Dept Of State Hospitals - Metropolitan Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 11401 South Bloomfield Avenue, Norwalk, California 90650
- CMS Provider Number
- 555731
- Inspections on file
- 40
- Latest survey
- March 7, 2026
- Citations (last 12 mo.)
- 28 (2 serious)
Citation history
Health deficiencies cited at Dept Of State Hospitals - Metropolitan Snf during CMS and state inspections, most recent first.
The facility failed to define resident‑to‑resident acts as abuse in its P&P and training, causing multiple resident‑to‑resident physical and alleged sexual assaults to be treated only as "altercations" rather than abuse. In one case, a highly dependent resident with a trach, G‑tube, and vision loss was punched in the face while sleeping by a resident with schizophrenia and a violent history, who alleged the other resident tried to have sex with him; staff did not classify this as physical or sexual abuse, did not initiate an abuse investigation, and delayed reporting to the state. In another case, a non‑ambulatory resident at high risk for violence kicked a resident with gait instability and a healing femur fracture, who then punched him three times in the face; this was not recognized as abuse, was reported late, and no enhanced monitoring or medication changes were implemented despite subsequent aggression. A third incident involved two residents with known DTO histories and moderate violence risk, where one struck the other in the chin during a verbal altercation; again, the event was not treated as abuse, reporting and SOC 341 completion were delayed, and behavioral care plans were missing or outdated despite ongoing aggressive behaviors. These failures, rooted in P&P and training that explicitly excluded resident‑to‑resident acts from abuse definitions, led to missed screening, protection, investigation, and timely reporting, and resulted in an Immediate Jeopardy finding under F607.
A resident with significant medical fragility, including a trach and G-tube, was punched in the face while sleeping by another resident with schizophrenia and a documented history of assault and moderate risk for violence. Staff and medical records showed the aggressive resident had previously attempted to hit staff, reported hearing voices to hurt others, and stated he would continue attacking people to secure discharge. Despite these known risks and facility policies requiring individualized treatment plans and monitoring for danger to others, the aggressive resident was not adequately supervised or managed, allowing him to enter the vulnerable resident’s room and inflict a facial laceration requiring wound care.
Surveyors found that staff were inadequately trained to recognize and report abuse when one resident punched another, causing a facial laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Multiple RNs and supervisory staff reported that their annual abuse training addressed only staff-to-resident abuse and that they did not consider resident-to-resident physical or sexual incidents to be abuse. Review of the facility’s policies and training materials confirmed that definitions of physical, psychological, verbal, and sexual abuse were limited to actions by someone other than another patient, resulting in resident-to-resident abuse not being identified or reported as required.
The facility failed to timely report multiple resident-to-resident abuse allegations as required by its own policy and regulatory standards. In three separate incidents, one resident punched another in the face causing a laceration after an alleged unwanted sexual advance, two residents engaged in a physical altercation involving kicking and repeated punching, and another resident allegedly punched a peer in the chin following a verbal dispute. These events were reported to the state survey agency days after they occurred instead of within the mandated 2-hour window, and the PRA was not notified of any of the physical or sexual abuse allegations.
Two residents were involved in an incident where one resident with schizophrenia punched another medically complex, wheelchair-dependent resident in the face while he was sleeping, causing a laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Nursing and clinical staff documented the injury and allegation but did not conduct further questioning, did not treat the physical or alleged sexual assault as abuse, and did not complete required SOC 341 abuse reports or notify the Patients’ Rights Advocate. Psychiatrists did not promptly evaluate the residents in relation to the allegation, and the facility reported the events to the state agency several days later instead of within the required 2-hour window, and did not submit investigation results within 5 working days as required by facility policy and regulations.
A resident with cognitive impairment and seizure history, identified as high risk for falls, was able to manipulate and open the zipper of an enclosure bed due to staff not properly securing it or a zipper malfunction. The resident subsequently fell from the bed despite being on 15-minute safety checks, as staff failed to ensure the bed was properly secured in accordance with facility policy.
A resident with a mental health diagnosis disclosed past physical and sexual abuse to a psychologist, but the psychologist did not report the allegation or complete required documentation as mandated by facility policy. Multiple staff confirmed that no incident report or notifications to authorities were made, resulting in a delay in the investigation process.
A psychiatric technician employed since 2017 did not receive any annual performance evaluations, as required by facility policy. The HR manager and unit supervisor confirmed the absence of these evaluations, citing oversight as the reason for non-compliance.
A facility failed to document a resident's leaking G-Tube, as observed by a Psychiatric Technician after the resident returned from dialysis. Despite notifying a registered nurse, the incident was not recorded in the medical records, violating the facility's policy for documenting abnormalities in G-Tube care.
The facility failed to maintain an effective infection prevention and control program, with deficiencies involving six residents. Trash and linen carts were improperly placed outside an isolation room, and staff did not use appropriate PPE during wound care and personal hygiene activities, contrary to Enhanced Barrier Precautions guidelines. This lack of adherence to infection control policies placed residents at risk of cross-contamination and infection spread.
The facility lacked a written QAPI plan for its Skilled Nursing units, failing to identify systemic issues related to infection prevention and enhanced barrier precautions (EBP). Interviews with a Supervising RN revealed the absence of data tracking and trending, and the facility's policy on quality assurance was not followed, leading to ineffective monitoring and evaluation of patient care quality.
The facility's QAA committee failed to include the Infection Preventionist/Public Health Nurse II in its meetings, as noted in the Quality Council Minutes from two separate dates. The facility's policy did not list the Infection Preventionist as a required member, contributing to this oversight.
The facility failed to implement an effective infection control training program for all staff by not developing a written policy and training on Enhanced Barrier Precautions (EBP). Staff interviews revealed a lack of awareness and training on EBP, with admissions of not using gowns during wound care. The facility was unable to provide a policy for EBP, potentially affecting the safety and infection control among residents.
Two residents were not treated with dignity during meal times as staff stood while feeding them, contrary to facility policy requiring seated interaction. One resident was nonverbal and the other was at risk for choking, highlighting the importance of following procedures for a respectful dining experience.
The facility failed to ensure that two residents had their call lights within reach, potentially resulting in unmet needs. One resident with a history of mental health and neurocognitive disorders was observed with the call light out of reach in an enclosure bed. Another resident was repeatedly observed with the call light hanging from the wall and out of reach, despite staff acknowledging the requirement for accessibility as per facility policy.
A resident with a gastrostomy tube did not receive the prescribed amount of tube feeding due to the feeding pump being left on hold. The pump was set to deliver 60 ml per hour, but the resident only received 470 ml instead of the 660 ml ordered by the physician. This deficiency was confirmed by nursing staff and the registered dietitian.
The facility failed to ensure food safety and sanitation by having unclean, chipped, and stained food trays, expired food items in storage, a dented can improperly stored, and a marred cutting board in use. These issues were contrary to the facility's policies, which require proper cleaning, sanitization, and monitoring of food items and equipment.
The facility failed to maintain cleanliness in food storage areas, with grape juice cups, chipped wood debris, and plastic wrappers found on the floors of the warehouse and walk-in freezer. The Dietetics Director and Assistant Dietetics Director acknowledged that these areas should have been cleaned, as per the facility's policy, which requires daily sweeping and proper disposal of garbage.
A facility failed to provide a qualified interpreter for a Spanish-speaking resident, leading to communication barriers. Staff used unapproved interpreters, including other residents, to communicate with the resident, raising concerns about translation accuracy. The resident's care plans indicated the need for an interpreter, but the facility lacked a process to ensure availability each shift, despite policy requirements.
A resident, who is blind and requires moderate assistance for ambulation, fell and sustained a scalp contusion due to the facility's failure to implement fall prevention interventions. A nurse observed the resident standing unassisted but did not intervene, contrary to the resident's care plan and the facility's fall prevention policy.
A resident experienced a fall resulting in a fractured finger due to the facility's failure to implement fall prevention measures. Despite the resident's documented need for supervision and a walker, a nurse observed her walking without assistance and did not intervene. The facility's policy required registered nurses to oversee fall prevention strategies, which were not adhered to in this case.
A resident with severe cognitive impairment was assaulted by another resident with a history of behavioral disturbances, resulting in significant injuries. Despite previous incidents of aggression, no interventions were implemented for the aggressive resident, who was roomed with the vulnerable resident due to a COVID quarantine. The facility's failure to monitor and manage the aggressive resident's behavior led to the assault.
Failure to Define and Manage Resident‑to‑Resident Abuse, Leading to Unrecognized and Unreported Assaults
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement abuse policies and procedures that clearly define all forms of abuse, including resident‑to‑resident abuse, which led to multiple resident‑to‑resident physical and alleged sexual assaults not being recognized, reported, or investigated as abuse. The facility’s written abuse P&P, incident management P&P, and related training materials explicitly limited abuse definitions to acts committed by someone other than another patient, and sexual abuse to employee‑patient contact or employee‑facilitated patient contact. As a result, staff, including the Standards Compliance Director, Standards Compliance Supervising RN, Program Director, RN Shift Lead, and other nursing staff, consistently stated that resident‑to‑resident physical or sexual assaults were not considered abuse and therefore did not trigger abuse investigations, SOC 341 completion, or 2‑hour reporting to CDPH. One incident involved a resident with significant physical impairments, including absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating, and wheelchair dependence, who sustained a 1.2 cm laceration above the right eyebrow with bruising after being punched in the face while sleeping by another resident. The aggressor resident had schizophrenia, a criminal history of assault with force likely to produce great bodily injury, and was assessed as a moderate risk for violence against others. Staff documented that the aggressor stated he punched the other resident because the resident “tried to have sex with me,” and the injured resident reported the attack was unprovoked. Despite this, the incident was treated as a physical altercation rather than abuse, the alleged sexual component was not treated as sexual assault or abuse, no abuse investigation was conducted, and the report to CDPH was delayed until three days later because the facility did not consider resident‑to‑resident events to meet its definition of abuse. The covering psychiatrist did not evaluate either resident at the time and was unaware of the sexual abuse allegation, and there was no treatment plan or interventions in place to address the aggressor’s known aggressive behaviors or to protect other residents. A second incident involved a resident with gastrostomy status, pulmonary fibrosis, nonfunctional ambulation, and a high risk for violence against others, who kicked another resident using a front‑wheel walker in the buttocks, prompting the second resident, who had unsteadiness on feet, blindness in one eye, and a healing femur fracture with a past history of danger‑to‑others behaviors, to turn and punch the first resident in the face three times. This event was documented in the interdisciplinary notes as a physical altercation in the day hall. The facility’s leadership confirmed that resident‑to‑resident abuse was not included in the abuse P&P and that there was no separate P&P addressing protection and prevention of resident‑to‑resident abuse. The altercation was not reported to CDPH within 2 hours but instead two days later, and the resident who retaliated did not receive medication changes or enhanced monitoring after the incident, despite later having another aggressive outburst toward staff. A third incident involved two residents both assessed as moderate risk for violence against others, one with a back fracture, epilepsy, and a significant history of danger‑to‑others behaviors, and the other with a history of verbalizing thoughts of harming another resident. Staff heard yelling in the day hall and found the two residents in a verbal altercation when one resident struck the other, who reported being hit in the chin. The striking resident later stated he used a closed fist to touch the other resident’s chin to make him stop cursing and yelling. This event was also treated as a resident‑to‑resident altercation rather than abuse, resulting in delayed reporting to CDPH by two days and delayed completion of the SOC 341 until several days after the incident, instead of by the end of the shift. The psychologist later confirmed that one resident had an extensive history of verbal aggression with prior alleged physical altercations and no behavioral care plan, and that another resident’s behavioral care plan had not been updated in over a year despite aggressive incidents and stated intent to harm another resident. Across these incidents, the facility’s P&P, definitions, and staff training excluded resident‑to‑resident acts from the abuse framework, leading to failures in recognizing, preventing, investigating, protecting, and timely reporting abuse, and placing all residents at risk of unreported and unmitigated abuse. On 3/5/2026, surveyors declared an Immediate Jeopardy related to the lack of written policies and procedures prohibiting and preventing abuse that included resident‑to‑resident abuse, and to staff competency in identifying, preventing, screening, investigating, protecting, and reporting abuse under F607.
Removal Plan
- Treat physical altercations, sexual allegations, possible mental or psychological abuse, and exploitation in the SNF area as potential abuse allegations.
- Complete an SOC 341 form for each allegation of an abuse incident.
- Verify completion of SOC 341 by the RN Health Services Specialist/Supervising Registered Nurse prior to the end of the shift.
- Update reporting of unusual occurrences related to possible abuse incidents to ensure compliance with the reporting requirement.
- Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within the required timeframe.
- Program VI manager on call/unit shift lead will notify CNS for HSS to complete reporting within the required timeframe.
- Issue a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting, clarifying resident-to-resident incidents must be treated as potential abuse, and including CMS SOM reference, recognition/identification, screening, prevention/protection measures, early intervention/behavioral monitoring expectations, investigation/documentation requirements, reporting requirements, and SOC 341 completion.
- Require SRN attestation that staff can verbalize understanding of the memo/education, track training via a tracking log, and provide clarification as needed to ensure staff understand the abuse screening and reporting process.
- Issue a written memorandum for all registry nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide training via memorandum to non-nursing clinical staff and ancillary staff on federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide additional staff training regarding intervention protocols to enhance behavioral monitoring and intervention strategies for residents identified as high risk for behavioral escalation or aggression, including identification of high-risk residents, enhanced monitoring/supervision strategies, early interventions/de-escalation techniques, implementation of individualized behavioral interventions, documentation, and communication to the interdisciplinary team.
- Conduct an analysis of the physical environment, staffing, supervision, and resident assessment/care planning/monitoring to identify, correct, and intervene in situations where possible abuse, neglect, or misappropriation of resident property is more likely to occur.
- Update Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental or psychological abuse, sexual allegations, and exploitation as potential abuse, including expectations for abuse screening, investigations, and reporting requirements.
- Conduct an ongoing review of all incident reports involving resident-to-resident altercations or allegations to ensure SOC 341 reports are completed and reporting timelines are met.
Failure to Protect Resident From Assault by Known Violent Peer
Penalty
Summary
The deficiency involves the facility’s failure to protect a medically fragile resident from physical abuse by another resident who had been previously identified as a moderate risk for violence against others. Resident 1’s MDS showed he had an absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating needs, and required a wheelchair for ambulation. On observation, Resident 1 was seen in bed with a noticeable laceration and bruising above the right eyebrow, and he reported that another resident attacked him in his sleep without provocation. A nurse later observed dried blood above Resident 1’s eyebrow, and Resident 1 again reported that he had been punched in the face while sleeping. Resident 2’s treatment plan documented diagnoses including schizophrenia and a criminal history of assault by means of force likely to produce great bodily injury, and an evaluation on 1/22/2026 identified Resident 2 as a moderate risk for violence against others. Staff interviews indicated that Resident 2’s medical condition had improved to the point that he was highly ambulatory and no longer medically fragile. The Registered Nurse Shift Lead stated she was not surprised by the incident because Resident 2 had attempted to punch a staff member in October 2025, and a prior recommendation from the state hospital indicated Resident 2 should be carefully monitored due to a demonstrated history of violent behaviors. Despite these known risks, Resident 2 was able to access Resident 1’s room and punch him in the face while he slept. Subsequent documentation and interviews confirmed Resident 2’s aggressive behavior and intent. During an interview, Resident 2 admitted punching Resident 1 and stated he did so because he believed Resident 1 wanted to have sex with him. Physician progress notes recorded that Resident 2 told staff he was hearing voices to hurt others, that he had attacked a peer and caused injury, and that he would continue hitting people until he was discharged. The facility’s policies on reporting abuse and on treatment planning required that abuse not be tolerated and that treatment plans address individualized risks, including danger to others, and that mini-team conferences be held after episodes of aggression. The failure to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, despite documented risk factors and prior aggressive behavior, led to Resident 1 being physically assaulted and injured while asleep.
Failure to Train Staff on Recognition and Reporting of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse, as required by Federal regulations. Surveyors reviewed an interdisciplinary note for one resident dated 2/7/2026, which documented that this resident was punched in the face by another resident, resulting in a 1.2 cm laceration to the right upper eyebrow that required medical attention. The note further documented that the resident who did the punching told staff, “I punched him early in the morning because he tried to have sex with me,” indicating an alleged attempted sexual contact and a physical assault between residents. During interviews, multiple staff members demonstrated that they did not recognize resident-to-resident physical or sexual incidents as abuse. One RN stated he received annual abuse training that covered only staff-to-resident abuse, reporting, and prevention. Another RN described finding dried blood above a resident’s right eyebrow, being told by that resident that another resident had punched him while he was sleeping, and then being told by the alleged aggressor that he hit the resident because the resident wanted to have sex with him. This RN characterized the incident as a physical altercation rather than abuse and did not consider the allegation of attempted sexual contact to be sexual assault or abuse, despite confirming he had received annual abuse training. Additional interviews with the Registered Nurse Shift Lead, the Program Director, and the Nursing Coordinator showed a consistent belief that only staff-to-resident physical or sexual assault constituted abuse and that residents could not be perpetrators of abuse. Review of the facility’s abuse training materials and policies showed that the definitions of physical, psychological, verbal, and sexual abuse were limited to actions by “someone other than another patient,” and sexual abuse was defined in terms of employee conduct or employee allowance of sexual contact between patients. These policy definitions and training content excluded resident-to-resident abuse, contributing directly to staff’s inability to recognize and report the resident-to-resident physical and alleged sexual assault as abuse for two sampled residents.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify and report resident-to-resident physical and sexual abuse allegations within the required timeframe for three separate incidents. In the first incident, one resident punched another in the face, causing a laceration above the right eyebrow, after alleging that the other resident attempted to engage in unwanted sexual activity. The Standards Compliance Supervising RN confirmed the incident and the sexual assault allegation but stated that the department of standards and compliance was not open over the weekend and that she did not consider resident-on-resident physical and/or sexual assault as abuse, so it was not reported within 2 hours. The facility’s own policy, however, defined abuse of a dependent adult/elder to include physical abuse and sexual assault and required all alleged violations involving abuse in skilled nursing units to be reported to CDPH immediately, but not later than 2 hours after the allegation. The Patients’ Rights Advocate (PRA) also reported not receiving any notification of physical and/or sexual assault or abuse related to this incident. In the second incident, one resident kicked another in the buttocks without provocation, and the second resident retaliated by punching the first resident in the face three times. The Standards Compliance Director confirmed that this physical altercation was not reported to CDPH until two days after it occurred, despite the policy requiring reporting within 2 hours, and the PRA stated he had not received any notification of physical abuse for either resident. In the third incident, a resident allegedly punched another resident in the chin following a verbal altercation; the Standards Compliance Director again confirmed that this allegation was not reported to CDPH until two days after the incident, and the PRA reported no notification of this physical abuse allegation. Across all three events, the facility did not follow its policy requiring immediate, but no later than 2-hour, reporting of all alleged abuse to CDPH and failed to notify the PRA of the allegations.
Failure to Investigate and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to treat resident-to-resident physical and sexual assault allegations as abuse, to conduct thorough investigations, and to report results to the State Survey Agency within required timeframes. One resident with schizophrenia (Resident 2) alleged that another resident (Resident 1) tried to have sex with him, and also admitted to punching that resident in the face. Interdisciplinary notes dated 2/7/2026 documented that Resident 1 sustained a 1.2 cm laceration to the right upper eyebrow requiring medical attention after being punched by Resident 2. Standards Compliance Supervising RN confirmed that these incidents were not considered abuse by the facility because they involved resident-to-resident physical and sexual assault, and therefore were not reported to the California Department of Public Health (CDPH) within 2 hours; instead, they were reported three days later. The facility did not conduct a thorough investigation into the alleged sexual assault. RN 2 stated he interviewed Resident 2, who reported he hit Resident 1 because he was trying to have sex with me, but RN 2 did not ask any further questions. The Program Director reported that after speaking with nursing staff and the treatment team, they concluded there was no validity to the sexual assault allegation and determined it was a delusion, and therefore did not investigate it as abuse or complete a SOC 341 suspected abuse report. Resident 2’s medical record did not contain a physician report following the sexual assault allegation, and the temporarily assigned psychiatrist did not see or evaluate Resident 2 until three days after the incident and did not address the allegation. The on-call psychiatrist on the date of the incident did not go to the unit to evaluate Resident 2 after the allegation, and the Patients’ Rights Advocate was not notified of the allegation. The facility also failed to investigate the physical assault on Resident 1 as abuse and to follow its own abuse reporting policies. Resident 1, who had multiple complex medical conditions including absence of the left eye, a tracheostomy, a gastrostomy tube, need for assistance, difficulty communicating needs, and use of a wheelchair for ambulation, was punched in the face by Resident 2 while sleeping, resulting in a laceration requiring medical attention. The Program Director stated that resident-on-resident physical assault was not considered abuse and that only staff could be perpetrators, so the incident was not investigated as abuse and a SOC 341 was not completed. The psychiatrist who saw Resident 1 four days after the incident focused only on medical issues related to the tracheostomy and did not address the physical assault. The Patients’ Rights Advocate was not notified of the physical assault, and the on-call psychiatrist did not evaluate either resident after being informed of the incident. These actions and inactions occurred despite facility policies defining physical abuse as including assault and requiring immediate completion of SOC 341, protection and counseling for the resident, notification of the Patients’ Rights Advocate, immediate reporting of alleged abuse to CDPH within 2 hours, and submission of investigation results to CDPH within 5 working days. The facility’s written policies on rape or sexual assault of elder/dependent adults and on reporting patient abuse and neglect required immediate medical attention, supportive counseling, evidence gathering, completion of SOC 341, physician reporting, and prompt reporting to CDPH for all alleged abuse, including in skilled nursing units. The policies also required that all alleged violations involving abuse be reported immediately but not later than 2 hours if the events involved abuse, and that results of investigations or follow-up reports be submitted to CDPH within 5 working days. In the incidents involving Residents 1 and 2, the facility did not follow these policies: alleged sexual assault and physical assault were not treated as abuse, SOC 341 forms were not completed, the Patients’ Rights Advocate was not notified, physician evaluations and reports were delayed or omitted, and the results of investigations were not submitted to the State Survey Agency within 5 working days because investigations were not conducted.
Failure to Ensure Enclosure Bed Safety Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of neurocognitive disorder, epileptic seizures, and traumatic brain injury, who was identified as high risk for falls, experienced a fall from an enclosure bed. The enclosure bed, designed with mesh walls and a zipper to prevent falls, failed to provide adequate protection when the net zipper malfunctioned or was not properly secured. Staff had previously observed the resident inspecting and attempting to manipulate the zipper while inside the bed. On the day of the incident, the resident was found on the floor after managing to open the zipper, either due to a malfunction or because it was not properly secured by staff. Record reviews and staff interviews revealed that the resident was on 15-minute supervision for safety at the time of the unwitnessed fall. Facility policy required nursing staff to ensure all zippers were secure and clipped during rounds, whether the bed was occupied or unoccupied. However, staff did not ensure the enclosure bed was properly secured or in good working condition, which contributed to the resident's ability to open the bed and fall.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for reporting allegations of abuse when a resident with schizoaffective disorder, bipolar type, disclosed to a psychologist that they had been beaten and raped. The psychologist documented the disclosure in a progress note but did not report the allegation to her supervisor, program management, or standards and compliance, nor did she complete the required incident report or SOC 341 form. The psychologist believed that abuse occurring in a different facility did not require reporting, despite facility policy stating that all allegations, regardless of when or where they occurred, must be reported if not previously documented. Interviews with facility staff, including the Standards and Compliance officer, Psychologist Director, Unit Supervisor, and Program Director, confirmed that no incident report was filed, and the required notifications to the state survey agency and other authorities were not made. The facility's policies clearly require immediate reporting and documentation of all abuse allegations, including those reported to have occurred prior to admission or in other facilities, but these procedures were not followed in this case.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a psychiatric technician who had been employed since November 2017, resulting in eight missed evaluations. During a review of the employee's file, it was confirmed by the Staff Services Manager HR that no performance evaluations had been conducted, despite facility policy requiring annual appraisals. The Unit Supervisor acknowledged that she had not completed any evaluations for the employee, attributing the omission to oversight. The facility's policy and procedure document specified that supervisors and managers are responsible for preparing annual performance appraisal summaries for their assigned employees.
Failure to Document G-Tube Leakage
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident with a leaking Gastrostomy-tube (G-Tube). The resident, who had a history of schizophrenia, end-stage renal disease, essential hypertension, heart failure, and type 2 diabetes mellitus, was admitted to the facility and required a G-Tube for nutrition. On a specific date, a Psychiatric Technician (PT) observed that the resident's G-Tube dressing was saturated with clear liquid, and the abdominal binder was wet after the resident returned from dialysis. The PT notified the registered nurse about the situation but did not document the assessment in the treatment record. During a review of the resident's medical records, it was confirmed that there was no documentation of the leaking G-Tube in the Interdisciplinary Note (IDN) or the Medication and Treatment Record. The facility's policy and procedure for enteral tubes required that any abnormalities or refusals discovered during G-Tube care should be documented in an IDN. However, the Registered Nurse Mentor (RNM) confirmed that no such documentation was present in the resident's medical record, indicating a failure to adhere to the facility's documentation policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving six residents. For Resident 7, trash and linen carts were improperly placed outside the isolation room, contrary to the facility's policy that requires these carts to be inside the room to contain infection. Additionally, a psychiatric technician accepted a water pitcher from Resident 7, who was on isolation precautions, without wearing gloves, risking the transmission of influenza. In the case of Resident 36, a registered nurse and a psychiatric technician performed wound care using only gloves and masks, without the required gowns, despite the resident having unstageable pressure injuries. This was a breach of the Enhanced Barrier Precautions (EBP) guidelines, which mandate gown and glove use during high-contact care activities for residents with wounds. Similarly, Resident 1 received wound care without the use of a gown, and the staff involved were unaware of the EBP guidelines, indicating a lack of training and policy implementation. Further deficiencies were noted with Residents 35, 11, and 54, where staff failed to wear gowns during personal hygiene and dressing changes, despite the presence of conditions such as MRSA colonization and pressure injuries. The facility's policies and procedures were not followed, and there was a lack of awareness and training regarding EBP among the staff, contributing to the risk of cross-contamination and the spread of infections.
Lack of QAPI Plan in Skilled Nursing Units
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place for the Skilled Nursing units, which is essential for evaluating and improving the quality of resident care and services. During interviews with the Supervising Registered Nurse (SRN) 3, it was revealed that there was no existing QAPI plan, and the facility was not actively tracking or trending data related to the program and residents. This lack of a structured QAPI plan resulted in the facility's inability to identify systemic problems, particularly concerning infection prevention and enhanced barrier precautions (EBP). The facility's policy and procedure document, titled 'Quality Assurance' and dated 5/3/24, outlined the purpose of the Quality Assurance Program as establishing a systemic process to monitor and evaluate patient care quality. However, the facility did not adhere to this policy, as evidenced by the absence of a QAPI plan and the failure to discuss EBP during QAPI activities. This deficiency highlights the facility's inability to implement and report on activities and mechanisms for monitoring and evaluating the quality of patient care, as required by the governing body.
QAA Committee Lacks Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee had the required members in attendance, specifically the Infection Preventionist/Public Health Nurse II for the Skilled Nursing unit. This was identified during a concurrent interview and record review with the Standards Compliance Director (SCD) on November 8, 2024, where the SCD acknowledged the absence of the Infection Preventionist in the Quality Council Minutes from the September 5, 2024 meeting. Additionally, a review of the Quality Council Minutes from April 23, 2024, also indicated the absence of the Infection Preventionist. The facility's Policy and Procedure titled 'Risk Management,' dated July 8, 2024, did not list the Infection Preventionist as a required member of the Quality Council under section 4.3.1, which contributed to this oversight.
Lack of EBP Training and Policy in Facility
Penalty
Summary
The facility failed to maintain an effective infection control training program for all 94 staff members by not developing a written policy and training regarding Enhanced Barrier Precautions (EBP). EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the spread of infections. During an observation, it was noted that there was no personal protective equipment (PPE) cart or EBP signage by the door of a resident's room who had unstageable pressure injuries. Interviews with various staff members, including the Interim Infection Preventionist, Registered Nurse, Psychiatric Technician, RN Shift Lead, Supervising RN, and Nursing Coordinator, revealed a lack of awareness and training on EBP. The staff admitted to not using gowns during wound care and were unaware of the EBP guidelines. The facility was unable to provide a policy for EBP upon review, and staff interviews confirmed that no training had been conducted. The Interim Infection Preventionist and other staff members acknowledged that they were not up to date with EBP and that the facility's policy did not address it. The lack of training and policy on EBP had the potential to negatively affect the facility's ability to maintain a safe environment and prevent the spread of infectious diseases among the 54 residents in the facility.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during meal times for two residents. In the first instance, a registered nurse (RN) was observed standing while feeding a nonverbal resident in bed, which did not allow for eye-level interaction. The RN acknowledged that standing over the resident could be intimidating and affect the resident's dignity. The facility's policy required staff to be seated and attentive when feeding residents, which was not followed in this case. In the second instance, another RN was observed standing while assisting a resident with drinking in the dining room. This resident was at risk for choking, and the RN admitted that he should have been seated while assisting the resident. The facility's policy also required staff to remain seated and attentive when feeding residents, which was not adhered to. Both instances highlight a failure to provide a respectful and dignified dining experience as per the facility's established procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which could potentially result in unmet needs. Resident 357, who has a history of schizoaffective disorder, bipolar type, and major neurocognitive disorder due to traumatic brain injury, was observed in an enclosure bed with the call light dangling outside and out of reach. During interviews, both a Psychiatric Technician and a Registered Nurse acknowledged that the call light should have been accessible to the resident, as per the resident's care plan and the facility's policy and procedure on call light use. Similarly, Resident 26 was observed multiple times with the call light hanging from the wall and out of reach. A Registered Nurse confirmed that the call light should have been within reach, and a Supervising Registered Nurse stated that rounds were conducted every 30 minutes to ensure resident safety, including the accessibility of call lights. Despite these procedures, the call light was repeatedly found out of reach during observations, indicating a failure to adhere to the facility's policy and procedure on call light use.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide tube feeding according to the doctor's order for a resident with a gastrostomy tube (GT). During an observation, the resident's tube feeding pump was found alarming and not delivering the prescribed nutrition. The feeding pump was set to deliver 60 milliliters of liquid nutrition per hour, but the pump was left on hold after patient care, resulting in the resident not receiving the correct amount of tube feeding. The registered nurse shift lead confirmed the pump was not infusing and was unaware of the duration or the amount of feeding missed. Further interviews revealed that the resident received only 470 milliliters of tube feeding instead of the 660 milliliters ordered by the physician. The registered dietitian confirmed that not receiving the ordered tube feeding could lead to weight loss for the resident. The physician's orders indicated the resident should receive tube feeding at a rate of 60 milliliters per hour for 22 hours via the GT, but this was not adhered to, leading to a deficiency in care.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to meet food service safety and sanitation requirements, as observed during a survey. In the clean tray area, 15 food trays were found to be unclean, chipped, and stained with brown and yellowish marks, with one tray still having an old meal ticket attached. This was contrary to the facility's policy, which mandates that all kitchen and dining room utensils, along with food contact surfaces, be cleaned and sanitized before use, after use, and after each meal. Additionally, expired food items, including a pack of sugar and 16 boxes of coleslaw, were found in the dry warehouse and food storage area, respectively. The facility's policy requires staff to observe all food item expiration dates to ensure no expired products are used or stored. Further deficiencies were noted in the dry warehouse, where a dented can of vanilla pudding was improperly stored on a rack labeled 'use it first' instead of being placed in the designated Dented Cans Area. The facility's policy states that any damaged or dented cans should be rejected at the point of delivery. In the cold prep area, a yellow cutting board was found to be heavily marred with deep cut marks, which could harbor bacterial growth. This was inconsistent with the facility's policy that requires all food contact surfaces to be cleaned and sanitized before and after use.
Improper Disposal of Garbage and Debris in Food Storage Areas
Penalty
Summary
The facility failed to maintain cleanliness in food storage areas, specifically in the warehouse and main kitchen, which could potentially lead to foodborne illness among residents. During an observation and interview with the Dietetics Director (DD), two cups of grape juice and chipped wood debris were found on the warehouse floor. The DD disposed of the grape juice cups and acknowledged that the trash and debris should have been cleaned. Similarly, during an observation with the Assistant Dietetics Director (ADD) in the walk-in freezer, chipped wood and plastic wrappers were observed on the floor, and the ADD confirmed that these should have been cleaned. The facility's Policy and Procedure, titled Nutrition Policy Manual Policy Number: 3401, dated July 2018, states that garbage should always be placed in designated disposal units with lids, and storerooms should be swept daily to remove debris from deliveries or daily activities. The failure to adhere to these procedures was noted during the survey.
Failure to Provide Qualified Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide a qualified, facility-approved interpreter for a Spanish-speaking resident, resulting in communication barriers. During an observation and interview, it was noted that the resident was unable to communicate effectively with staff due to the lack of a Spanish-speaking interpreter. The Lead Registered Nurse admitted to using non-approved interpreters, including other residents, to communicate with the resident. This issue was further highlighted when a medical evaluation was conducted using an unapproved interpreter, raising concerns about the accuracy of the translation and the resident's ability to convey his needs and concerns. The resident's care plans and assessments clearly indicated the need for a Spanish-speaking interpreter, yet the facility did not have a process to ensure interpreters were available each shift. Interviews with staff, including a Supervising Registered Nurse and a Social Worker, confirmed the absence of a reliable system for providing interpreters, leading to reliance on unapproved staff for translation. This deficiency was compounded by the facility's policy, which stated that accommodations should be made for non-English speaking patients, yet failed to implement a practical solution to meet this requirement.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fall and a scalp contusion. During an observation and interview, the resident was found with discoloration on the left side of his forehead and reported not using his wheelchair when standing, which led to a fall. The resident, who is blind and requires moderate assistance for ambulation and transfers, experienced pain and nausea following the incident. A registered nurse observed the resident standing unassisted from his wheelchair and falling forward but did not intervene or educate the resident to sit down. The resident's care plan indicated the need for moderate assistance and education to prevent unassisted transfers. The facility's policy on fall prevention requires registered nurses to implement and oversee fall prevention strategies, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fracture to the resident's left fifth finger. During an observation and interview, the resident revealed that she did not use her walker while ambulating, which led to her fall and subsequent injury. The resident's Minimum Data Set indicated that she required supervision or assistance when ambulating, and her treatment plan highlighted her unsteadiness and risk for falls, specifying the need for a walker and staff assistance. Despite these documented needs, a registered nurse observed the resident walking without her walker and did not intervene or educate her to use it. The supervising registered nurse confirmed that the resident should have been stopped and reminded to use her walker. The facility's policy on fall prevention emphasized the responsibility of registered nurses to implement fall prevention strategies, which were not followed in this instance, leading to the resident's fall and injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident 1, who was non-verbal, medically compromised, and bedridden, was assaulted by Resident 2, who had a history of major neurocognitive disorder with behavioral disturbances. Resident 1 sustained multiple facial lacerations, contusions, and a nasal bone fracture due to the assault. The incident was unwitnessed, but Resident 2 was found with bloodied hands and blanket, and Resident 1 was transferred to the hospital for evaluation. Resident 2 had a documented history of impulsivity, low frustration tolerance, and dangerousness to others, with previous incidents of aggression towards peers. Despite this, no interventions were implemented following a prior altercation with another resident, and Resident 2 was roomed with Resident 1 due to a COVID quarantine on the unit. The facility's treatment plan for Resident 2 noted a moderate violence risk factor, but lacked documented interventions related to dangerousness and impulsivity. Interviews with facility staff revealed that Resident 2's behaviors were unpredictable, and no PRN medication or increased observation was ordered after the incident. The facility's policy on reporting patient abuse and neglect clearly stated that abuse is not tolerated, yet the lack of appropriate interventions and monitoring for Resident 2 contributed to the failure to protect Resident 1 from harm.
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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