. Despite these diagnoses and behaviors, the PASRR Level 1 screening was marked as negative, indicating no mental illness, intellectual disability, or related conditions, and the case was closed without a Level II PASRR being conducted. This incorrect documentation was confirmed by the Case Manager, who acknowledged the resident's diagnosis of schizophrenia and agreed that the PASRR screening was completed incorrectly. Further review of the resident's records showed ongoing behavioral issues, including an incident where the resident hit another resident and could not recall the reason for the action. The Director of Nursing stated that improper or inaccurate PASRR screening would result in an incorrect plan of care for the resident. The facility's policy requires proper PASRR screening for individuals with major mental illness, intellectual disability, or developmental disabilities prior to admission and throughout their stay, in compliance with federal regulations.
Failure to Document Change of Condition and Develop Care Plans for Acute Events
Penalty
Summary
The facility failed to ensure comprehensive care planning and appropriate documentation of change of condition (COC) for two residents. For one resident, who had diagnoses including acute respiratory failure, muscle weakness, and type 2 diabetes, there was an incident where the resident passed out while sitting on a shower chair and was assisted to the floor. Despite the event, there was no care plan or COC documentation completed regarding the incident. The charge nurse present at the time did not document the incident, assuming the Registered Nurse Supervisor (RNS) would handle the assessment, physician notification, and care plan initiation, but this was not done. The Director of Nursing (DON) confirmed that the RNS should have assessed and documented the COC and implemented a care plan to monitor the resident's status after the incident. For another resident with diagnoses including type 2 diabetes, dementia, and depression, there was a documented infection of the left big toe, for which bacitracin ointment was ordered and administered. However, there was no COC documentation or comprehensive care plan developed for the infection. The Infection Preventionist (IP) and DON both acknowledged that a care plan should have been initiated to guide staff in providing appropriate care and monitoring the resident's condition. The absence of a care plan meant that staff lacked guidance on interventions and monitoring for potential decline related to the infection. Review of facility policies confirmed that changes in condition require prompt assessment, documentation, physician notification, and care plan development. The policies also require that all services, changes in condition, and progress toward care plan goals be documented in the resident's medical record to facilitate communication among the interdisciplinary team. In both cases, the facility did not follow its own policies regarding COC documentation and care planning for acute changes in residents' conditions.
Failure to Arrange Timely Ophthalmology Referral and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received timely referral, appointment, and follow-up for ophthalmology services as ordered by the physician. The resident, who had a history of diabetes, heart failure, and chronic kidney disease, was documented as needing an ophthalmology consultation for diabetic eye examination and cataract management. Despite physician orders and an eye doctor consultation recommending follow-up for cataracts and referral for occult macular dystrophy, the necessary arrangements for these services were not made. Record reviews showed that the resident had been waiting for new glasses for a year and was using inadequate over-the-counter glasses, which did not sufficiently address her vision needs. Interviews with staff revealed that the process for arranging such appointments required communication between licensed nurses, case managers, and the social service director (SSD). However, the SSD was unaware of the eye doctor consultation and its recommendations until the time of the survey, indicating a breakdown in communication and follow-through on the referral process. Facility policy required that social services or their designee assist with appointments, referrals, and transportation for ancillary services, and that orders for such services be relayed promptly. Despite these policies, the resident's referral and follow-up for vision care were not completed, and staff acknowledged that failure to arrange these services could result in worsening vision for the resident.
Failure to Provide Timely Podiatry Care for Foot Infection
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, dementia, and depression was not seen by a podiatrist for a left big toe infection as ordered. The resident was admitted with multiple diagnoses that increase the risk of complications from foot infections. Medical documentation showed that a physician assistant ordered bacitracin ointment and a podiatry consult for toenail care due to a skin infection on the left big toe. The facility's policy required that ancillary services, including podiatry, be scheduled within 1-3 weeks of referral unless it was an emergency. Despite the order for a podiatry consult, the resident's appointment was not completed as scheduled. The social services staff reported that the resident was scheduled to see the podiatrist, but the appointment was missed due to the resident having COVID-19. The appointment was not rescheduled, and both the social services staff and the DON acknowledged that the resident should have been seen by podiatry as soon as possible after the initial referral. This lapse resulted in the resident not receiving timely podiatric care for the toe infection.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and congestive heart failure was admitted to the facility and required continuous oxygen therapy as indicated in their Minimum Data Set assessment. The physician's order specified that the resident should receive oxygen at eight liters per minute via a re-breathable mask to maintain oxygen saturation at 92% or above. However, during an observation, the resident was found to be receiving only three liters per minute of oxygen via a nasal cannula, which did not match the physician's order. Interviews with the LVN responsible for the resident's care revealed that she had not checked the physician's order and was unaware of the correct oxygen administration method and flow rate. The Director of Nursing confirmed that all licensed staff are responsible for following physician orders and that failure to do so could result in inadequate care. Review of facility policy and the LVN job description further emphasized the requirement to check physician orders and administer treatments as prescribed.
Failure to Complete Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations and competency assessments for a Certified Nursing Assistant (CNA) who had been employed since 2013 and worked the night shift. Record review and interviews with the Director of Staff Development (DSD) revealed that there were no records of annual competency training for this CNA for the years 2022, 2023, and 2024. The DSD acknowledged missing the required evaluations, attributing the oversight to the CNA's night shift schedule. The CNA could not recall the last time an annual skills performance training was completed. Further interviews with the DSD and the Director of Nursing (DON) confirmed the importance of annual competency and skills evaluations for CNAs to ensure they are competent in their duties. Review of the facility's policy and procedure indicated that departmental training and competency assessments are to be repeated annually, with the DSD responsible for maintaining appropriate records. The lack of documented annual evaluations for the CNA constituted a failure to follow facility policy and regulatory requirements.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had specialized training in infection prevention and control, as required by federal regulations. During an interview, the Director of Staff Development (DSD) emphasized the necessity for the IP to be full-time and possess an IP certificate to ensure adequate training. The IP, who works full-time at the facility, confirmed her responsibility for training staff on infection control practices but was unable to provide her IP certificate. The IP acknowledged the importance of proper training to equip staff with the necessary knowledge and skills to prevent the spread of infections. Further interviews revealed that the Registered Nurse Supervisor (RNS) and the Administrator were also aware of the requirement for the IP to have the necessary training. The RNS stated that without proper training, both staff and residents are at risk of infection. The Administrator, who was new to the facility, admitted he was unaware of the IP's certification status but confirmed that certification is a regulatory requirement. A review of the job description for the IP position indicated that training in infection prevention and control is mandatory according to federal requirements.
Delayed Transfer to Hospital Leads to Resident's Death
Penalty
Summary
The facility failed to promptly transfer a resident to a general acute care hospital (GACH) after a significant change in condition was observed. The resident, who had a history of chest pain, hypertension, and anemia, experienced a sudden drop in oxygen saturation to 86% on room air, accompanied by chest and abdominal pain, and fluctuating blood pressure. Despite these alarming symptoms, the resident was not transferred to the hospital until eight hours later, during which time the resident's condition deteriorated further. The nursing staff, including Licensed Vocational Nurses (LVNs) and a Registered Nurse Supervisor (RNS), did not adequately monitor or assess the resident's vital signs, nor did they inform the resident's physician of the continuous oxygen desaturation and other symptoms. Text messages sent to a Nurse Practitioner (NP) failed to mention the resident's chest pain and shortness of breath, and there was a lack of timely communication and documentation regarding the resident's condition. The facility's policy to call 911 in such situations was not followed, leading to a delay in transferring the resident to a higher level of care. Interviews with staff revealed a lack of urgency and communication breakdowns, with some staff members unsure why the resident was not transferred sooner. The Director of Nursing (DON) eventually instructed the staff to call 911, but by then, the resident's condition had worsened significantly. Upon arrival at the hospital, the resident experienced severe complications, including bradycardia and respiratory failure, and ultimately passed away despite resuscitation efforts.
Failure to Provide Recommended Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that three residents with limited range of motion (ROM) and/or limited mobility received restorative nursing care as recommended by physical and occupational therapists. For Resident 16, the facility did not apply the left-hand splint as recommended, and there was no documentation of the resident receiving the prescribed RNA services. Despite the resident's request for more therapy, the RNA services were inconsistently provided, and the left-hand splint was not found in the resident's room. The Director of Rehabilitation confirmed that the RNA services were not documented, and the nursing staff did not follow through with the recommended care plan. Resident 34 also did not receive the recommended RNA services, including the use of a right-hand splint and specific ROM exercises. The resident reported receiving RNA services only twice in three weeks, contrary to the therapist's recommendation of five times a week. The RNA services were not documented, and the facility's RNA Program Binder showed incomplete records and meetings. The Director of Nursing acknowledged that the RNA services were not provided as recommended, and there was no system to track the residents' progress. Resident 3, who had severe cognitive impairment and hemiplegia, did not receive the prescribed RNA services for bilateral upper and lower extremities. The resident's medical records lacked documentation of RNA services, and there was no evidence of joint mobility assessments. During an observation, the RNA was unable to perform the exercises due to the resident's pain, but there was no record of pain medication being administered. The Director of Nursing confirmed that the RNA services were not provided as recommended, and the facility did not have a system to assess the residents' progress.
Failure to Properly Store Morphine Tablets
Penalty
Summary
The facility failed to ensure that two cartridges of morphine tablets were properly stored in the cubex machine after delivery by the pharmacy. During a medication storage room observation, two red containers with plastic locks, not labeled, were found inside the medication storage room. Each container had a cartridge containing four morphine extended-release 15 mg tablets. The Registered Nurse Supervisor (RNS) confirmed that the morphine tablets were not properly stored, which could lead to drug diversion. The facility's Delivery Reconciliation Form indicated that the morphine tablets were received on two separate occasions, but they were not stored in the cubex machine as required. Interviews with the RNS and the Director of Nursing (DON) revealed that it was the responsibility of the licensed nurses to store the morphine in the cubex machine upon receiving it from the pharmacy. The facility's policy and procedure for medication ordering and receiving from the pharmacy, as well as controlled substance storage, were not followed. These policies required that controlled substances be signed for, inspected, reconciled, and stored in a permanently affixed double lock compartment. The failure to adhere to these procedures resulted in the potential for drug diversion and theft of the controlled substances.
Failure to Communicate Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations in the Medication Regimen Review (MRR) were communicated to the physician for four residents, resulting in the administration of unnecessary medications. Resident 2 was on Ativan at a dose exceeding the daily threshold for anxiolytics, and the pharmacist recommended reducing the dose. However, this recommendation was not communicated to the physician, and the resident continued to receive the higher dose despite minimal episodes of anxiety. Similarly, Resident 56 was prescribed Metformin, and the pharmacist recommended taking it with food, but this recommendation was not followed up with the physician, and the resident continued to take the medication without the advised precaution. Resident 24 was prescribed metoclopramide, and the pharmacist recommended assessing the ongoing need for the medication due to the risk of tardive dyskinesia with long-term use. This recommendation was not communicated to the physician, and the resident continued to receive the medication without reassessment. Resident 1 was prescribed tamsulosin, and the pharmacist recommended clarifying the indication for its use, as it is typically used for stone expulsion in females. This recommendation was also not communicated to the physician, and the resident continued to receive the medication without clarification. Interviews with the Director of Nursing (DON) and Registered Nurse Supervisor (RNS) revealed that the facility did not have a consistent process for following up on the pharmacist's recommendations. The DON admitted that the MRR forms for February and March 2024 were blank, indicating that the recommendations were not followed up. The Pharmacist Consultant confirmed that he did not receive feedback from the facility regarding the implementation of his recommendations. The facility's policy and procedure on pharmacy services emphasized the importance of addressing unnecessary medications, but this was not adhered to in these cases.
Expired Medications and Improper Medication Administration
Penalty
Summary
The facility failed to ensure that seven over-the-counter medications were not expired in one of the two sampled medication storage rooms. During an observation and interview, it was found that multiple bottles of multivitamins, Vitamin B12, nasal decongestants, Aspirin, and Vitamin D were expired and stored in an open cabinet. The Registered Nurse (RNS 2) acknowledged that these medications should have been discarded and not left in the cabinet uncovered, as they could mistakenly be used to administer to residents. The interim Director of Nursing (DON) confirmed that expired medications are not effective and could affect residents' health. Additionally, the facility failed to ensure that a resident's medications were not left on the bedside table by an LVN. Resident 22, who had diagnoses including paraplegia, dementia, and heart failure, was observed with a medicine cup filled with medications on her bedside table. The LVN admitted to signing the medications as administered without waiting for the resident to take them, contrary to the facility's policy. Both the LVN and the DON acknowledged that medications should not be left unattended and should be administered in the presence of a licensed nurse to ensure they are taken by the resident.
Failure to Ensure Safe and Sanitary Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen. During an observation, it was found that banana puree, egg puree, lettuce, and eggs with use-by dates that had already passed were still present in the kitchen. An interview with a dietary aide revealed that cooks were responsible for labeling and dating food, while all kitchen staff were responsible for removing expired items. The facility's policy and procedure on food safety indicated that food should be stored to minimize contamination and bacterial growth, and expiration dates should be checked to ensure they are within acceptable parameters.
Failure to Assess Mental Capacity Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to assess the mental capacity of two residents, Resident 60 and Resident 45, before having them sign arbitration agreements. Resident 60, who had diagnoses including traumatic brain injury and cerebral infarction, was documented as unable to make his own medical decisions. Despite this, Resident 60 signed an arbitration agreement without the signature of an authorized agent or a witness. Resident 60's family member was unaware of the arbitration agreement and believed that Resident 60 could not understand its content. Similarly, Resident 45, who had diagnoses including Parkinson's disease and metabolic encephalopathy, was also documented as lacking the mental capacity to make decisions. Resident 45 signed an arbitration agreement without the signature of an authorized agent or a witness. The Admission Coordinator and her assistant, who were still in training, were unsure about the requirements for the arbitration agreement and did not ensure that the residents understood the agreement. Interviews with the Director of Nursing and the Administrator revealed that the facility's policy required that residents or their designated representatives be fully informed about the arbitration agreement and their right to refuse it. However, this policy was not followed, leading to the deficiency. The facility's policy also stated that the arbitration agreement should not be a condition for admission or continued care, and residents had the right to rescind the agreement within 30 days.
Infection Control Deficiencies in Dietary and PPE Practices
Penalty
Summary
The facility failed to observe proper infection control practices and procedures in two key areas. Firstly, dietary staff stored personal food items in the kitchen refrigerator, which had the potential to result in cross-contamination of resident food. During an observation, a dietary aide was found to have a personal cup with an undated and unlabeled thick brown substance in the refrigerator. Both the dietary aide and the registered dietician confirmed that staff were not supposed to keep personal food items in the refrigerator due to infection control policies. The facility's policy on kitchen sanitation and cleaning schedules emphasized maintaining a clean, sanitary, and safe kitchen environment. Secondly, the facility failed to ensure proper use of personal protective equipment (PPE) when providing care for a resident. An LVN was observed wearing an isolation gown improperly while performing a fingerstick to check the resident's blood sugar. The gown was untied at the front and back, covering only half of the body and touching the floor. The resident was on Enhanced Standard Precaution due to dialysis access, and the improper use of the gown had the potential to spread infection. Both the Director of Nursing and the Infection Preventionist Nurse confirmed that the gown should be tied at the back and front to completely cover the body, as per the facility's policy on donning PPE.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to ensure that five of 14 sampled residents were informed of their right to develop an advance directive. This deficiency was identified through interviews and record reviews, revealing that the residents or their responsible parties were not provided with information regarding advance directives upon admission or during their stay. The residents involved had various medical conditions and required different levels of assistance from the staff, but the facility did not fulfill its obligation to inform them about their rights to formulate advance directives. Resident 35, who was admitted with multiple fractures and hypertension, did not have the mental capacity to make decisions. The Social Services Director (SSD) confirmed that no information about advance directives was provided to Resident 35's responsible party. Similarly, Resident 24, who had COPD and an abdominal aortic aneurysm, was capable of making medical decisions but was not offered information on advance directives as per the facility's policy. Resident 5, with diagnoses including rheumatoid arthritis, schizoaffective disorder, and dementia, was alert and oriented but was not provided with advance directive information. The SSD mistakenly believed that offering a Durable Power of Attorney (DPOA) was sufficient. Resident 49, who had metabolic encephalopathy and end-stage renal disease, was also not given information about advance directives. The SSD only documented whether the resident had an advance directive without offering further information. Resident 1 and Resident 3, both with significant medical conditions, were similarly not informed about their rights to formulate advance directives, despite the facility's policy requiring such information to be provided upon admission and periodically thereafter.
Failure to Conduct Proper PASARR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that two residents, Resident 24 and Resident 5, had a Preadmission Screening and Resident Review (PASARR) assessment done when diagnosed with a mental illness prior to admission. Resident 24, who was diagnosed with schizophrenia, was admitted and readmitted to the facility without a proper PASARR Level II screening. The PASARR Level I screening incorrectly indicated that Resident 24 did not have a diagnosis of schizophrenia. This error was not caught by the facility staff, and as a result, Resident 24 did not receive the necessary PASARR Level II assessment for appropriate mental health support and services. Similarly, Resident 5, who was diagnosed with schizoaffective disorder, was admitted to the facility without a proper PASARR Level II screening. The PASARR Level I screening incorrectly indicated that Resident 5 did not have a diagnosis of schizophrenia. The Assistant Director of Nursing (ADON) acknowledged that both residents had mental disorders and that the PASARR screenings from the hospital were incorrect. The facility's policy and procedure indicated that the Level I Screening should always reflect the individual's current condition, which was not adhered to in these cases.
Inaccurate MDS Coding for Resident with Lower Extremity Impairments
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for one resident, leading to potential issues in care planning and service provision. Specifically, the MDS for Resident 24 was not correctly coded to reflect the resident's lower extremity impairments, including ankle contractures and footdrop. This discrepancy was identified during a review of the resident's records, which showed that the MDS indicated no impairment to the lower extremities on multiple dates, despite the resident's documented conditions. Interviews with the MDS nurse revealed that the MDS had been updated to reflect the resident's current condition only after the deficiency was identified. The facility's policy and procedure for MDS Standard of Practice, which mandates accurate coding and delivery of services, was not followed in this case. The failure to accurately assess and code the MDS had the potential to result in delayed or missed identification of joint range of motion changes, leading to inadequate care planning and provision of services for Resident 24.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that Resident 56 and/or their responsible party were informed in advance of the risks and benefits of psychoactive medications. Resident 56, who was admitted with diagnoses including unspecified dementia, depression, diabetes, and anxiety disorder, had moderately impaired cognitive skills and required partial or moderate assistance with daily activities. Despite this, the facility did not obtain informed consent for the use of Ativan and ABHR cream, both of which contain psychoactive components. The Ativan was ordered to be administered every 12 hours for anxiety, and the ABHR cream was to be used every four hours as needed for agitation or restlessness when the resident refused Ativan. The lack of informed consent was confirmed during interviews and record reviews with the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the consent was obtained only after the medications had already been administered. The Pharmacist Consultant also confirmed that these medications could affect the resident's behavior and should have required informed consent before administration. The facility's policy and procedure on 'Psychotropic Medication Management' dated 2/2017 indicated that informed consent for psychoactive medicines must be verified before use. However, this policy was not followed in the case of Resident 56. The Director of Nursing noted a discrepancy in the consent form, which was signed by a licensed nurse instead of a physician, and confirmed that the consent was obtained after the medications had already been administered. This failure to obtain informed consent before administering psychoactive medications violated the resident's right to make an informed decision regarding their treatment.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 60, who was admitted with diagnoses including traumatic brain injury, cerebral infarction, muscle weakness, history of falling, and acute respiratory distress syndrome. Resident 60 required maximal assistance for various activities and was unable to make his own medical decisions. Despite the care plan intervention indicating that the call light should be kept within reach, an observation revealed that the call light was placed on top of a nightstand behind a radio, making it inaccessible to the resident. Interviews with staff confirmed that the call light should always be within reach to ensure timely assistance and maintain the resident's dignity and self-worth. Resident 60 expressed feelings of helplessness and sadness due to the inability to reach the call light, which led to incidents of falls and attempts to get up unassisted to use the bathroom. The facility's policies on residents' rights, dignity, and call light accessibility were reviewed, all of which emphasized the importance of keeping the call light within reach to accommodate residents' needs and ensure timely responses. Despite these policies, the facility failed to adhere to them, resulting in a deficiency that impacted Resident 60's self-determination, dignity, and ability to receive necessary care promptly.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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