Corona Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corona, California.
- Location
- 1400 Circle City Drive, Corona, California 92879
- CMS Provider Number
- 055255
- Inspections on file
- 36
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Corona Health Care Center during CMS and state inspections, most recent first.
A resident with fragile skin, bone density disorders, and a history of falls sustained an unwitnessed bathroom fall resulting in a posterior head injury, right arm skin tear with exposed dermis and drainage, and right upper extremity bruising with pain. Although initial assessments and notes documented the fall, head lump and erythema, right arm skin tear, right elbow discoloration, and significant pain, there was no ongoing monitoring or reassessment of the head and arm injuries over the following shifts, no MD order obtained for wound treatment of the skin tear, and no care plan update to address the fall, injuries, or bleeding risk, contrary to facility policy and the DON’s stated expectations.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during the inspection.
The facility did not ensure that outside food items stored in a shared refrigerator were properly labeled, dated, or discarded according to policy, resulting in multiple undated and unlabeled items, some past expiration. Additionally, a cook failed to consistently disinfect the food thermometer between uses when measuring food temperatures, increasing the risk of cross-contamination. These actions were confirmed by staff interviews and policy review.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A cook did not follow the established recipe or measure ingredients when preparing pureed vegetables for multiple residents on a pureed diet. The cook added excess water and thickener, resulting in an improper consistency, and did not adhere to the facility's documented procedures. The dietary supervisor confirmed that recipes and measurement protocols were not followed, potentially impacting the quality of the pureed diet provided.
Surveyors identified multiple infection control deficiencies, including a nurse providing direct care while wearing long acrylic nails, failure to follow enhanced barrier precautions during airway suctioning for a resident with a gastrostomy tube, and improper storage and maintenance of respiratory equipment for another resident. These lapses were confirmed by staff interviews and review of facility policies.
The facility did not provide written information or offer assistance in formulating Advance Directives to two residents or their representatives, as required by policy. One resident lacked decision-making capacity and the other was capable, but in both cases, there was no documentation that the required information or assistance was offered or provided.
A resident with multiple medical conditions left the facility against medical advice after notifying staff of his intention not to return. Although staff discussed the risks and benefits of leaving AMA and notified appropriate personnel, the required AMA acknowledgement form was not signed by the resident, nor was refusal to sign documented as per policy. Additionally, there was no documentation that the physician was notified upon the resident's return or discharge, resulting in a failure to follow established discharge procedures.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Nursing staff did not clarify or follow a physician’s order for lidocaine 4% patches for a resident with multiple chronic conditions, resulting in inconsistent application and removal times that did not match the prescribed regimen or manufacturer’s instructions. The DON confirmed the order was not followed and that staff should have sought clarification.
Two residents did not receive care as ordered: one did not have a neurology follow-up scheduled within the required timeframe after hospital discharge, and another had multiple new skin discolorations that were not identified, monitored, or reported to the physician. Nursing staff did not follow procedures for assessment and communication, and documentation did not reflect the residents' conditions or required actions.
A resident with severe cognitive impairment and nonverbal status was assessed for pain using a numeric pain scale by an LVN, despite the resident's inability to communicate verbally or with gestures. The appropriate PAINAD tool, designed for individuals with advanced dementia, was not used, and pain assessments were documented using an unsuitable method. The DON confirmed that facility policy requires the use of a pain assessment tool appropriate to the resident's cognitive level, which was not followed.
A Social Service Designee used a resident's bank card to make unauthorized personal purchases totaling about $2,300, which the resident discovered after reviewing bank statements. The staff member admitted to the transactions and agreed to repay the amount. The incident was not reported to management for approximately two weeks, and the resident, who was cognitively intact and had a history of depression and hemiplegia, expressed feeling hurt and betrayed by the staff member's actions.
Surveyors found that the facility did not properly clean or maintain the ice machine, with black and brown flakes, dust, pest remnants, and leaking water observed during inspection. The Dietary Supervisor and maintenance supervisor were unable to confirm when the machine was last serviced or when water filters were last changed, and the DON identified deteriorating rubber inside the machine. Facility policies required regular cleaning and filter changes, but these were not consistently followed, affecting nearly all residents who received ice.
Surveyors found that a pill crusher used for multiple residents was coated with a brown, sticky substance, and a stand lift machine had visible crumbs and skin flakes where a resident's feet are placed. Staff interviews revealed confusion about cleaning responsibilities, and facility policies for cleaning and disinfection were not followed.
Two residents with significant medical conditions independently used a smoking patio where the fire door closer had been dismantled, causing the door to not close properly and creating a risk of injury. Both were observed struggling to close the door, with one nearly pinching his fingers. The ceiling above the door was also found to be stained and deteriorating, with a possible leak noted by the maintenance supervisor. Facility policies required these safety features to be maintained and issues reported, but these were not followed.
A resident with muscle weakness, difficulty walking, and dementia, assessed as high risk for falls, suffered injuries due to a lack of effective communication and monitoring systems in the facility. Staff interviews revealed that there were no updated lists of high-risk residents, preventing adequate supervision and intervention.
The facility failed to accurately reconcile controlled medications for two residents, resulting in missing Norco and Tramadol tablets. Despite policies requiring end-of-shift counts, discrepancies were found, indicating lapses in procedure adherence. Interviews revealed that the missing medications were discovered after a pharmacy call, prompting an investigation by the DON.
The facility failed to ensure that the advance directives of two residents were documented in their medical records and that a POLST form for another resident was completed to reflect their treatment wishes. This oversight could result in the residents' treatment preferences not being honored during emergencies.
A facility failed to document and administer narcotic medications properly for five residents, leading to discrepancies between the narcotic count sheet and the MAR. Medications were removed but not documented as administered, and some were not given according to physician orders. Interviews with staff confirmed the failure to follow facility policies on medication documentation and administration.
The facility failed to properly store and label medications, leading to several deficiencies. Expired and used medications were not discarded, and some were mixed with those intended for use. Expired IV kits and unlabeled saline bags were found, posing contamination risks. Medications of different forms and routes were improperly stored together, and discontinued medications were not removed from the cart. Additionally, a medication bottle had an illegible label, risking administration errors.
The facility was found to have multiple deficiencies in kitchen sanitation and food handling practices, including improper stacking of wet pans, dust and rust on surfaces, broken floor tiles, and inadequate hygiene practices by staff. These issues were confirmed by the Dietary Services Supervisor and Registered Dietician, highlighting potential risks for cross-contamination and resident harm.
The facility failed to maintain a pest-free kitchen environment, as black flies were observed in food preparation areas, potentially leading to foodborne illnesses. Despite having a pest control contract, flies were present, indicating non-compliance with the facility's fly and vermin control policy.
The facility failed to provide a SNF-ABN to two residents transitioning from Medicare-covered skilled services to custodial care, potentially leaving them uninformed about financial liability for services not covered by Medicare. Interviews confirmed the oversight, despite facility policy requiring the notice.
A facility failed to accurately code the MDS for a resident, indicating discharge to a short-term hospital instead of home. This error was identified during an interview and record review with the MDS Coordinator, who confirmed the inaccuracy. The incorrect coding could lead to misidentification of the resident's care and support needs.
The facility failed to administer medications according to physician orders and policy for two residents. An LVN did not give medications to a resident due to the resident sleeping and being busy, yet signed the MAR as if administered. Another resident's medications were not given due to unavailability and were also incorrectly signed as administered. The DON confirmed the need for proper documentation.
A facility failed to provide proper respiratory care for a resident by not dating the humidifier bottle on the oxygen concentrator, as observed during a survey. The resident, who had diagnoses including sepsis and COVID-19, was receiving oxygen at 2 liters per minute via nasal cannula. Interviews with staff confirmed the oversight, which was against the facility's policy requiring daily dating and replacement of the humidifier bottle to prevent infection.
A resident with depression and schizophrenia was prescribed risperidone without documented assessment by the IDT or psychiatrist upon readmission to the facility. The medication was reordered despite the facility's policy requiring evaluation to determine clinical necessity, leading to potential unnecessary medication use.
A facility failed to complete ordered HgbA1C tests for a resident with diabetes mellitus. The resident had physician orders for insulin and HgbA1C tests on specific dates, but there was no evidence the tests were conducted. The DON confirmed the absence of test results and the contracted lab verified no tests were done. This was contrary to the facility's policy for processing lab orders.
The facility failed to implement infection control measures for a resident's IV site, which was not assessed or labeled upon readmission, and did not report a COVID-19 outbreak to the CDPH in a timely manner. The IV dressing was undated and unlabeled, and the facility's policy for reporting communicable diseases was not followed, leading to delayed outbreak management.
The facility failed to develop and implement appropriate interventions for a resident with severe osteoporosis and a history of fractures. Despite sustaining a leg fracture during a transfer using a Hoyer lift, no further assessment or evaluation was conducted, and an individualized care plan was not created. This led to the resident sustaining a second fracture during a subsequent transfer.
Failure to Monitor Post-Fall Injuries, Obtain Wound Orders, and Update Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring and assessment after a resident experienced a fall with injuries, to obtain a physician’s order for treatment of a skin tear, and to develop a care plan addressing the fall and related injuries. A resident with a history of falls and bone density disorders was admitted with fragile skin and had an existing care plan indicating a potential for skin tears, with instructions to treat per facility protocol and notify the MD and family if a skin tear occurred. On the date of the incident, documentation showed the resident sustained a fall in the bathroom, with a posterior head injury described as mild erythema and a raised lump, and a right arm skin tear with a partially attached skin flap, exposed dermis, and moderate drainage. A change of condition/INTERACT assessment documented a fall, right elbow discoloration, and pain rated 7/10, and a pain assessment noted pain to the right arm related to the skin tear and to the posterior head. Progress notes from the incident described the resident found on the bathroom floor on her right side, with her head resting on the bathtub, a right arm skin tear, and complaints of back and head pain. A subsequent skin/wound note documented dark maroon ecchymosis with a scab on the right upper extremity, consistent with the recent fall, and ongoing pain to the affected extremity. Despite these findings, there was no documented evidence that the right upper arm skin tear, right elbow discoloration, or back-of-head raised areas and erythema were monitored or reassessed after the initial change in condition. The DON stated that the facility process required the licensed nurse to complete change-of-condition documentation, update care plans, and monitor neurological status, pain, and skin status every shift for 72 hours, but confirmed that this monitoring did not occur for this resident’s head and right arm injuries. Record review further showed there was no documented wound treatment order for the right arm skin tear, despite the open wound with exposed dermis and moderate drainage. Additionally, there was no updated care plan developed to address the unwitnessed fall, the right upper arm skin tear, right elbow discoloration, back-of-head raised areas/erythema, or risk for bleeding following the change in condition. Facility policies required nurses to assess and document recent injuries, especially head injuries, and to follow up on any fall with associated injury until the resident was stable and delayed complications were ruled out, as well as to revise care plans when there was a significant change in the resident’s condition. The lack of ongoing monitoring, absence of a physician order for wound treatment, and failure to update the care plan following the fall and injuries constituted the identified deficiency.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Sanitary Food Storage and Thermometer Disinfection
Penalty
Summary
The facility failed to maintain sanitary conditions in its food and nutrition services by not properly labeling, dating, and discarding outside food items stored in a shared residents' refrigerator. During an inspection, several food items were found in the refrigerator that were either undated, unlabeled, or past their expiration date, including containers of food, bags of leftovers, and dairy products. The Dietary Supervisor confirmed that these items should have been labeled with the resident's name, room number, and date, and discarded if expired, as per facility policy. Signage on the refrigerator and the facility's written policy both required proper labeling and timely removal of perishable items, but these procedures were not followed. Additionally, the facility did not ensure that food thermometers were properly disinfected between uses when measuring food temperatures on the steam table. Observations showed that a cook inconsistently wiped the thermometer with a paper towel or alcohol swab and sometimes used the same paper towel or swab between different food items. Both the cook and the Dietary Supervisor acknowledged that the thermometer should be cleaned and disinfected between each use to prevent cross-contamination, as outlined in the facility's policy. These lapses in food safety practices were confirmed through interviews and review of facility policies.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Pureed Diet Recipe and Measurement Protocols
Penalty
Summary
The facility failed to ensure that the cook followed the established recipe for preparing pureed vegetables for residents on a pureed diet. During an observation and interview, the cook stated that she prepared pureed vegetables for 18 residents and added two cups of water, resulting in a consistency that was more liquid than the required pudding-like texture. The cook was also observed pouring thickener directly from a container into the vegetables without measuring, later stating that she used 1.5 cups of thickener, which exceeded the recipe's requirements. The facility's recipe specified maximum amounts of fluid and thickener for specific serving sizes, which were not followed. Further interviews and record reviews confirmed that the cook did not adhere to the recipe for either the pureed vegetables or the thickener, and the dietary supervisor acknowledged that the thickener should have been measured and the recipe followed. The facility's documentation indicated that the pureed diet is intended for residents with difficulty chewing or swallowing, requiring a smooth and moist consistency that holds its shape. The failure to follow the recipe and measure ingredients as required could affect the consistency, taste, and nutritional value of the pureed foods provided to residents.
Infection Control Lapses in Nail Hygiene, Barrier Precautions, and Equipment Storage
Penalty
Summary
The facility failed to uphold infection prevention and control practices in several instances involving both staff and residents. One licensed nurse was observed wearing long, red acrylic nails while providing direct patient care, including checking blood sugars and administering insulin. The nurse admitted to not knowing the facility's specific policy on artificial nails but acknowledged that long nails could increase the risk of infection transmission. The Infection Preventionist and Director of Nursing both confirmed that long or artificial nails were not permitted for direct care staff due to infection risks and potential for causing skin tears. The facility's employee handbook required nails to be kept clean but did not specifically address artificial or long nails in relation to infection control. Another deficiency was observed when a licensed nurse failed to follow enhanced barrier precautions (EBP) while providing direct care to a resident with a gastrostomy tube. The nurse donned gloves but did not wear a gown or mask while suctioning the resident's airway, despite signage and facility policy indicating that gown and gloves were required for high-contact activities under EBP. The nurse acknowledged not following the EBP procedure, and the resident's care plan and physician's order both indicated the need for EBP due to the presence of a gastrostomy tube. Additionally, infection control practices were not followed regarding the storage and maintenance of respiratory equipment for another resident. Nebulizer tubing and mask, as well as suction tubing and a Yankauer suction tip, were found placed directly on a bedside dresser and not stored in appropriate container bags when not in use. The nebulizer tubing was overdue for replacement, and the suction canister was undated and not discarded after use as required by facility practice. The Infection Preventionist confirmed that these items should have been stored properly and replaced or discarded according to protocol.
Failure to Provide Advance Directive Information and Assistance
Penalty
Summary
The facility failed to provide written information and offer assistance in formulating Advance Directives (AD) to two residents or their representatives, as required by facility policy. For one resident with severe cognitive impairment and no capacity to make decisions, there was no documented evidence that the resident's representative was offered the opportunity to formulate an AD upon admission or during the baseline care planning period. The medical records director confirmed this omission during a review and interview. For another resident, who had the capacity to make decisions, there was also no documentation that the resident or their representative was offered education or assistance regarding ADs within the required timeframe after admission. The case manager and MDS coordinator both confirmed that this step was missed. Facility policies reviewed indicated that such information and assistance should be provided upon admission and documented in the medical record, but this was not done for either resident.
Failure to Follow AMA Discharge Policy and Documentation Requirements
Penalty
Summary
The facility failed to implement its policy and procedure regarding the discharge of a resident without physician approval for one resident. The resident, who had multiple diagnoses including diabetes mellitus, hypertension, muscle weakness, abnormal gait, and a local skin infection, left the facility against medical advice (AMA) after communicating his intention to staff via text and phone. Documentation shows that the resident was advised of the risks and benefits of leaving AMA and that the physician, DON, Administrator, and SSD were notified of his absence. However, there was no evidence that the resident signed the required AMA acknowledgement form, nor was there documentation that the resident refused to sign the form, as required by facility policy. Additionally, there was no documentation that licensed nurses notified the physician when the resident returned to the facility or when he was officially discharged AMA. Interviews with staff, including an LVN and the DON, confirmed that the established process for AMA discharges was not followed. The DON stated that the process should have included physician notification, discussion of risks and benefits with the resident, and obtaining the resident's signature on the AMA form, or documenting refusal to sign. The facility's policy requires that if a resident insists on discharge without physician approval, a release of responsibility form must be signed or refusal documented and witnessed by two staff members. These steps were not completed in this case, resulting in a failure to follow the facility's discharge policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Clarify and Follow Lidocaine Patch Orders
Penalty
Summary
Nursing staff failed to ensure a resident’s drug regimen was free from unnecessary medications by not clarifying the physician’s order for lidocaine 4% transdermal patches. The physician’s order specified that the patch should be applied to the lower back at 9 a.m. and removed at 9 p.m., for a total of 12 hours per day. However, review of the Medication Administration Record (MAR) showed inconsistent application and removal times, including instances where the patch was removed at 9 a.m. or applied at 9 p.m., and on some dates, the patch was applied twice daily at both 9 a.m. and 9 p.m. These actions were not in accordance with the physician’s order or the manufacturer’s instructions. The resident involved had multiple diagnoses, including dementia, major depressive disorder, anxiety, osteoporosis, osteoarthritis, difficulty walking, and a history of falls. The DON confirmed that the lidocaine patch should have been administered once daily as ordered and acknowledged that staff should have clarified the order with the physician. Facility policy required medications to be administered according to prescriber orders and for staff to contact the prescriber if a dosage was believed to be inappropriate or excessive, but this was not followed in this case.
Failure to Arrange Timely Neurology Follow-Up and Address New Skin Discolorations
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident with a history of seizures and narcolepsy, the facility did not arrange a follow-up neurology appointment within 5 to 7 days as ordered in the hospital discharge summary and by the physician. Documentation showed that the resident was admitted, discharged, and then readmitted to the facility, but there was no evidence of a neurology consult being scheduled until four months after the initial recommendation. The Director of Nursing confirmed that the resident did not see the neurologist within the required timeframe and that there was no facility policy for scheduling appointments. For another resident with chronic conditions including COPD, diabetes, and congestive heart failure, the facility failed to identify, monitor, and notify the physician about multiple new skin discolorations on both hands and the left upper extremity. The care plan indicated the resident was at risk for bleeding and skin integrity issues, and required notification of the physician for any significant changes. However, documentation from body checks did not reflect the presence of the new skin discolorations, and there was no evidence that these findings were communicated to the physician or family, or that a care plan was initiated for the new skin issues. Interviews with nursing staff and the DON revealed that the process for reporting and monitoring new skin problems was not followed. The licensed nurse acknowledged that a change of condition report, incident report, and physician notification should have occurred but did not. The DON confirmed that new skin discolorations should have been investigated and reported immediately, and that the lack of timely identification and communication could delay treatment. Facility policy required incident reporting and physician notification for skin abnormalities, but this was not done in these cases.
Failure to Use Appropriate Pain Assessment Tool for Nonverbal Resident
Penalty
Summary
The facility failed to accurately conduct a pain assessment for a resident with severe cognitive impairment and a history of dementia, bilateral osteoarthritis of the knee, and right knee contracture. During an observation and interview, a Licensed Vocational Nurse (LVN) attempted to assess the resident's pain using both English and Spanish, but the resident did not respond verbally or with gestures. The LVN stated that pain was determined by observing for grimacing or moaning. The resident's records indicated a lack of capacity to understand and make decisions, and a Brief Interview for Mental Status (BIMS) score of 00 confirmed severe cognitive impairment. Despite this, the resident's pain was documented using a numeric pain scale, which is not appropriate for nonverbal residents with advanced dementia. The Medication Administration Record (MAR) showed that pain levels were recorded using the numeric scale, and pain medication was administered based on these assessments. On one occasion, the LVN acknowledged that the PAINAD scale, which is designed for nonverbal individuals with advanced dementia, should have been used but was not. The Director of Nursing (DON) confirmed that the appropriate pain assessment tool was not utilized, as required by facility policy, which mandates the use of a standardized pain assessment instrument suitable for the resident's cognitive level.
Misappropriation of Resident Funds by Social Service Designee
Penalty
Summary
A Social Service Designee (SSD) used a resident's bank card to make unauthorized purchases for personal use, totaling approximately $2,300, without the resident's consent. The resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including hemiplegia and depression, discovered the discrepancy after reviewing his bank statements. The SSD admitted to the unauthorized transactions and arranged to repay the resident in installments. The incident was not reported to facility management for about two weeks, as the resident initially chose to see if the SSD would return the money rather than report the issue. The Director of Nursing (DON) and Administrator were unaware of the situation until it was brought to their attention by a Certified Nursing Assistant (CNA) after the resident expressed concerns about his Social Security Income. The facility's policy prohibits misappropriation of resident property by staff. The resident reported feeling hurt and betrayed by the SSD's actions but did not wish to pursue legal action as long as the money was returned. The incident was documented in the resident's progress notes and discussed in an Interdisciplinary Team (IDT) meeting.
Failure to Clean and Maintain Ice Machine Resulting in Potential Contamination
Penalty
Summary
The facility failed to ensure that the ice machine and its components were properly cleaned and sanitized, affecting 87 of 90 residents who received ice from the machine. During an unannounced visit, surveyors observed multiple black and brown flakes on paper towels swiped along the inside bin of the ice machine, as well as dust, brown stains, and pest legs on the exterior. Water was found leaking from the plastic pipes, with runoff spilling onto the floor, and there was no indication of when the water filters had last been replaced. The Dietary Supervisor confirmed that the inside of the ice machine was supposed to be cleaned monthly and the exterior wiped down weekly, but was unsure of the last service date or water filter replacement. Interviews with the Director of Nursing and the maintenance supervisor revealed further issues. The DON observed the black and brown flecks and identified them as coming from the deteriorating rubber lining of the ice dispenser, which was cracking and breaking down. The DON also noted that water should not be leaking onto the floor and that the pipes needed to be secured. The maintenance supervisor stated that the ice machine was serviced by an outside company twice a year and that water filters were changed every six months, but admitted to not dating the filters and forgetting to activate the filter timer. The kitchen staff were responsible for daily cleaning, but the observed conditions indicated this was not being done consistently. A review of facility policies and manufacturer recommendations confirmed that the ice machine should be cleaned and sanitized monthly, with water filters replaced every six months or as needed. The policies also required all equipment to be kept clean, maintained in good repair, and free from breaks, corrosion, cracks, and chipped areas. Pest control was to be conducted monthly. Despite these requirements, the observed presence of dirt, pest remnants, deteriorating rubber, and undated water filters demonstrated a failure to follow established cleaning and maintenance protocols for the ice machine.
Failure to Maintain Sanitary Resident Care Equipment
Penalty
Summary
During an unannounced complaint investigation, surveyors observed that devices used for resident care were not maintained in a sanitary condition. Specifically, a pill crusher located on top of a medication cart was found coated with a brown, semi-soft, sticky substance in the area where pills are placed for crushing. This device was used for 15 out of 27 residents who required their medications to be crushed. Additionally, a stand lift machine (EZ-Up brand) used to assist a resident in standing was observed to have crumbs and white and beige colored flakes, including what appeared to be food debris and skin flakes, on the area where residents' feet are placed. Interviews with facility staff revealed uncertainty and inconsistency regarding responsibility for cleaning these devices. The LVN acknowledged the pill crusher had not been wiped down and should be cleaned before use, and expressed concern about the cleanliness of the stand lift machine, noting it looked dirty and needed cleaning. The administrator also observed the unclean equipment and stated that nurses should clean the pill crusher while housekeeping should clean the stand lift, but admitted there was a lack of clarity about who was responsible for cleaning equipment between uses. Review of facility policies confirmed requirements for cleaning and disinfecting environmental surfaces and maintaining an infection prevention and control program, but these were not followed in practice.
Failure to Maintain Safe and Functional Fire Door and Ceiling in Smoking Patio Area
Penalty
Summary
The facility failed to provide a safe and functional environment for two residents who independently used the smoking patio. Observations revealed that the fire door closer at the end of hallway 100 was dismantled, causing the door to not close properly. Both residents were seen struggling to close the door, with one nearly getting his fingers caught. The Maintenance Supervisor confirmed that he had dismantled the door closer to prevent the door from slamming shut, but acknowledged that the door now did not close completely and was not safe in the event of a fire. Additionally, the ceiling tile above the fire door exit sign was found to be stained, splitting, and deteriorating, with the Maintenance Supervisor noting a possible leak and the need for repair to prevent the tile from falling. Resident A, who has paraplegia and diabetes, was observed independently accessing the smoking patio and manipulating the malfunctioning door. Resident B, with cirrhosis of the liver and ascites, was also observed using the same door and nearly pinched his fingers while closing it. Both residents' care plans allowed for smoking, with Resident B requiring supervision and protective clothing. Facility policies required fire and smoke barrier doors to remain operable at all times and for staff to report any issues, but these procedures were not followed, resulting in the identified deficiencies.
Failure to Implement Fall Risk Monitoring System
Penalty
Summary
The facility failed to implement a system for identifying and monitoring residents at high risk for falls, as evidenced by the case of a resident who was observed with injuries consistent with a fall. This resident, who was admitted with diagnoses including muscle weakness, difficulty in walking, and dementia, was assessed as high risk for falls upon admission. Despite this, the staff did not have a system in place to communicate the resident's fall risk status to all relevant personnel, including non-nursing staff such as those in the activity department. Interviews with various staff members, including the Activity Director, Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Nursing, revealed a lack of awareness and communication regarding residents at high risk for falls. The staff did not have access to updated lists of high-risk residents, which hindered their ability to provide necessary supervision and interventions. The facility's policy on fall risk assessment, which requires collaboration among nursing staff, physicians, and therapy staff to establish a resident-centered falls prevention plan, was not effectively implemented, leading to the resident's fall and subsequent injuries.
Failure in Medication Reconciliation Leads to Missing Controlled Substances
Penalty
Summary
The facility failed to ensure a consistent and accurate reconciliation of controlled medications for two residents, leading to the loss of medications and the potential for inadequate pain management. Resident 1, who was admitted with acute respiratory failure, difficulty walking, and idiopathic peripheral neuropathy, had a physician's order for Norco 5/325 mg to be administered as needed for pain. Resident 2, admitted with osteoarthritis and osteoporosis, was prescribed Tramadol HCL for pain management. However, discrepancies in the medication count were identified, with missing Norco and Tramadol tablets, indicating a failure in the facility's medication reconciliation process. Interviews with staff revealed that the missing medications were discovered after a call from the pharmacy, and the Director of Nursing initiated an investigation. The investigation found that a bubble pack of Norco tablets and two bubble packs of Tramadol tablets, along with their respective narcotic count sheets, were missing. The facility's policy required controlled substances to be reconciled upon receipt, administration, and at the end of each shift, but this process was not followed, leading to the discrepancies. Staff interviews highlighted that the procedure for counting and verifying medications was not consistently adhered to, contributing to the loss of medications.
Failure to Document Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that the advance directives (AD) of three residents were properly documented and accessible in their medical records. For two residents, the facility did not have a copy of their formulated ADs available for review in their medical records. Resident 38, who was admitted with atrial fibrillation and esophageal cancer, had a formulated AD provided by their family, but it was not found in the resident's record. Similarly, Resident 76, admitted with cerebral infarction and sickle cell disease, had an AD but it was not available in their medical record. The facility's policy requires that copies of advance directives be maintained in the resident's medical record and be readily retrievable by staff. Additionally, the facility failed to ensure that the POLST form for another resident was completed to reflect the resident's treatment wishes. Resident 37, who was admitted with respiratory failure, had a POLST form signed by their representative, but it did not indicate the resident's treatment preferences in case of an emergency. The facility's policy states that the POLST form should be completed as part of the healthcare planning process and should reflect the resident's or their representative's treatment decisions. The lack of a completed POLST form could lead to staff being unaware of the resident's treatment wishes during an emergency.
Failure to Document and Administer Narcotic Medications Properly
Penalty
Summary
The facility failed to ensure that controlled medications, specifically narcotic medications used for pain management, were properly documented and administered according to physician orders for five residents. During an inspection, it was observed that narcotic medications were removed from the narcotic box but not documented on the Medication Administration Record (MAR) as administered to the residents. This discrepancy was noted for Residents 26, 32, 21, 6, and 39. Additionally, for Residents 26 and 39, the narcotic pain medication was not given as ordered by the physician, with instances where the medication was administered for severe pain but documented as given for moderate pain. Interviews with Licensed Vocational Nurse (LVN) 3 and the Director of Nursing (DON) confirmed that the licensed nurses should document the removal and administration of narcotic medications in the MAR and ensure the dosage matches the pain rate scale as per the physician's order. The facility's policies on administering pain medications and documentation of medication administration were not followed, leading to potential issues with medication management and accountability.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. In the medication storage room at Station 1, multiple over-the-counter and treatment medications were found to be expired or used, yet they were not discarded or disposed of as required. These items were mixed with medications intended for resident use, which was acknowledged by the Infection Preventionist and Minimum Data Set Coordinator as inappropriate. Additionally, three expired Luer Lock IV kits were found in the IV cart, and two bags of normal saline IV were unlabeled, posing a risk of contamination or infection. At Station 3, medications for two residents were improperly stored together despite being of different forms and routes, which could lead to administration errors. The Licensed Vocational Nurse confirmed that these medications should be stored separately. Furthermore, discontinued medications for three residents were found in the medication cart, which should have been removed to prevent accidental administration. The Director of Nursing confirmed that discontinued medications should not be present in the medication cart. Lastly, a medication bottle for a resident was found with an illegible label, making it impossible to identify the medication's name, dose, route, and frequency of administration. This was confirmed by both the Licensed Vocational Nurse and the Treatment Nurse, who stated that the label should be clear and readable. The Director of Nursing also acknowledged the issue, emphasizing the importance of legible labels to prevent medication administration errors.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Several issues were identified, including the improper stacking of wet food preparation and cooking pans, which were found stacked one on top of another in the 3-sink washing area and clean storage. This practice was confirmed by the Dietary Services Supervisor (DSS) as inappropriate and having the potential for cross-contamination and the spread of food-borne illness. Additionally, dust was observed on several kitchen storage shelves, equipment, and ventilation vents, which the DSS acknowledged could lead to cross-contamination and harm to residents. Further observations revealed rust on metal storage shelves, the back stove hood, and fire suppression water pipes, as well as chipped paint and dust on wooden shelves in the storage room. The DSS confirmed these conditions and acknowledged the potential for cross-contamination. The survey also noted broken and missing floor tiles in the walk-in refrigerator, walk-in freezer, and dishwashing machine area, with brown deposits in the cracked tiles and water pooling on the uneven floor. The DSS confirmed these issues and their potential to cause harm to residents. Additionally, a Dietary Aide (DA) was observed not following proper hygiene practices, as he did not remove gloves or wash his hands after handling trash before entering the supply room. This was acknowledged by both the DA and the DSS as a failure to prevent cross-contamination. The Registered Dietician (RD) confirmed the presence of broken tiles and water pooling but was unaware of other issues such as rust and improper stacking of wet pans. The facility's policies on preventing foodborne illness and maintaining sanitation were reviewed, indicating that these practices were not followed as required.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an environment free of pests, specifically black flies, in the kitchen area, which could potentially lead to foodborne illnesses among residents. On multiple occasions, black flies were observed flying and landing in areas where food was being prepared and plated for residents. During an observation and interview with the Dietary Services Supervisor (DSS), a black fly was seen flying over the back stove area, and the DSS confirmed that the fly should not have been present as it could cause cross-contamination of the residents' food. Further interviews and record reviews with the Registered Dietitian (RD) and the Maintenance Supervisor (MS) revealed that the facility had a known pest control issue with house flies, despite having a contract for regular pest control services. The RD and MS both expressed that their expectation was for the kitchen to be free of pests to prevent disease spread through cross-contamination. The facility's policy on fly and vermin control emphasized the importance of maintaining high sanitation standards and ensuring all doors and windows were properly screened, yet flies were still present in the kitchen, indicating a failure to adhere to these policies.
Failure to Provide SNF-ABN to Residents Transitioning to Custodial Care
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) to two residents, which is required when transitioning from skilled services covered by Medicare to custodial care. Resident 75 was readmitted from a general acute hospital and received skilled services under Medicare Part A from February 28, 2024, to April 12, 2024. Upon transitioning to custodial care on April 13, 2024, the resident was not given the SNF-ABN, which should have been provided to inform the resident of potential financial responsibility for services not covered by Medicare. Similarly, Resident 52's last covered day for skilled services was March 6, 2024, and the resident transitioned to custodial care on March 7, 2024, without receiving the required SNF-ABN. Interviews with the Business Office Manager and the Social Services Director confirmed that the SNF-ABN was not provided to either resident, despite the facility's policy indicating that it should be issued prior to providing care that Medicare may not cover. This oversight had the potential to leave residents uninformed about their financial liability for continued services.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set Assessment (MDS) for a resident who was reviewed for hospitalization. During an interview and record review, the MDS Coordinator acknowledged that the Discharge MDS Section A - Identification Information for the resident, dated March 29, 2024, incorrectly indicated that the resident was discharged to a short-term general hospital, whereas the resident was actually discharged to home. This inaccuracy in coding the MDS had the potential to cause errors in identifying the resident's care and support needs, potentially delaying the fulfillment of these needs.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to the physician's order and the facility's policy and procedure for two residents during a medication storage inspection. For Resident 192, several medications, including Levothyroxin, Metoprol Suc, Diltiazem, Eliquis, and Indapamide, were not administered on the prescribed dates and times. The Licensed Vocational Nurse (LVN) responsible for administering these medications admitted to not giving them as the resident was sleeping and he was busy. Despite this, the LVN signed the Medication Administration Record (MAR) as if the medications had been administered at the prescribed time. For Resident 51, medications such as Furosemide, Gabapentin, and Spironolactone were not administered on the prescribed dates because the LVN could not locate them after the resident was moved to a different station. The LVN attempted to order the medications from the pharmacy but was informed it was not time for a refill. Additionally, other medications, including Tiotropium bromide, Arformeoterol tartrate, and Budesonide inhalation, were also not administered as they could not be found. The LVN signed the MAR indicating these medications were administered, despite acknowledging they were not given. The Director of Nursing (DON) confirmed that medications should be administered according to the physician's order and the facility's policy, which includes documenting any medications not administered and the reasons why. The facility's policy on medication administration documentation requires recording the date and time of administration and reasons for withholding or not administering medications.
Undated Humidifier Bottle on Oxygen Concentrator
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 77, by not ensuring that the humidifier bottle connected to the resident's oxygen concentrator was dated. This oversight was observed on June 26, 2024, when Resident 77 was seen sitting upright in bed with an oxygen concentrator delivering oxygen at a rate of 2 liters per minute via nasal cannula. The humidifier bottle, which is essential for increasing moisture and reducing dryness from the oxygen, was found undated, which could potentially place the resident at risk for infection and respiratory failure. Interviews conducted with the Infection Preventionist and a Certified Nursing Assistant confirmed that the humidifier bottle was not dated, as required by the facility's policy. The Infection Preventionist stated that the humidifier bottle should be dated and replaced daily to prevent infection risks. A review of Resident 77's medical records revealed that the resident had been admitted with diagnoses including sepsis and COVID-19, and had a physician's order for oxygen administration at 2-3 liters per minute via nasal cannula. The facility's policy on oxygen administration, dated October 2010, mandates that the date and time be recorded for equipment used during oxygen administration, including the humidifier bottle.
Failure to Assess Necessity of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary for managing mental illness in a resident diagnosed with depression and schizophrenia. The resident was initially prescribed risperidone for schizophrenia manifested by delusions of persecution. A gradual dose reduction was recommended by the psychiatrist, and the medication was eventually discontinued. However, upon the resident's readmission to the facility, risperidone was reordered without any documented assessment or evaluation by the interdisciplinary team (IDT) or psychiatrist. The Director of Nursing confirmed that there was no documentation of an assessment or evaluation prior to the reinitiation of risperidone. The facility's policy requires an evaluation by the IDT to determine the clinical significance of symptoms before initiating or modifying medication therapy. The lack of evaluation and assessment before resuming the medication led to the potential for the resident to receive unnecessary psychotropic medication, placing them at risk for adverse reactions.
Failure to Complete Ordered HgbA1C Tests for a Resident
Penalty
Summary
The facility failed to ensure that laboratory orders for hemoglobin A1C (HgbA1C) tests were completed as ordered for a resident with diabetes mellitus. The resident was admitted with a diagnosis of diabetes mellitus and had physician orders for insulin medications and laboratory tests to monitor blood sugar levels. Specifically, the orders included a baseline HgbA1C test on January 14, 2024, and a routine HgbA1C test on April 17, 2024. However, there was no documented evidence that these laboratory tests were completed as ordered. During an interview and record review on June 28, 2024, the Director of Nursing (DON) confirmed the absence of HgbA1C test results for the specified dates. The DON contacted the contracted laboratory, which confirmed that no HgbA1C tests were conducted for the resident on the ordered dates. The facility's policy and procedure for laboratory and diagnostic test results, revised in November 2018, outlined the process for ordering and completing diagnostic tests, which was not followed in this instance.
Infection Control and Reporting Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures for Resident 85, who was readmitted with an intravenous (IV) site that was not assessed or changed according to the facility's policy. On observation, the IV dressing was undated, unlabeled, and lifting, which was acknowledged by the Licensed Vocational Nurse (LVN) and Registered Nurse (RN) during interviews. The RN admitted that the IV should have been labeled and assessed upon the resident's readmission, and the dressing should have been changed every seven days or as needed. The facility's policy required the IV dressing to be labeled with the date, time, and initials at the time of insertion, which was not followed. Additionally, the facility did not report a COVID-19 outbreak in a timely manner to the California Department of Public Health (CDPH). The first positive COVID-19 case was identified on June 8, 2024, but the facility did not report the outbreak until June 25, 2024, when the survey team was informed. The Infection Preventionist (IP) incorrectly believed that an outbreak was only reportable if there were three positive cases, despite the All Facilities Letter (AFL) indicating that even one facility-acquired COVID-19 case should be reported. The facility's policy also required prompt reporting of communicable diseases to the appropriate health department, which was not adhered to. The deficiencies in infection control and reporting procedures were identified through observations, interviews, and record reviews. The failure to assess and label the IV site for Resident 85 and the delayed reporting of the COVID-19 outbreak were not in compliance with the facility's policies and procedures, potentially compromising resident safety and effective outbreak management.
Failure to Implement Appropriate Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure appropriate interventions were developed and implemented to address the high risk for fractures in a resident with severe osteoporosis and a history of fractures. Resident A sustained a leg fracture on September 8, 2023, during a transfer using a Hoyer lift, but no further assessment or evaluation was conducted to determine if the resident was still a candidate for transfer using the Hoyer lift. Additionally, an individualized care plan to prevent further fractures during transfers was not developed for Resident A. On February 10, 2024, Resident A sustained a second fracture after being transferred to a geri-chair using the Hoyer lift. Interviews with the Director of Nursing (DON) and Certified Nursing Assistants (CNAs) revealed that the staff were aware of Resident A's severe osteoporosis and contractures, but continued to use the Hoyer lift for transfers without exploring alternative methods or equipment. The DON admitted that no further assessment or evaluation was conducted after the first fracture, and no individualized care plan was created to address the specific risks associated with using the Hoyer lift for Resident A. The facility's policy on safety and supervision of residents emphasizes the importance of individualized, resident-centered approaches to safety and the implementation of interventions to reduce accident risks. However, the facility failed to adhere to this policy by not reassessing Resident A's transfer method after the initial fracture and not developing a care plan to prevent further injuries. This oversight resulted in Resident A sustaining a second fracture, highlighting the facility's failure to provide adequate supervision and appropriate interventions for high-risk residents.
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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