Chino Valley Health Care Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 2351 S Towne Avenue, Pomona, California 91766
- CMS Provider Number
- 055126
- Inspections on file
- 40
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Chino Valley Health Care Cente during CMS and state inspections, most recent first.
Surveyors found that bathroom call light pull cords in two shared bathrooms were too short to be reached from the floor, contrary to facility policy requiring residents to be able to call staff from toileting/bathing areas and from the floor. Ten residents using these bathrooms had significant medical conditions, including metabolic encephalopathy, schizophrenia, acute respiratory failure, Alzheimer’s disease, heart failure, gait and coordination problems, and many had moderately to severely impaired cognition and required assistance with ADLs such as bathing and toileting. During an interview, a resident reported falling on the bathroom floor and being unable to reach the pull cord for help. CNAs and the Maintenance Assistant acknowledged that the cords were too short to be reached from the floor and recognized this as a safety issue when a resident falls and cannot call for assistance.
The facility failed to timely report an allegation of resident-on-resident abuse as required by its abuse reporting policy. A cognitively impaired resident with anxiety, metabolic encephalopathy, and dementia reported that a roommate grabbed and choked their neck. Another cognitively impaired resident with similar diagnoses had documented increased confusion and verbal aggression and was identified by staff and a family member as the alleged aggressor. Multiple staff, including an RN and an LVN, received the choking allegation directly from the resident and from a family member, and the DON was also informed, but the allegation was not reported to the administrator, the state agency, the Ombudsman, or local law enforcement within the required two-hour timeframe.
Surveyors observed a black, mold-like substance on the shower wall tile beneath the shower handle and above the grab bar in the only shower room, indicating the area was not maintained in a clean and sanitary condition. During interviews, a maintenance assistant confirmed the substance was mold and a housekeeping supervisor acknowledged it as a health hazard that should not be present. This condition conflicted with facility policies requiring a safe, clean, sanitary, and hazard-free environment.
The facility did not consistently monitor or document refrigerator, freezer, and food temperatures as required, resulting in food items such as milk and ice cream being stored and served at unsafe temperatures. Staff failed to check and log temperatures before serving meals, and food items like gravy and fish were served without proper temperature verification. These actions were not in accordance with facility policy and were confirmed by staff interviews and record reviews.
Staff did not fully close privacy curtains during perineal care and incontinence brief changes for two residents with cognitive and physical impairments, resulting in the residents being visible to anyone entering the room. Facility policy and staff interviews confirmed that privacy should have been maintained during these care activities.
A resident with diabetes and cognitive impairment was discharged without a required skin check by an LVN, despite facility policy and care plan directives. The discharge documentation was incomplete, and the omission was only discovered when the resident's family and a home health nurse observed a widespread rash and bleeding scabs after discharge.
A resident with dementia and a history of falls did not receive a STAT x-ray for a swollen hand in a timely manner after the radiology technician was unable to complete the procedure and failed to notify staff, resulting in a delay in care due to lack of communication and follow-up.
The facility did not maintain the fire alarm system in accordance with regulatory requirements, as the fire alarm circuit disconnect was not easily identifiable or properly indicated. During an inspection, the Maintenance Supervisor was unable to locate the disconnect, despite facility policies requiring clear identification and maintenance of the fire alarm system.
The facility did not perform or document required monthly inspections of a portable fire extinguisher in the main electrical panel room, as evidenced by missing inspection dates and initials on the tag for a two-month period, contrary to NFPA 10 standards and facility policy.
Surveyors found that a resident room door was blocked from closing by a bed, and a corridor door in the Medical Records Office was improperly held open with a kick down stopper instead of an approved automatic release device. Maintenance staff confirmed these practices were not compliant with facility policy and regulatory requirements.
Surveyors found that full and empty oxygen cylinders were not properly separated in the oxygen storage room, with some full cylinders stored under the 'EMPTY' sign and some empty cylinders stored under the 'FULL' sign, contrary to facility policy and NFPA 99 requirements.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a secured unit after a CNA failed to ensure the exit door was closed and locked, and the main entrance was left unsecured and unmonitored. Required 15-minute visual checks were not completed or documented, and no staff were present in the lobby to prevent the resident from leaving the building.
Two residents did not receive adequate privacy during personal care and treatment procedures. In one case, a resident dependent on staff for all activities of daily living was left visible to others during incontinence care because the privacy curtain was not fully closed. In another case, a newly admitted resident was exposed during an assessment when the privacy curtain was left open, making the resident visible from the doorway. Staff acknowledged that privacy measures were not properly followed.
Staff failed to recognize and report an incident where a resident with cognitive impairment and behavioral issues verbally abused another resident, using racial slurs and profanity. Although one CNA attempted to de-escalate the situation, neither CNA present reported the incident to supervisory staff as required by facility policy. The Administrator and DON were not made aware of the event, resulting in a lack of timely investigation and intervention.
Surveyors observed expired food items stored in the kitchen and improper ice handling by a dietary aide, who touched ice and milk cups with bare hands after handling the trash can without washing hands. These actions were not in accordance with facility policies or FDA Food Code requirements.
Four gnats were observed below the kitchen sink, and the Dietary Manager confirmed their presence and the potential for food particles to attract them. The facility's pest control policy requires maintaining a pest-free environment, but the presence of gnats indicated a failure to meet this standard.
A resident with a documented diagnosis of schizophrenia did not have this condition coded in the MDS, despite its presence in the medical record. The omission was confirmed by the MDSC and DON, who both acknowledged the importance of accurate coding for care planning and assessment accuracy.
A resident with dysphagia and cognitive impairment experienced repeated coughing episodes during meals and therapy, indicating aspiration risk. Despite a care plan requiring monitoring and intervention, staff continued feeding and did not notify nursing or seek speech therapy assessment as required by facility policy.
A resident with a language barrier and multiple medical conditions did not have a communication board at bedside as required by their care plan. Staff and the DON confirmed the absence of this essential communication aid, despite facility policy and documented interventions calling for its use to support the resident's ability to express needs.
A resident under Enhanced Barrier Precautions for a colostomy received personal care from a CNA who failed to wear a gown as required by facility policy. The CNA provided direct physical care without appropriate PPE, despite clear signage and established protocols for EBP, which mandate gown and glove use during high-contact activities to prevent the spread of MDROs.
A resident with a history of behavioral issues verbally abused another resident by yelling profanities and a racial slur, causing visible emotional distress. Staff confirmed the incident occurred during a high-risk period and that the abusive resident had previously exhibited similar behavior. Facility policy requires protection from all forms of abuse, but the incident was not prevented.
A resident with dementia and anxiety was subjected to verbal abuse, including a racial slur and profanity, by another resident with cognitive impairment. The incident, which left the abused resident visibly distressed, was not reported to the Administrator or DON within the required two-hour window, contrary to facility policy. Staff admitted to not fully disclosing the details of the event, resulting in a delay in investigation and protective actions.
A review of room sizes found that 27 rooms did not meet the required 80 square feet per resident for multiple occupancy, with several rooms housing two or three residents in less space than mandated. Despite a resident and an LVN reporting no issues with comfort or care delivery, the deficiency was based on measured room dimensions and occupancy levels.
A resident with cognitive impairment and multiple diagnoses was allegedly abused by a CNA, as witnessed and reported by another CNA to nursing staff and the DON. Despite receiving a written statement detailing the abuse, the facility did not report the allegation to the Department, Ombudsman, or law enforcement within the required two-hour window, contrary to facility policy.
Two staff members, a CNA and an RN, did not demonstrate knowledge of the facility's abuse reporting procedures, including the identity of the Abuse Coordinator and the requirement to report allegations to the Department of Public Health, Ombudsman, and law enforcement within two hours. The RN also incorrectly believed that abuse should only be reported after internal investigation and confirmation, contrary to facility policy.
An Office Assistant in a LTC facility continued to perform duties requiring a nursing license after surrendering their LVN license. The OA administered medications and monitored residents, violating facility policy and posing a safety risk. The facility's system failed to alert staff of the license expiration, leading to unlicensed care provision.
Two residents in an LTC facility were not properly informed about their right to formulate an advance directive (AD). One resident, who spoke Arabic and had impaired cognitive skills, received an AD form in English, while another resident, lacking decision-making capacity, signed an AD form without consulting their primary decision maker. The facility's policy required that incapacitated residents' legal representatives be informed, which was not followed.
The facility failed to accurately complete the MDS assessments for two residents, omitting active diagnoses of schizophrenia, Parkinson's disease, and bipolar disorder. The MDSC acknowledged the errors, which were contrary to the facility's policy and CMS guidelines requiring all active diagnoses to be included in the MDS.
A resident with schizophrenia was prescribed Seroquel, and the facility failed to monitor and document side effects, specifically Tardive Dyskinesia (TD), as required by their policy. Despite observations of tongue thrusting, a sign of TD, staff did not record this in the Medication Administration Record (MAR). The Director of Nursing confirmed the importance of documenting side effects for proper medication management.
The facility failed to follow proper food storage practices in Kitchen 1 by not labeling or dating food items, as observed during a survey. An undated can of oil spray was found without a cap, and five unlabeled packages of frozen waffles were in the freezer. The Dietary Manager acknowledged the oversight, which violated the facility's policy requiring labeling and dating of food items to ensure safety and quality.
The facility failed to implement its policy for labeling and storing food brought in by family and visitors. Staff were unclear about responsibilities for checking and discarding food in the refrigerator, leading to inconsistent practices. A jar of instant coffee was found without a use-by date, and conflicting information was provided by staff and management regarding food handling procedures.
A resident with dementia and a G-tube was not provided adequate privacy during medication administration, resulting in exposure of their legs and diaper. The LVN did not fully draw the drapes around the bed, contrary to the facility's policy on maintaining resident dignity and privacy.
A resident's care plans were not updated to reflect the removal of bilateral floor mats, despite a decision made in an IDT meeting to remove them due to tripping risks. The resident, who was at risk for falls due to blindness and unsteadiness, had care plans that still included the mats as an intervention. The facility's policy required updates to care plans with significant changes, which was not followed.
A facility failed to involve a resident with schizophrenia and their family in the discharge planning process. The resident, who had moderately impaired cognitive skills and required assistance with daily activities, was discharged without proper involvement or documentation of the family's participation in the planning. The Social Service Representative confirmed that the family was notified of the discharge plan on the day of discharge, contrary to the facility's policy requiring earlier involvement.
A facility failed to ensure a registered nurse had the necessary competencies to communicate with a resident who spoke Arabic, leading to a deficiency in care. The resident, who required assistance for daily activities and preferred to communicate in Arabic, had a care plan that included using communication boards and Arabic-speaking staff. However, the nurse did not use the communication book as per the care plan, resulting in an inability to understand and meet the resident's needs.
A resident with multiple diagnoses, including neuropathy and anxiety disorder, did not receive their prescribed Tramadol for pain management as ordered. An LVN held the medication without notifying the physician, despite the absence of parameters to do so. The facility's policy required medications to be administered as prescribed, which was not followed, leading to a deficiency.
The facility did not meet the required 80 square feet per resident in 27 out of 37 rooms, affecting the ability to provide adequate care and accommodate necessary furniture. Despite a waiver request indicating no congestion, room sizes were insufficient. Interviews confirmed residents' preference to stay, but space requirements were not met.
Inaccessible Bathroom Call Light Cords for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s resident call system related to bathroom and bathing areas. The facility’s policy titled “Call System, Residents” states that each resident must be provided with a means to call staff directly for assistance from toileting/bathing facilities and from the floor, and that the resident call system remains functional at all times. However, during observations in two shared bathrooms, the red pull cords for the call lights were found to be too short to be reached from the floor, contrary to the facility’s policy. The deficiency involved ten sampled residents who used these bathrooms. These residents had multiple medical diagnoses and varying levels of cognitive impairment and functional dependence. For example, one resident with metabolic encephalopathy, schizophrenia, and moderately impaired cognition required substantial/maximal assistance with bathing, personal hygiene, toilet use, and lower body dressing. Other residents had conditions such as acute respiratory failure with hypoxia, major depressive disorder, generalized anxiety disorder, history of falls, unsteadiness on feet, difficulty in walking, Alzheimer’s disease, metabolic encephalopathy, heart failure, and cognitive communication deficits, with many having moderately or severely impaired cognition. During an interview and observation in one resident’s room, the resident reported having fallen on the bathroom floor and being unable to reach the red pull cord to call for help. Subsequent observations in the shared bathrooms confirmed that the red pull cords did not reach the floor. Certified Nursing Assistants acknowledged during concurrent observations and interviews that the pull cords were too short and could not be reached from the floor by a resident in an emergency, and described this as a safety issue when a resident falls and cannot call for help. The Maintenance Assistant also acknowledged that all red pull cords in the bathrooms were too short in length for residents to reach from the floor.
Failure to Timely Report Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving Resident 15, as required by its abuse reporting policy. Resident 15 had diagnoses including anxiety disorder, metabolic encephalopathy, and dementia, and was documented as lacking capacity to understand and make decisions, with moderately impaired cognitive skills and a need for partial to moderate assistance with ADLs. On a Change of Condition form dated 1/22/2026, Resident 15 stated during a nursing interview that their roommate had grabbed their neck the previous week. Resident 17, who was the roommate, also had anxiety disorder and metabolic encephalopathy, lacked capacity to understand and make decisions, and had moderately impaired cognitive skills with a need for partial to moderate assistance with ADLs. On 1/15/2026, Resident 17 was noted to have increased confusion and verbal aggression with staff, was kept at the nurses’ station for close supervision, and was prescribed PRN lorazepam for verbal aggression. Social service notes indicated that Resident 17 was moved to a different room and later discharged to a general acute hospital for behavioral evaluation. On or about 1/15/2026, RN 1 was informed by an LVN and a CNA that Resident 17 had touched Resident 15 on the neck; RN 1 assessed Resident 15 and found no redness or changes and informed the DON, who started an investigation. On 1/16/2026, Family Member 1 reported to RN 3 by phone that Resident 15 said Resident 17 had choked them; RN 3 then interviewed Resident 15, who repeated the allegation that the roommate choked them on the neck. Resident 15 also told LVN 6 that they had been choked by Resident 17. RN 3 acknowledged not reporting this allegation to the administrator, the Department, the Ombudsman, or local law enforcement, and LVN 6 acknowledged not reporting the allegation to the administrator. Family Member 1 reported the choking allegation to the DON, and the DON later stated they did not report the allegation to the Department, the Ombudsman, or law enforcement. The administrator stated they did not receive an allegation of abuse report from staff on 1/16/2026. The facility’s policy required that suspicion of abuse be reported immediately to the administrator and to the Department, Ombudsman, and local law enforcement within two hours of an allegation, which did not occur in this case.
Failure to Maintain Clean and Sanitary Shower Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe and sanitary shower environment in the only shower room. During an observation in one of the bathrooms, which was large enough to accommodate a shower across from the toilet area, a black substance approximately two tiles (about eight inches) in length was observed on the shower wall tile below the shower handle and above the grab bar. This condition was present in 1 of 1 shower rooms in the facility and was noted as having the potential to affect all residents who used that shower. During concurrent observations and interviews, the Maintenance Assistant stated that the black substance on the shower tiles was mold and acknowledged it should be cleaned right away. In a separate concurrent observation and interview, the Housekeeping Supervisor also identified the black substance on the shower tile and stated it would be cleaned immediately because it was a health hazard to residents who use the shower. Review of the facility’s “Homelike Environment” policy indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment. Review of the “Maintenance Service” policy indicated the maintenance department is responsible for maintaining the building in good repair and free from hazards at all times. The observed mold-like substance on the shower tile demonstrated a failure to follow these policies.
Failure to Maintain Safe Food Handling and Temperature Monitoring
Penalty
Summary
The facility failed to maintain safe food handling practices as required by its own policies and procedures, specifically regarding the monitoring and documentation of refrigerator and freezer temperatures, as well as the temperatures of food items served to residents. Observations and record reviews revealed that the temperatures of two freezers and two refrigerators were not checked or logged for a period of over two weeks. When checked, freezer 2 was found to be at 10 degrees F, and fridge 1 was at 43 degrees F, both outside the safe temperature ranges specified in facility policy. Additionally, the temperature of milk stored in fridge 1 was measured at 45 degrees F, and this milk was served to 72 residents. Six residents were served ice cream from freezer 2 during this period. Staff interviews confirmed a lack of knowledge regarding required temperature ranges and inconsistent practices in monitoring and recording temperatures. Further deficiencies were observed in the process of serving food during meal tray lines. The facility failed to consistently check and log the temperatures of hot and cold food items before serving breakfast, lunch, and dinner on multiple occasions. Specifically, the temperature of gravy, milk, and fish was not checked before being served to residents. Gravy was observed being kept on a counter instead of in the steam table, and additional gravy prepared during meal service was not checked for temperature before serving. Staff interviews indicated that there was confusion about where to record certain food temperatures and that the process for checking and documenting these temperatures was not consistently followed. Review of the facility's policies and procedures confirmed that all hot and cold foods were required to be checked and recorded prior to every meal service, and that refrigerators and freezers should be maintained at or below specified temperatures. Staff interviews, including those with the Dietary Service Supervisor, Registered Dietician Consultant, and Director of Nursing, acknowledged the importance of these practices and confirmed that the observed failures were not in compliance with facility policy. The lack of consistent temperature monitoring and documentation for both food storage and meal service directly led to the deficiency.
Failure to Ensure Privacy During Perineal Care and Incontinence Brief Changes
Penalty
Summary
Staff failed to provide adequate privacy during perineal care and incontinence brief changes for two residents. In both cases, certified nursing assistants closed the privacy curtain around the residents' beds but left a visible gap of 2 to 3 feet, making the residents visible to anyone entering the room. One resident, admitted with hypertension and diabetes, required moderate to maximal assistance with personal care and was exposed during perineal care and a diaper change. The other resident, diagnosed with Alzheimer's disease and experiencing memory problems, also required significant assistance and was similarly exposed during perineal care due to the curtain not being fully closed. Interviews and policy review confirmed that facility procedures require staff to fully close privacy curtains during personal care to maintain resident dignity and privacy. The Director of Staff Development acknowledged that privacy was not maintained as required, and the facility's policy emphasized the importance of protecting bodily privacy during care activities. These observations and interviews demonstrate that staff did not follow established protocols to ensure resident privacy during intimate care tasks.
Failure to Complete Required Skin Assessment Prior to Discharge
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to perform a required skin check on a resident prior to discharge. The resident, who had a history of type 2 diabetes mellitus and major depressive disorder, was moderately impaired in cognitive skills and required assistance with several activities of daily living. The resident's care plan specifically identified a risk for skin breakdown and required daily skin assessments and weekly body checks. On the day of discharge, the post-discharge plan of care for the resident was left incomplete, with the section for skin condition assessment left blank. The LVN signed the discharge plan of care but did not conduct the necessary skin check. This omission was contrary to both the facility's policy and the statements of other nursing staff, who confirmed that a skin check should be completed and documented prior to discharge to determine if treatment or family education was needed. After discharge, the resident's family member discovered the resident had bleeding scabs covering the body and was unaware of any skin issues prior to taking the resident home. A home health nurse assessed the resident the following day and observed a rash all over the resident's body, with the resident complaining of itching. Facility policies required assessment and documentation of skin integrity, notification of the physician, and communication with the family in cases of skin alterations, none of which were completed prior to discharge.
Plan Of Correction
F0684-Quality of Care Corrective Immediate Action: LVN1 was immediately in-serviced by the Administrator on 07-09-25 ensuring that discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge, emphasizing the resident's skin assessment. Others Affected: On 07-09-25, the Licensed Treatment Nurses did a body check on all residents and no new rashes were identified. Preventative Measures: On 07-08-25 and 7-10-25, the Quality Assurance and Staff Developer conducted an in-service training for the Licensed Nurses on focusing on the facility's policy and procedure on Discharge Summary Planning with emphasis on the following: 1. Proper completion of discharge summary records. 2. The critical importance of assessing and documenting the resident's skin condition prior to discharge, whether the resident is leaving for home, a hospital, or a lower level of care. Monitoring Performance: The Medical Records Director will review all discharge records the day after a resident has been discharged whether to home, a hospital, or a lower level. The review ensures that licensed nurses are complying with facility policies and procedures, particularly the completion of the required skin assessments. If discrepancies or issues are found during the discharge record audit, the Medical Records Director will notify the DON. The DON will then provide counseling and re-education to the licensed nurse involved, ensuring the importance of completing skin assessments and adhering to procedures is emphasized. The result of all discharge record audits will be reported to the QA Committee Monthly by the Director of Nursing for further review and follow-up recommendations, for a period of three months. Corrective Action will be accomplished on 7/10/25.
Failure to Timely Implement STAT X-ray Order Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a STAT x-ray order for a resident's left hand was implemented in a timely manner. The resident, who had diagnoses including dementia, a history of falls, and osteoporosis, was noted to have swelling in the left hand. The physician ordered an immediate x-ray, but the procedure was not completed as ordered. The radiology technician (RT) attempted to perform the x-ray but reported that the resident was combative and uncooperative. However, the RT did not inform facility staff that the x-ray could not be completed. The registered nurse (RN) who placed the order assisted the RT but was not told that the x-ray was unsuccessful. The RN attempted to follow up on the results later but was unable to reach the radiology company and was off duty the following day. It was only two days later that the facility became aware that the x-ray had not been performed. Facility policy required that diagnostic services, including STAT x-rays, be available at all times and that orders be promptly carried out as instructed by the physician. The failure to communicate the unsuccessful attempt and to follow up within the expected timeframe resulted in the resident not receiving the ordered diagnostic service in a timely manner.
Plan Of Correction
Immediate Action: Resident 1 was discharged to the hospital on 6/9/25. On 6/9/25, the D.O.N provided 1:1 inservice training and re-education to R.N. 1 with emphasis on availability and timeliness of clinical laboratory and radiology services to meet the needs of the residents provided by the facility. On 6/9/25, the facility notified the Diagnostic lab account executive of the importance of communication with the facility Licensed Staff if a Radiology Technician is unable to get an x-ray. On 6/10/25, an x-ray of the left wrist was performed at the hospital indicating no acute osseous or soft tissue abnormality; osteopenia. **Identification Of Others at Risk:** On 6/9/25, the DON reviewed all current lab/radiology orders to ensure timeliness of services to meet the needs of residents. No other residents were identified with the same deficient practice. **Process to Prevent Recurrence:** On 6/9/25 and 6/24/25, the DON provided inservices to Licensed Nurses (RN, LVN) to reinforce the facility's policy and procedure of availability of diagnostic, clinical laboratory, and radiology services to meet the needs of the residents provided by the facility. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. **Monitoring Process:** The DON will conduct random weekly audits on 5 residents for 4 weeks and then randomly for 3 months to ensure orders for clinical laboratory and radiology services are met in a quality and timely manner. The DON will report the findings to the QAPI committee monthly for further recommendations and resolutions for 3 months. Completion date: 6/24/25. **Identification Of Others at Risk:** On 6/9/25, the DON reviewed all current lab/radiology orders to ensure timeliness of services to meet the needs of residents. No other residents were identified with the same deficient practice. **Process to Prevent Recurrence:** On 6/9/25 and 6/24/25, the DON provided inservices to Licensed Nurses (RN, LVN) to reinforce the facility's policy and procedure of availability of diagnostic, clinical laboratory, and radiology services to meet the needs of the residents provided by the facility. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. **Monitoring Process:** The DON will conduct random weekly audits on 5 residents for 4 weeks and then randomly for 3 months to ensure orders for clinical laboratory and radiology services are met in a quality and timely manner. The DON will report the findings to the QAPI committee monthly for further recommendations and resolutions for 3 months. Completion date: 6/24/25.
Failure to Clearly Identify Fire Alarm System Disconnect
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During an observation and interview at the fire alarm electrical panel, the Maintenance Supervisor was unable to identify the fire alarm circuit disconnect. The fire alarm panel disconnect was not easily identifiable nor properly indicated, and the Maintenance Supervisor acknowledged that it should be clearly indicated on the electrical panel. A review of the facility's policies and procedures showed that maintenance personnel are responsible for maintaining the building in compliance with applicable laws and regulations, including keeping the fire alarm system in good working order. The facility's policy also states that an operable fire alarm system must be maintained at all times, with emergency power available in case of power loss. However, the inability to identify the fire alarm disconnect indicated a failure to comply with these requirements, affecting all smoke compartments and the safety of all residents, staff, and visitors.
Plan Of Correction
Immediate Corrective Action: On 5/20/25 the Maintenance Supervisor consulted with the Corp. Electrician, and he was able to identify and label all the fire alarm panel disconnect. Identify Other Residents: Corporate Electrician made rounds with the MS and checked all fire alarm electrical panels to ensure that all the fire alarm panel disconnects are identified. No other fire panels had this deficient practice. Measures into place: On 5/22/25 the Administrator serviced the MS and Maintenance assistant, ensuring that all fire alarm panels are labeled indicating the fire alarm circuit disconnect is easily identifiable. Monitoring: Administrator and DSD will randomly check the fire panels on a monthly basis for 3 months to ensure that the fire alarm panel disconnect is identifiable. Findings will be presented to the QAPI meeting quarterly for further review and/or actions if necessary. Completed date: 5/22/25
Failure to Perform and Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to ensure that the portable fire extinguisher (PFE) located in the main electrical panel room was inspected and maintained monthly as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation and interview, it was found that the PFE inspection tag was missing monthly inspection dates and the initials of the person performing the inspection for the period between 2/25 and 4/25. There was no documentation indicating that the PFE had been inspected during this time frame. The facility's policy and procedure titled 'Maintenance Service' required maintenance personnel to maintain the building in compliance with applicable laws and regulations, including regular inspection of safety equipment.
Plan Of Correction
Corrective Action: On 5/5/25 the Maintenance Supervisor immediately dated and initialed the monthly PFE tag. Identify Other Residents: No other portable fire extinguisher had this deficient practice. Measures into place: On 5/6/25 the Administrator serviced the MS and Maintenance Assistant ensuring that all PFE tags are monthly inspected with a date and initials of person doing the inspection. Monitoring: Administrator and Director of Staff Development will monitor monthly PFE tags to ensure that all are being inspected with dates and initials of the person doing inspection x 3 months. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completed date: 5/22/25
Corridor Door Obstructions and Improper Hold-Open Device
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in compliance with NFPA 101 requirements in one of eight smoke compartments. Specifically, in Resident Room 139, a bed was positioned in such a way that it impeded the closure of the corridor door, preventing it from closing and positively latching as required. The maintenance staff member present had to move the bed to allow the door to close properly, acknowledging that the door closure pathway should remain clear. Additionally, in the Medical Records Office, the corridor door was found to be held open by a kick down stopper, which is not an approved automatic door release device. The maintenance staff member confirmed that the use of such a device is not permitted and that an approved release device should be used instead. Review of facility policies indicated that hazardous areas and equipment should be identified and addressed to ensure safety, and that maintenance personnel are responsible for keeping the building in compliance with regulations and free from hazards.
Plan Of Correction
Immediate Correction Action: On 5/6/25 the MS switched out the bed that was impeding the doorway closure pathway with a smaller frame bed. It no longer impedes the doorway closure pathway. On 5/5/25 the MS immediately removed the door stopper in order for _the corridor door to remain closed. Identifying Other Residents: No other rooms had this deficient practice. Measures into place: On 5/20/25 the Administrator in serviced MS and Medical Records Director on not to impede the doorway closure pathway with a door stopper or any furniture. Monitoring: During daily rounds the MS and MS assistant will visually monitor that all resident room doors will be able to and positively latch x 3 months. Also monitoring daily x 3 months that no office door be propped open with a kick down stopper. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completion date: 5/20/25 K 363
Improper Storage of Oxygen Cylinders
Penalty
Summary
Surveyors observed that the facility failed to maintain proper separation between full and empty pressurized oxygen cylinders in accordance with NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.6.5.2. During an inspection of the Oxygen Storage Room, one full oxygen cylinder was found stored with empty cylinders under the 'EMPTY' indicator sign, and two empty cylinders were found stored with full cylinders under the 'FULL' indicator sign. The staff member present confirmed that full and empty oxygen cylinders should be stored separately. A review of the facility's policies and procedures revealed that hazardous areas, devices, and equipment are to be identified and addressed to ensure resident safety and compliance with regulations. The maintenance policy also requires the building to be maintained in compliance with current laws and free from hazards. Despite these policies, the improper storage of oxygen cylinders was observed, indicating a failure to follow established procedures for hazardous materials management.
Plan Of Correction
K 923 Immediate Corrective Action: The MS immediately removed the full oxygen cylinder that was stored in the "EMPTY" indicator side, to the "FULL" indicator side. The two empty oxygen cylinders that were stored in the "FULL" indicator side were moved to the "EMPTY" indicator side. Identifying of Others: All full and empty oxygen cylinders were stored in their appropriate indicated sign. No other oxygen cylinders had this deficient practice. Measures in place: On 5/22/25 the DSD in serviced the licensed staff on the storing of oxygen. The "FULL" indicator of oxygen needs to be stored on the right side as it indicates and the "EMPTY" needs to be stored on the left side as indicated. Monitoring: The MS and the MS assistant, when doing their daily rounds x 3 months, will ensure the oxygen storage room is being maintained with the full and empty oxygen cylinders separated and as indicated. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completion date: 5/22/25
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, who was assessed as being at risk for elopement, was able to leave the facility's secured unit unsupervised. The resident's care plan required staff to conduct visual checks every 15 minutes and to follow specific protocols to prevent elopement. On the day of the incident, a CNA exited the secured unit without ensuring the door was closed and locked behind them, and did not confirm that no residents were following. Surveillance footage showed the resident holding the door open after the CNA exited, then proceeding through the lobby and out the facility's main entrance, which was neither locked nor alarmed at the time. No staff were present in the lobby to monitor the exit. The resident's whereabouts were not documented in the 15-minute monitoring log for several hours, and the assigned CNA later stated that it was unrealistic to monitor and document all assigned residents every 15 minutes due to workload. The facility's receptionist was not present at the front desk during the time of the elopement, and the main entrance door was not secured or alarmed, allowing the resident to exit undetected. The resident was not discovered missing until later in the evening, after which a search was initiated. The resident had a history of exit-seeking behaviors, including wandering, expressing a desire to leave, and packing belongings. Medical records indicated diagnoses such as paranoid schizophrenia, anxiety disorder, epilepsy, and diabetes mellitus, and the resident required regular medication and supervision. The facility's policies required regular checks and supervision for residents at risk of wandering or elopement, but these protocols were not followed, resulting in the resident's unsupervised exit from the secured unit and the facility.
Plan Of Correction
F-tag: 689 Free of Accident Hazards/Supervision/Devices Immediate corrective action: On 4/28/2025, Resident 3 was found by the local police and dropped off at Clinic 1 at "approximately" 6:30 am. The DON notified Resident 3's Primary Physician / Medical Doctor (MD1) and instructed Resident 3 to come back to the facility. On 4/28/2025, two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility at 4:35 pm. On 4/28/2025, RNS 1 conducted a comprehensive assessment of Resident 3 upon return to the facility with vital signs stable. No signs and symptoms of major injury or negative outcome were noted. On 4/28/2025, Primary MD ordered to transfer Resident 3 to a General Acute Hospital for further evaluation and transferred on 4/29/2025. Resident's 3 Conservator was notified and made aware. On 4/24/2025, the DON / DSD provided a verbal 1:1 in-service to CNA 6 regarding the elopement policy. Emphasized to ensure the secured unit door is closed and locked when getting out from the secured unit. On 05/02/25, CNA 6 is no longer in the facility. On 05/02/25, the Administrator provided 1:1 in-service to Receptionist 1 on policy regarding safety and supervision of residents in the secured unit. To ensure the front door in the front lobby is locked and the alarm is set to enhance resident safety. From 05/02/25 to 05/10/25, the DON / DSD provided 1:1 in-service to CNA 7 on the policy of elopement and emphasized following the facility's visual check every 15 minutes to monitor residents' whereabouts and safety. On 4/28/25, the DON posted a visual alert sign at the secured unit exit areas, reminding staff to ensure doors are closed before walking away as part of ongoing safety education. On 4/28/2025, the facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility. On 4/29/2025, the facility installed a new door keypad for safety in the front lobby. During 4/28/2025 - 4/29/2025, the DON/DSD provided in-services to staff members regarding the elopement policy covering the following topics: a. Supervise and redirect residents who are close to the exits to mitigate the risk of elopement. b. While entering or exiting the secured unit, staff members must check/confirm that no resident is exiting before walking away from the door. c. The importance of conducting rounds every 15 minutes and as needed for adequate supervision. d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision. The DON conducted rounds on 05/02/25 and 05/20/25 in the secured unit to identify any elopement risk residents. No other residents were affected by this deficient practice. Process to prevent recurrence: Effective 4/29/2025, the DON / DSD will repeat the in-service and reinforce the policy of elopement to nursing staff (CNA, LVN, RN) every month for 3 months. Monitoring process: The DON / DSD will conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the findings in the monitoring log. During the monthly QAPI, the DON will report any deficient findings for follow-up resolution for 3 months. Completion date: 5/20/25
Removal Plan
- The DON provided a verbal one-on-one in-service via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction.
- The Registered Nurse Supervisor contacted nearby hospitals and the local police department to locate Resident 3. The ADM contacted private investigators who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.
- The local police found Resident 3 and dropped Resident 3 off at Clinic 1. The DON communicated with Clinic 1's Nurse who confirmed Resident 3 was currently in Clinic 1 with stable vital signs. The DON notified Resident 3's Primary Physician/Medical Doctor who instructed to transfer Resident 3 back to the facility.
- Two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility.
- The Registered Nurse Supervisor conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's vital signs were stable, no signs or symptoms of major injury were noted. The Medical Doctor ordered to transfer Resident 3 to a General Acute Care Hospital for further evaluation. Facility staff notified Resident 3's conservator regarding Resident 3 was found.
- The DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.
- The facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.
- The DON and the Director of Staff Development provided in-services to staff members regarding the elopement policy, covering the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- Elopement Trainings: RNs, LVNs, CNAs, department managers and assistants, activity assistants, housekeeping and laundry employees, and dietary service staff received the in-service training for elopement. Staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Staff not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.
- The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan.
- The facility also installed a new door keypad for safety in the front lobby.
- There were residents residing in the secured unit.
- The ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.
- The maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.
- The DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.
- The facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.
- The DON, the DSD or the Registered Nurse Supervisor would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log.
- The ADM and the DON developed a Quality Assurance and Performance Improvement for elopement to address the deficient practice in the IJ findings.
Failure to Ensure Privacy During Personal Care and Treatment Procedures
Penalty
Summary
The facility failed to provide adequate privacy during personal care and treatment procedures for two residents. In the first instance, a resident with Alzheimer's disease and dementia, who was dependent on staff for all activities of daily living and rarely able to communicate, was transferred to bed by two CNAs. Although the privacy curtain was closed from both sides, it was not fully extended to the front of the bed, leaving the resident visible to anyone entering the room or restroom. The CNAs proceeded to change the resident's incontinence pad and reposition the resident while the curtain remained partially open. One CNA acknowledged that the curtain should have been completely closed to protect the resident's privacy. In the second instance, a newly admitted resident with cardiomegaly and chronic respiratory failure was observed during an assessment by a Treatment Nurse. The resident's room door was closed, but the privacy curtain was left open, and the resident was uncovered, with their gown pushed up and incontinence brief exposed. The resident was visible from the doorway. The Treatment Nurse admitted to not closing the privacy curtain during the assessment, despite the resident being exposed. The facility's policy requires staff to promote and protect resident privacy during personal care and treatment procedures.
Plan Of Correction
F-tag 550 Resident Rights/Exercise of Rights Immediate corrective action: On 5/2/25, DON provided 1:1 retraining and reeducation to CNA 8, CNA 14, and Tx Nurse regarding Resident's rights/Privacy and Dignity policy and procedure, emphasizing the importance of providing privacy during personal care and treatment by completely closing the privacy curtain and not visible to any staff or Resident who enters the room to promote, maintain, and protect resident's privacy. Resident 45 and Resident 202 were visited by Social Service on 5/2/25; there were no signs of emotional distress noted. Identification of others at risk: DON/DSD made random rounds on 05/02/25 and 05/20/25 to ensure the residents are provided with privacy during personal care and treatment. No other residents were identified with this same deficient practice. Process to prevent recurrences: In-services by the DON/DSD were provided on 05/02/25 and 05/20/25 to nursing staff to reinforce the policy of resident's rights, privacy, and dignity. Monitoring process: The DON/DSD will conduct weekly random checks for 3 months to ensure nursing staff are providing privacy during personal care and treatment. The Administrator will conduct monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Completion date: 5/20/2025 F 550
Failure to Ensure Staff Competency in Recognizing and Reporting Verbal Abuse
Penalty
Summary
Facility staff failed to ensure that Certified Nurse Assistants (CNAs) possessed the necessary competencies to recognize and respond to verbal abuse, as required by facility policy. On the date of the incident, one resident with a history of impulse disorder, dementia, and mood disorder was observed in a heightened emotional state, yelling a racial slur and profanity at another resident who has dementia, restlessness, agitation, and anxiety disorder. The second resident, who has severely impaired cognition and requires moderate assistance with activities of daily living, was visibly frightened and attempted to move away from the situation. Interviews revealed that CNA 8 was present but did not hear the abusive language, although aware of the resident's history of such behavior. CNA 9, who was also present, acknowledged hearing the loud and aggressive statements and attempted to de-escalate the situation but did not report the incident as required. Both the Administrator and Director of Nursing were not notified of the incident at the time, contrary to facility policy, which mandates immediate reporting of abuse allegations to supervisory staff for investigation and state reporting if necessary. The facility's policies define verbal abuse as any use of disparaging or derogatory language within hearing distance of residents and require immediate reporting of suspected abuse. The Director of Staff Development later identified a need for reinforcement of abuse reporting protocols among staff, noting that delayed reporting could allow further incidents to occur and negatively impact residents' well-being.
Plan Of Correction
F-tag: 726 Competent Nursing Staff Immediate corrective actions: On 05/02/25, DON / DSD provided 1: - in-service/training, and re-education to CNA 8 and CNA 9 regarding policy for Abuse reporting with emphasis on the importance of: - How to recognize verbal abuse on residents. - Implement the facility's policy on abuse. - Immediately report any alleged abuse to the Administrator/DON for further investigations and reporting. Identification of others at risk: The Administrator conducted rounds on 05/02/25 and 05/10/25 and interviewed: - nursing staff (CNA, LVN, RN) on how to recognize verbal abuse and state the facility's policy of abuse. No other staff were found with the same deficient practice. Process to prevent recurrence: In-services were given by the Administrator on 05/02/25 through 05/10/25 and 05/20/25 to reinforce the policy of Abuse reporting. Monitoring Process: The Administrator will conduct random weekly interviews of facility staff and residents to reinforce the policy of Abuse with emphasis on recognizing abuse, implementing policy on abuse, and immediate reporting for 3 months. Identification of others at risk: The Administrator conducted rounds on 05/02/25 and 05/10/25 and interviewed: - nursing staff (CNA, LVN, RN) on how to recognize verbal abuse and state the facility's policy of abuse. No other staff were found with the same deficient practice. Process to prevent recurrence: In-services were given by the Administrator on 05/02/25 through 05/10/25 and 05/20/25 to reinforce the policy of Abuse reporting. Monitoring Process: The Administrator will conduct random weekly interviews of facility staff and residents to reinforce the policy of Abuse with emphasis on recognizing abuse, implementing policy on abuse, and immediate reporting for 3 months. The Administrator's findings for abuse/allege reporting will be presented to the monthly QAPI committee for further recommendations and resolutions for 3 months. Completed date: 5/20/2025 F 726
Deficient Food Storage and Handling Practices Observed in Kitchen
Penalty
Summary
The facility failed to ensure proper storage and handling of food items in the kitchen, as observed during a survey. In the dry storage area, expired food items, including a pack of hamburger buns and a can of pork and beans, were found to be kept in stock past their use-by dates. The Dietary Manager acknowledged that these items should have been discarded and stated that the facility follows a first-in, first-out process, but these expired items were missed. The facility's policy and procedure on storage of canned and dry goods specifies that no expired or beyond best buy date food items should be in stock. Additionally, improper ice handling practices were observed during the lunch tray line. A dietary aide was seen touching ice with bare hands while preparing residents' drinks, then touching the trash can liner with bare hands, and subsequently handling milk cups and ice without washing hands. Both the dietary supervisor and the aide confirmed that hand washing should have occurred after touching the trash can to prevent cross-contamination. The facility's policy on sanitation and infection control, as well as the FDA Food Code, require hand washing after handling waste and prohibit bare hand contact with ready-to-eat foods.
Plan Of Correction
Ftag=812 Food Procurement, Store/Prepare/Serve-Sanitary Immediate corrective action/s: The Dietary Supervisor on 4/28/2025 immediately discarded the 1 pack of hamburger buns and the 1 can of pork and beans. The Infection Prevention (IP) on 5/5/2025 and 5/20/2025 provided a one-to-one in-service to Dietary Aide 1 regarding policy and procedure on Infection Control, emphasizing the importance of proper sanitary manners after touching the trash, handling ice, and any food items. The Dietary Supervisor on 5/5/2025, 5/8/2025, and 5/20/2025 in-serviced the Dietary Staff regarding the policy and procedures on "Storage of Canned and Dry Goods," emphasizing food storage and that expired dry food items must be discarded immediately, as well as the importance of proper sanitary manners after touching the trash, handling ice, and any food items. Identification of others at risk: The Dietary Supervisor on 4/28/2025 and 5/20/2025 conducted a thorough check in the dry storage area of Kitchen 1. No other deficiencies were identified. The Dietary Supervisor on 4/29/2025 and 5/20/2025 spot checked the dietary staff on proper hand washing, and no other staff were identified with the same deficient practice. The Dietary Cook will perform checks of food storage areas using a "Food Storage Audit Checklist" 3 times a week that includes label and expiration date; any findings will be reported to the Dietary Manager for follow-up. The Dietary Manager will conduct daily spot checks to Dietary staff to ensure all staff are performing good hand hygiene/washing, especially in handling ice and any other food items. On 5/8/2025, the Dietary Manager provided posters and visual guides placed in storage areas as reminders. Monitoring process: The Administrator will conduct monthly reviews of findings with the Dietary Supervisor. Any deficient practice identified will be discussed during the monthly CQI/QA meeting for further recommendation and resolution for 3 months. Completion Date: 5/20/25 On 4/29/2025 and 5/20/2025, the Dietary Manager provided a random check on the dietary staff regarding proper sanitary manners such as good handwashing technique, and no other staff were identified with the same deficient practice. Process to prevent recurrence: The Dietary Cook will perform checks of food storage areas using a "Food Storage Audit Checklist" 3 times a week that includes label and expiration date; any findings will be reported to the Dietary Manager for follow-up. The Dietary Manager will conduct daily spot checks to Dietary staff to ensure all staff are performing good hand hygiene/washing in handling ice and any other food items. On 5/8/2025, the Dietary Manager provided posters and visual guides placed in storage areas as reminders. Monitoring process: The Administrator will conduct monthly reviews of findings with the Dietary Supervisor. Any deficient practice identified will be discussed during the monthly CQI/QA meeting for further recommendation and resolution for 3 months. Completion Date: 5/20/25
Failure to Prevent Presence of Gnats in Kitchen Area
Penalty
Summary
During an observation in the kitchen area, four small black flying insects identified as gnats were found below the sink. The Dietary Manager confirmed that these insects were gnats and acknowledged that food particles could attract them. The facility's policy and procedure on pest control requires an ongoing program to keep the building free of insects and rodents. However, the presence of gnats in the kitchen indicated that the facility failed to ensure the kitchen was free from pests as required by their policy. This deficiency was identified through observation, interview, and review of the facility's pest control policy, which mandates maintaining a pest-free environment to prevent contamination and uphold food safety standards.
Plan Of Correction
Ftag=925 Maintains an effective pest control program so that the facility is free pest and rodents. Immediate corrective action: On 4/28/25, the Dietary Supervisor deep cleaned the dietary areas including floors, walls, ceilings, drains, behind/under equipment. On 4/28/25, the Dietary Supervisor discarded all contaminated and exposed food and sanitized affected surfaces. The Dietary Supervisor on 5/5/25, 5/6/25, 5/8/25, and 5/20/25 provided an in-service to the dietary staff regarding the facility's "Pest Control Policy," emphasizing thorough cleaning and keeping the kitchen area free from flies/gnats. On 4/28/25, the Dietary Supervisor contacted the Pest Control Company. On 4/29/25, the Pest Control Company rendered treatment to the affected area as per guidelines. Identification of others at risk: Pest Control Company rendered treatment to the kitchen area, and no other deficient practices were noted. Process to prevent recurrence: The Dietary Supervisor provided an in-service to the dietary staff regarding the facility's "Pest Control Policy," emphasizing thorough cleaning and keeping the kitchen area free from flies/gnats. The Dietary Supervisor scheduled deep cleaning of the dietary areas twice a week, including floors, walls, ceilings, drains, behind/under equipment. The Pest Control Company is scheduled to come monthly and will be called as needed. Monitoring process: The Administrator will conduct monthly reviews of findings with the Dietary Supervisor. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendation and resolution for three months.
Failure to Accurately Code Schizophrenia Diagnosis in MDS
Penalty
Summary
The facility failed to accurately code a resident's diagnosis of schizophrenia in the Minimum Data Set (MDS), despite the diagnosis being documented in the resident's medical record. The resident was admitted and readmitted with multiple diagnoses, including schizophrenia, as indicated in the History and Physical (H&P) dated after the most recent admission. However, review of the MDS showed that the checkbox for schizophrenia under the psychiatric/mood disorders section was not marked, resulting in the resident's MDS not reflecting the current diagnosis. Interviews with the MDS Coordinator confirmed that the diagnosis of schizophrenia was present in the medical record and should have been coded on the MDS to accurately represent the resident's condition. The Director of Nursing also acknowledged the importance of accurate coding for care planning and treatment. The omission was identified through record review and staff interviews, and it was noted that failure to code an active diagnosis can result in inaccurate assessments and improper care planning, as referenced in the CMS RAI User's Manual.
Plan Of Correction
F-tag: 640 Encoding/Transmitting Resident Assessments Immediate corrective actions: On 4/29/2025, MDS Coordinator conducted a meeting with the IDT team and psychiatrist to clarify Resident 15's diagnosis of Schizophrenia. On 4/29/2025, MDS Coordinator modified Resident 15's MDS to reflect current diagnosis of Schizophrenia. On 5/2/2025 & 5/23/2025, DON & MDS Consultant provided in-service/training and re-education to MDS/Designee with emphasis on accuracy of encoding/transmission of assessment. Identification of others at risk: On 05/02/2025, the MDS reviewed clinical records of active residents with diagnosis of Schizophrenia. No other residents were identified with the same deficient practice. Process to prevent recurrence: On 05/02/25 and 05/20/25, the DON provided inservices/retraining to MDS staff (LVN, RN) to reinforce policy on accuracy of coding in MDS and transmission assessment. Monitoring process: The MDS consultant will review MDS of 5 residents with current diagnosis of Schizophrenia x 3 months to ensure accuracy of coding in the MDS. DON will report MDS findings to the QAPI committee monthly for further recommendations, resolution, and follow-up. Completion date: 5/23/2025 NotSpecified
Failure to Implement Aspiration and Choking Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement the care plan to prevent aspiration and/or choking for a resident assessed as being at risk. The resident had a history of mood affective disorder, dementia, and dysphagia, and was dependent on staff for activities of daily living. The care plan included monitoring the resident's tolerance to diet and fluids, assessing for signs and symptoms of aspiration, and involving speech therapy as indicated. The resident's diet had been changed to a puree texture with nectar/mildly thick consistency following episodes of delayed swallowing and coughing on liquids. Despite these interventions, multiple observations showed that the resident experienced repeated episodes of coughing while being fed by a CNA, both during meals and in occupational therapy. The CNA continued to feed the resident after several coughing episodes, only stopping after persistent coughing. The CNA attempted to manage the coughing by giving the resident thickened water and milk, but the coughing continued. Food and fluids remained on the tray after feeding was stopped. Interviews with staff revealed that the CNA did not notify nursing staff about the resident's repeated coughing during meals, and the DON was not made aware of the situation. The facility's policy required staff to identify and respond to signs of swallowing difficulties, including notifying appropriate personnel and seeking further evaluation by a speech therapist. These steps were not followed, resulting in a failure to fully implement the care plan for aspiration and choking prevention.
Plan Of Correction
F-tag: 656 Develop/implement Comprehensive Careplan Immediate corrective action: On 05/02/25, DON reassessed Resident 32 and implemented the plan of care to prevent risk of aspiration and choking. On 05/02/25, DON/DSD provided 1:1 in-service/re-training, and re-education to CNA 13 regarding policy on "Dysphagia." Emphasized to stop feeding the resident if any signs and symptoms of coughing are noticed, and to report to RN/Charge Nurse for further evaluation and notification of MD and responsible party. On 05/02/25, ST (Speech Therapist) evaluated Resident 32 and obtained an order for ST treatment for diet texture analysis and management, compensatory strategies training, and caregiver education training. Identification of others at risk: MDS Coordinator / MDS assistants continued to review residents' care plans with diagnosis of Dysphagia on 05/02/25 and 05/20/25. No additional discrepancies were identified with the same deficient practice. Process to prevent recurrences: On 05/02/25 and 05/20/25, DON provided in-services to nursing staff (CNA, LVN, RN) regarding policy on "Dysphagia," emphasizing the importance of the following: - To stop feeding the resident if any signs and symptoms of coughing are noticed during feeding. - To report observation immediately to RN supervisor or charge nurse for further assessments. In-services were given by the DON on 05/02/25 and 05/20/25 to reinforce to MDS staff (RN, LVN) their responsibility for accuracy in resident care plans to accurately reflect residents' current medical status. Monitoring process: The MDS Coordinator will review resident care plans with diagnosis of Dysphagia x 3 months to ensure care plans reflect residents' current medical status. The MDS Coordinator will report to the Administrator for review of findings, and any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendation and resolution. Completed date: 5/20/2025
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A resident who primarily spoke Mandarin and was admitted with multiple diagnoses, including osteoporosis and chronic pulmonary edema, was identified as having a language barrier. The resident's care plan, which addressed the language barrier, specified that staff should provide and utilize communication boards in the resident's preferred language to facilitate communication. The resident was assessed as having the capacity to understand and make decisions and required partial or moderate assistance with activities of daily living such as toileting hygiene and bathing. Despite these documented needs and interventions, observations and interviews revealed that a communication board was not present or accessible at the resident's bedside. Both the treatment nurse and the Director of Nursing confirmed that a communication board should have been available to support the resident's ability to communicate needs, especially in the absence of a translator, family member, or bilingual staff. The facility's policy also required identification and accommodation of communication deficits, but this intervention was not implemented for the resident.
Plan Of Correction
F-tag 676 Activities Daily Living (ADLs) Maintain Abilities Immediate corrective action: On 04/28/25, Social Services Director provided Resident 24 a Mandarin communication board at bedside. From 05/02/25 to 05/10/25, DON provided in-services/retraining and re-education to Social Services regarding policy on accommodation of needs to ensure communication boards are provided to residents with language barriers. Identification of others at risk: On 05/02/25, Social Services Director and Social Services Assistant conducted rounds on residents with language barriers to ensure communication boards are provided at bedside. No other residents were identified with the same deficient practice. Process to prevent recurrences: In-services by the DON were provided on 05/02/25 and 05/20/25 to nursing staff (CNA, LVN, RN) and Social Services to reinforce the policy of accommodation of needs. Social Services Director and Social Services Assistant will screen new admits to ensure if a resident speaks a language other than English, a communication board/book will be given. Monitoring process: The Social Services Director will conduct weekly random checks for 3 months to ensure communication boards are provided and kept at the bedside of residents with language barriers. The Administrator will spot check monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Repeated identification of others at risk: On 05/02/25, Social Services Director and Social Services Assistant conducted rounds on residents with language barriers to ensure communication boards are provided at bedside. No other residents were identified with the same deficient practice. Process to prevent recurrences (continued): In-services by the DON were provided on 05/02/25 and 05/20/25 to nursing staff (CNA, LVN, RN) and Social Services to reinforce the policy of accommodation of needs. Social Services Director and Social Services Assistant will screen new admits to ensure if a resident speaks a language other than English, a communication board/book will be given. Monitoring process (continued): The Social Services Director will conduct weekly random checks for 3 months to ensure communication boards are provided and kept at the bedside of residents with language barriers. The Administrator will spot check monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Completed date: 5/20/2025
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program for a resident who was under Enhanced Barrier Precautions (EBP) due to a physician's order related to a colostomy. The resident, who required substantial assistance with activities of daily living and did not have the capacity to make decisions, had signage indicating EBP outside their room. Despite this, a Certified Nursing Assistant (CNA) entered the resident's room and provided personal care involving direct physical contact without donning a gown, as required by the facility's policy and procedure for EBP. During interviews, the CNA acknowledged forgetting to wear a gown and confirmed that it was a requirement to wear both gloves and a gown before providing personal care to residents on EBP. The Infection Preventionist also stated that staff were expected to wear gowns during high-contact care for residents on EBP to prevent the transmission of infectious microorganisms. The facility's policy specified that gowns and gloves must be used during high-contact resident care activities, such as dressing, bathing, and providing hygiene, to reduce the spread of multidrug-resistant organisms (MDROs).
Plan Of Correction
Ftag=880 Infection Prevention & Control Immediate correction action: On 05/02/25, DON/DSD provided CNA 9 a 1:1 in-service, re-training, and re-education on policy of EBP and infection prevention program. Identification of others at risk: DON/IP made random rounds on 05/02/2025-05/10/2025 on EBP rooms to ensure nursing staff (CNA, LVN, RN) are wearing appropriate PPE on high contact care residents. No other nursing staff were found with the same deficient practice. Process to prevent recurrence: In-services were provided by the DON/IP on 05/02/2025 and 05/20/2025 on policy on infection prevention control program to reinforce use of PPEs on high contact care residents on EBP and ensure nursing staff understand and follow EBP guidelines. Monitoring process: The DON/IP will conduct random weekly rounds on high contact care residents on EBP rooms to ensure staff wear appropriate PPE and follow infection control prevention program x3 months. Completion date: 5/20/2025
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as required by its Abuse, Neglect, Exploitation and Misappropriation Prevention Program. During a midday observation, a certified nursing assistant (CNA) was wheeling a resident, who appeared visibly scared and emotionally distressed, through a corridor after a loud altercation. Another resident, standing in a doorway, was observed yelling profanities and a racial slur at the resident in the wheelchair, in the presence of staff and other residents. The resident in the wheelchair audibly expressed fear during the incident. Interviews with staff confirmed that the resident who used abusive language had a history of similar behavior, particularly when frustrated or waiting for food or care. Staff reported that the altercation could potentially have been avoided with increased monitoring, especially during high-risk times such as lunch. The staff member present during the incident intervened verbally to stop the abusive language and attempted to de-escalate the situation, but the incident had already caused emotional distress to the resident targeted by the abuse. A review of the facility's policy confirmed that residents are to be free from all forms of abuse, including verbal and mental abuse. The administrator acknowledged that the language used constituted verbal abuse and should have been addressed according to internal protocols. The incident was witnessed by multiple staff and residents, and the facility was aware of the behavioral history of the resident who committed the abuse.
Plan Of Correction
F-tag: 600 Free from Abuse, Neglect, and Exploitation Immediate corrective action: Resident 23 is no longer in the facility. On 4/30/25, licensed nurses monitored Resident 47 for signs of emotional distress and psychosocial harm from verbal abuse. There were no signs of emotional distress noted. On 5/1/25, Psychiatrist NP came to evaluate Resident 47. There were no negative outcomes as a result of this allegation. Identification of others at risk: The Administrator conducted rounds to identify any resident-to-resident verbal abuse. No other residents were identified with the same deficient practice. Process to prevent recurrence: Licensed nurses will conduct rounds during mealtime to ensure residents' safety. On 05/02/25-05/10/25, the DON/DSD provided in-services to nursing staff (CNA, LVN, RN) to reinforce the policy of Abuse, Neglect, Exploitation or Misappropriation Prevention Program. Monitoring process: The DON will conduct random weekly audits on 4-5 residents for 4 weeks and then randomly for 3 months to ensure that residents are free from verbal abuse. The Administrator findings will be reported to the QAPI committee monthly for further recommendations and resolutions for 3 months or until no negative trends are found. Completion date: 5/20/2025
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an incident of verbal abuse involving two residents within the required two-hour timeframe, as outlined in its own policy and procedure for reporting and investigating abuse. The incident occurred when one resident, who had a history of impulse disorder, dementia, and mood disorder, yelled profanities and a racial slur at another resident with dementia, restlessness, agitation, and anxiety disorder. The resident who was the target of the abuse appeared visibly scared and emotionally distressed during the event, as observed by staff. Despite the severity of the language used, including a racial slur and profanity, the incident was not reported immediately to the Administrator or the Director of Nursing. Both the Administrator and the DON confirmed in interviews that they had not been made aware of the incident and emphasized that such events should be reported right away according to facility policy. The staff member who witnessed the incident admitted to not reporting it as thoroughly as required, only mentioning there was yelling to another nurse without specifying the details of the abuse. A review of the facility's policy confirmed that all allegations of abuse, including verbal abuse, must be reported to the Administrator and appropriate authorities within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the incident in a timely manner prevented the facility from initiating an immediate investigation and implementing protective measures for the resident who was verbally abused.
Plan Of Correction
F-tag: 609 Reporting of alleged violations Immediate corrective actions: On 05/02/25 - 05/10/25, DON / DSD provided 1:1 in-service/training, and re-education to CNA 8 and CNA 9 about Abuse allegation reporting to the Administrator/DON. Resident 23 is no longer in the facility. Resident 47 was monitored with no signs of emotional distress or psychosocial harm noted. Identification of others at risk: The Administrator conducted rounds on 05/02/25 - 05/10/25 to identify any occurrence of allegation of abuse. No other residents were identified with the same deficient practice. Process to prevent recurrence: On 05/02/25 - 05/10/25, the DON/DSD provided in-services to nursing staff (CNA, LVN, RN) to reinforce the policy of reporting of Abuse, Neglect, Exploitation, or Misappropriation—Reporting and Investigating—with emphasis on the importance of the following: - Immediate reporting of all allegations of abuse (immediately or within 2 hours involving alleged abuse or resulting in serious bodily injury). - Notification of Facility administrator, State law agencies (CDPH, Ombudsman), and local law enforcement. - Responsible party, attending physician, and facility's medical director. Monitoring process: The Administrator will conduct random weekly audits on 4-5 residents for 4 weeks and then randomly for 3 months to ensure that residents are free from alleged abuse. The Administrator's findings will be reported to the QAPI committee monthly for further recommendations and resolutions for 3 months or until no negative trends are found. Completed date: 5/20/2025
Resident Rooms Below Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that 27 out of 37 resident rooms met the minimum space requirements of 80 square feet per resident in multiple occupancy rooms, as required. Specifically, several rooms with two or three beds each were found to have less than the required square footage per resident, according to the facility's Client Accommodation Analysis. The analysis detailed the dimensions and floor areas of each deficient room, confirming that the space provided was insufficient for the number of residents assigned. During the survey, interviews were conducted with a resident and a Licensed Vocational Nurse (LVN). The resident reported feeling comfortable and did not express any complaints about the room size, while the LVN stated that the room sizes did not interfere with their ability to perform care duties. The facility had submitted a waiver request, noting that there were no unnecessary furnishings causing congestion and that residents benefited from the familiar environment. However, the deficiency was identified based on the objective measurements of room sizes and the number of residents accommodated.
Plan Of Correction
Flag=912 Bedroom Measure at least 80 Sq/Ft/Resident Immediate correction action: The facility applied for a room waiver on 04/30/2025. Residents affected were ambulatory and can get in and out of their rooms without difficulty. The nursing staff has full access to provide treatment, administer medications, and assist residents to perform their individual routine of activities of daily living. Process to prevent recurrences: In-services were conducted by the Administrator and Maintenance Supervisor to facility staff on 05/02/25 and 05/20/25 to ensure that affected rooms will not have any adverse effects on residents' health, welfare, and safety and enough space for the provision of care to residents. Monitoring process: The Administrator and Maintenance Supervisor will conduct rounds monthly throughout the facility as needed x 3 months to ensure that the affected rooms will not have any adverse effects on residents' health, welfare, and safety and enough space for the provision of care to residents and that residents will not have any adverse effect on their health, welfare, and safety. Maintenance supervisor will report findings to the QAPI committee quarterly for review, resolution, and follow-up. Completion date: 5/20/2025 F 912
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with diagnoses including type 2 diabetes mellitus, dementia, and unsteadiness of feet. The resident was assessed as moderately impaired in cognitive skills and required supervision for lower body dressing and bathing. On the evening of the incident, a CNA witnessed another CNA mistreat and physically abuse the resident and reported the incident to an LVN, an RN, and the DON. The CNA also provided a written statement about the abuse. Despite these reports, the facility did not notify the California Department of Public Health, the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's policy and procedure for reporting abuse. Interviews with staff confirmed that the incident was discussed among the CNA, LVN, RN, and DON, and that a written statement detailing the abuse was received by the DON and DSD the following day. Both the DON and DSD acknowledged that the written statement contained allegations of abuse and that the facility should have reported the incident within two hours, as required by their policy. A review of the facility's policy confirmed the requirement to report all allegations of abuse to the appropriate authorities within the specified timeframe.
Staff Lack of Knowledge on Abuse Reporting Procedures
Penalty
Summary
The facility failed to ensure that staff members understood and followed the facility's policies and procedures regarding abuse reporting. Specifically, a Certified Nursing Assistant (CNA) was unable to identify the facility's Abuse Coordinator and did not recall receiving training on abuse prevention. Additionally, a Registered Nurse (RN) was unaware of the required agencies to notify in the event of an abuse allegation and incorrectly believed that the facility had 24 hours to report such allegations, rather than the required two hours. The RN also stated that they would wait to investigate and confirm abuse before reporting, contrary to policy. Interviews with the Director of Staff Development confirmed that all allegations of abuse must be reported to the Department of Public Health, the Ombudsman, and local law enforcement within two hours, as outlined in the facility's policies. Review of the facility's policies further indicated that staff orientation and training should cover abuse prevention, identification, and reporting. The failure of staff to know and follow these procedures was identified through interviews and record reviews, with no mention of specific residents being directly affected at the time of the deficiency.
Unlicensed Staff Member Provides Care in LTC Facility
Penalty
Summary
The facility failed to ensure that an Office Assistant (OA), who previously held the position of Director of Staffing Development (DSD), did not work without a valid nursing license. The OA continued to perform duties that required a licensed nurse, such as administering medications and monitoring residents, despite having surrendered their Licensed Vocational Nurse (LVN) license. This occurred over a period of time, during which the OA provided care to nine residents, all of whom had various medical conditions including dementia, malnutrition, and chronic diseases. The OA's license was surrendered following a decision by the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) and the Department of Consumer Affairs (DCA) for the State of California. Despite this, the OA continued to work in a nursing capacity, signing off on medication administration records (eMAR) and treatment administration records (eTAR) for multiple residents. The facility's policy required that employees present valid licenses, certifications, or registrations to perform their duties, and the OA's actions were in direct violation of this policy. Interviews with facility staff, including the Administrator (ADM) and Director of Nursing (DON), revealed that the OA did not disclose the surrender of their license. The ADM and DON were unaware of the OA's license status until notified by the BVNPT. The facility's system for tracking license expirations failed to alert the DON of the OA's expired license, allowing the OA to continue providing direct patient care without the necessary credentials. This oversight posed a significant safety risk to the residents under the OA's care.
Failure to Provide Advance Directive Information to Incapacitated Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 33 and Resident 57, and/or their representatives were provided with information regarding the right to formulate an advance directive (AD). Resident 33, who was admitted and readmitted to the facility with diagnoses including dysphagia, abnormal posture, and dementia, had an AD Acknowledgment form provided in English, despite the resident's preferred language being Arabic. The resident's care plan indicated a language barrier, and the resident was noted to have moderately impaired cognitive skills and was dependent on staff for various activities. Interviews with the Social Services Representative (SSR) and the Director of Nursing (DON) confirmed that Resident 33 could not make decisions and required communication in their preferred language to understand the AD. Resident 57, admitted with diagnoses including metabolic encephalopathy, dementia, Alzheimer's disease, and anxiety, also signed an AD Acknowledgment form despite lacking the capacity to make decisions. The resident's History and Physical and Minimum Data Set (MDS) indicated moderately impaired cognitive skills and a need for moderate assistance with daily activities. Interviews with the MDS Coordinator and SSR revealed that Family Member 2 (FM 2) was the primary decision maker for Resident 57, yet was not consulted regarding the AD. The DON confirmed that Resident 57 should not have signed the AD Acknowledgment due to the lack of decision-making capacity. The facility's policy and procedure on advance directives, revised in September 2022, stated that residents have the right to formulate an AD and that ADs should be honored in accordance with state law and facility policy. The policy also indicated that if a resident was incapacitated, the information about the right to formulate an AD should be provided to the resident's legal representative. The failure to adhere to this policy resulted in the potential for Residents 33 and 57 to receive unwanted care and treatment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, which could potentially impact their treatment and services. Resident 7's MDS did not reflect an active diagnosis of schizophrenia, despite the admission record and history and physical (H&P) indicating this diagnosis. The MDS Coordinator (MDSC) acknowledged the omission, explaining that the resident was not on medication for schizophrenia, which influenced the assessment. However, the facility's manual and the CMS's RAI Version 3.0 Manual require that all active diagnoses be included in the MDS, regardless of medication status. Similarly, Resident 8's MDS failed to indicate active diagnoses of Parkinson's disease and bipolar disorder, even though these were documented in the resident's admission record and H&P. The MDSC admitted the need for accuracy in the MDS to ensure appropriate care and compliance with CMS requirements. The facility's policy on comprehensive assessments, aligned with the RAI User Manual, mandates the inclusion of active diagnoses as documented by the physician in the H&P. The administrator confirmed that active diagnoses are documented by the physician on the H&P.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor for side effects of psychotropic medications for a resident, as per the facility's policy and procedure on psychotropic medication use. The resident, who was admitted with multiple diagnoses including schizophrenia, was prescribed Seroquel to manage symptoms of paranoia. The care plan and physician orders required monitoring for side effects, specifically Tardive Dyskinesia (TD), a condition characterized by involuntary movements. However, observations and interviews revealed that the resident exhibited tongue thrusting, a sign of TD, which was not documented in the Medication Administration Record (MAR) for April 2024. Staff members, including a CNA, a Treatment Nurse, and an LVN, acknowledged the presence of tongue thrusting in the resident, identifying it as a side effect of the medication. Despite this, the MAR did not reflect these observations, indicating a lack of accurate documentation. The Director of Nursing confirmed that staff should document any side effects in the MAR to ensure proper medication management and adjustment. The failure to document and monitor these side effects could potentially impact the resident's health and psychosocial well-being.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to safe and proper food storage practices in Kitchen 1, as observed during a survey. Specifically, the facility did not label or date food items, which is a violation of professional standards for food service safety and the facility's own policy and procedure. During an observation and interview with the Dietary Manager, it was noted that a 16 oz can of Sprease brand all-purpose oil-based spray was undated, unlabeled, and without a cap, sitting on the counter by the stove. Additionally, five unlabeled and unmarked sealed plain plastic packages of multiple frozen waffles were found inside the standalone freezer. The Dietary Manager acknowledged that the opened oil spray can should have been covered and labeled to ensure staff could determine if the item had expired, know the open date, and assess the quality of the food to prevent foodborne illness. The facility's policy and procedure documents, although undated, indicated that opened oil should be stored on the shelf for no more than three months, and baked goods like waffles should be labeled and dated with a freezer storage time of three months. The failure to follow these guidelines could compromise the quality and safety of the food served to residents.
Failure to Implement Food Labeling and Storage Policy
Penalty
Summary
The facility failed to implement its policy and procedures for labeling and storing food items brought in by family and visitors for residents. During an observation, a sealed jar of instant coffee was found in the refrigerator without a use-by date, although it was labeled with a resident's name. Licensed Vocational Nurse 2 (LVN 2) stated that food brought in by family should be kept for only 24 hours, but there was no clear understanding among staff about who was responsible for checking the refrigerator and discarding food. Licensed Vocational Nurse 3 (LVN 3) and LVN 4 provided conflicting information about the labeling and discarding process. LVN 3 mentioned that the night and morning shift charge nurses were responsible for checking the refrigerator, but was unaware of a specific policy for discarding food without a use-by date. LVN 4 was unsure if the nurse assigned to Medication Cart A was responsible for checking the refrigerator and stated that food should be labeled with the resident's name, date, and time, and discarded after 24 hours. The Dietary Manager (DM) and the Administrator (ADM) also provided inconsistent information regarding the handling of food brought in by family. The DM stated that food without an expiration date was only good for 2 hours, while the ADM mentioned that non-refrigerated food should be discarded within 24 hours. The facility's policy indicated that perishable foods should be labeled with a use-by date and discarded accordingly, but this was not consistently followed, leading to the potential risk of residents consuming spoiled food.
Failure to Maintain Resident Dignity During G-tube Medication Administration
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident during medication administration via a gastrostomy tube (G-tube). The incident involved a resident who was dependent on assistance for daily activities and had a feeding tube. During the administration of medication, the Licensed Vocational Nurse (LVN) did not fully draw the drapes around the resident's bed, resulting in the exposure of the resident's legs and diaper. This action was contrary to the facility's policy, which required maintaining resident privacy and dignity during such procedures. The resident, who had multiple diagnoses including dementia and cachexia, was unable to understand and make decisions. The facility's care plan for the resident emphasized treating the resident with respect and dignity. However, during the observed incident, the LVN acknowledged the failure to provide adequate privacy by not drawing the drapes completely. The facility's policy on administering medications through an enteral tube and on maintaining dignity clearly outlined the need for privacy and respect, which were not adhered to in this case.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise the care plans for a resident, identified as Resident 19, regarding the use of bilateral floor mats, which were initially included as an intervention to minimize injury from falls. Resident 19 was admitted with diagnoses including blindness, lack of coordination, unsteadiness on feet, and dementia, placing them at risk for falls. Despite an Interdisciplinary Team (IDT) meeting on November 20, 2023, where it was decided to remove the floor mats based on a therapist's recommendation due to tripping risks, the care plans were not updated to reflect this change. Observations and interviews conducted on April 30, 2024, revealed that the care plans titled "Risk for Fall/Injury" and "Falling Star Program" still included the use of bilateral floor mats, despite their removal. The Infection Preventionist Nurse and the Director of Nursing acknowledged that the care plans were not updated, which was necessary for staff to provide proper and consistent care. The facility's policy required care plans to be revised when there was a significant change in the resident's condition, which was not adhered to in this case.
Failure to Involve Resident and Family in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident and their family were involved in developing the resident's post-discharge plan prior to discharge. Resident 102, who was admitted with schizophrenia and had moderately impaired cognitive skills, was discharged without proper involvement of the resident and their family in the discharge planning process. The Minimum Data Set indicated that Resident 102 required supervision or assistance with activities of daily living, highlighting the importance of a well-coordinated discharge plan. The Social Service Representative acknowledged that the resident and their family should have been informed of the discharge plan at least two weeks prior to the discharge date. However, there was no documentation in the clinical record indicating their involvement in the planning process. The facility's policy required resident and family involvement in discharge planning, but this was not adhered to, as evidenced by the lack of documentation and the late notification of the final discharge plan to the family on the day of discharge.
Failure to Address Language Barrier for Arabic-Speaking Resident
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 2) had the necessary competencies to communicate effectively with a resident who spoke Arabic, leading to a deficiency in care. Resident 33, who was readmitted to the facility with diagnoses including dysphagia, abnormal posture, and dementia, preferred to communicate in Arabic. The resident was dependent on assistance for various daily activities and had a care plan in place that included the use of communication boards and Arabic-speaking staff or volunteers to address language barriers. However, during an observation, RN 2 attempted to communicate with the resident in English, despite knowing the resident only spoke Arabic. The RN did not utilize the communication book, which contained Arabic words and gestures, to facilitate understanding. Interviews with RN 2 and the Director of Nursing (DON) confirmed that the communication book should have been used to translate and communicate with the resident. The facility's policy on accommodating communication barriers emphasized the importance of identifying communication needs and developing appropriate interventions. Additionally, the facility's staffing policy required nursing staff to demonstrate the skills necessary to meet residents' needs, including communication. The failure to use the communication book as per the care plan and facility policies resulted in RN 2 being unable to understand and meet Resident 33's needs, potentially impacting the resident's quality of life.
Failure to Administer Tramadol as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering the prescribed medication, Tramadol, as ordered by the physician. The resident, who was admitted with multiple diagnoses including idiopathic progressive neuropathy, anxiety disorder, and a fracture of the cervical vertebra, had a physician's order for Tramadol to be given every morning and at bedtime for pain management. However, during a medication pass, the LVN decided to hold the medication because the resident reported a pain level of zero, despite there being no parameters in the physician's order to hold the medication. The LVN did not notify the physician about holding the medication, which was against the physician's orders and the facility's policy. The Medication Administration Record indicated that Tramadol was not administered on several occasions, and the care plan for the resident emphasized the importance of administering pain medications as ordered. The facility's policy required medications to be administered as prescribed, but this was not followed, leading to the deficiency.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 27 out of 37 resident rooms met the minimum requirement of 80 square feet per resident in multiple resident rooms. Specifically, seven rooms housed two residents each, and twenty rooms housed three residents each, all of which were below the required space per resident. This deficiency was identified through observation, interviews, and record reviews, indicating that the rooms did not provide adequate space for nursing staff to deliver care, accommodate functional furniture or care devices, or allow room for visitors. During the review of the facility's room waiver request letter and Client Accommodation Analysis, it was noted that the rooms were less than the required 80 square feet per resident. Despite the waiver request indicating that residents' needs were comfortably met and that there was no unnecessary congestion, the actual measurements showed insufficient space. Interviews with a CNA and a resident revealed that while the resident did not wish to move and felt there was enough space, the room sizes did not meet regulatory standards. The waiver request was recommended for the rooms in question.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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