El Encanto Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in City Of Industry, California.
- Location
- 555 South El Encanto Road, City Of Industry, California 91745
- CMS Provider Number
- 555395
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at El Encanto Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia, dementia, and severe cognitive impairment was transferred from the facility to a GACH via 911 for AMS, increased respirations, and desaturation, and then admitted to an LTACH for further evaluation and therapy. LTACH records documented that the resident’s discharge goal was return to a SNF and that a psychiatric consult found the resident calm, quiet, and manageable. When the LTACH requested readmission, the facility’s ACD and DON declined, initially citing unresolved behavioral issues, despite having received the psychiatric consult report and having multiple available female beds in semi-private rooms. This refusal conflicted with the facility’s bed-hold and return policy, which required allowing residents to return after hospitalization to their previous room if available or to the first available semi-private bed when they still required facility services and remained Medicare/Medicaid eligible.
A resident with dementia, hemiplegia, and hemiparesis was transferred to a GACH via 911 for AMS, increased respirations, and desaturation following a physician’s telephone order. Despite facility policy requiring a Notice of Transfer or Discharge (NTD) to be provided to the resident and RP and sent to the LTC ombudsman as soon as practicable before transfer, no NTD was found in the medical record, and staff acknowledged that the NTD was not completed or faxed to the ombudsman.
Two residents with significant mobility and cognitive impairments did not have accessible or functioning call lights. In one case, a call light was placed out of reach, and in another, a call light was nonfunctional for two days despite staff being informed. Facility policy required prompt response and functioning call lights, but these were not followed, resulting in delayed or unmet care needs.
The facility did not accurately post daily nurse staffing information, failing to display the actual hours worked by RNs, LPNs, and CNAs for multiple shifts. Observations and interviews confirmed that required staffing details were incomplete and not posted in visible areas, contrary to facility policy.
Surveyors observed that expired and unlabeled food items were not removed from storage, and multiple food items lacked required labeling with use by or expiration dates. Staff confirmed these practices were not in line with facility policy. Additionally, a malfunctioning convection steamer with missing rails caused a staff injury and delayed meal service, with maintenance staff aware of the issue but repairs not completed. Facility policies require proper food labeling and equipment maintenance, which were not followed in these instances.
A resident with hyperlipidemia and type 2 diabetes was discharged home after dialysis, but the MDS assessment was incorrectly coded as a discharge to a short-term general hospital. Review of records and staff interviews confirmed the error, resulting in inaccurate reporting to CMS.
A resident with significant mobility and cognitive impairments, requiring two-person assistance for all ADLs, was left in the care of a single CNA during personal care. The resident slid off the bed during a diaper change and fell, leading to an emergency room visit. Staff interviews and documentation confirmed that two-person assistance was required but not provided at the time of the incident.
A resident with an indwelling Foley catheter, admitted with chronic kidney disease, urinary retention, and dementia, was observed with unsecured catheter tubing despite care plan and facility policy requiring it to be secured to the leg. Both an LVN and the ADON confirmed the tubing should have been secured to prevent injury, and the facility's policy also specified the use of leg straps for this purpose.
A resident receiving oxygen therapy via nasal cannula was found to have tubing that was not labeled with the date of last change, contrary to facility policy requiring labeling and dating for infection control. Staff confirmed the omission during interviews, and record review showed the resident had multiple chronic conditions requiring respiratory care.
A resident with severe cognitive impairment and multiple medical conditions was found with bilateral one-fourth siderails in use without a physician's order or informed consent. Staff confirmed that required documentation was missing, and facility policy mandates these steps before siderail installation, especially when used as a restraint.
A resident with severe cognitive impairment and full dependence on staff was observed lying in bed with ripped and damaged padded side rails, despite care plan and physician orders requiring intact pads for safety and skin protection. Facility policy required staff to report and document defective equipment, but this was not done, resulting in the continued use of damaged side rail pads.
A nurse administered Zofran to a resident for nausea without verifying a current physician order in the MAR, contrary to facility policy requiring staff to check orders before giving medications. The medication was given after the resident vomited, and the error was discovered when the nurse attempted to document the administration and found no active order.
A resident with a history of fracture and dementia exhibited unusual pain behaviors during care, which were reported by a CNA to an LVN. The LVN and RN checked on the resident but did not perform or document a full assessment of the lower extremities, missing signs of pain and swelling. Later, the resident was found to have a tibial fracture, and staff interviews confirmed that required documentation and assessment were not completed according to facility policy.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with severe cognitive impairment had their call light caught between the bed and bedrails, while another resident with a history of falls had their call light on the floor. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's policy.
The facility failed to include Advance Directive forms in the medical records of two residents, risking care against their wishes. One resident, with intact cognition, had preferences for no resuscitation and no tube feeding, while the other, with impaired cognition, lacked an AD Acknowledgement Form. Staff confirmed the absence of these forms, which are essential for guiding care decisions in emergencies.
The facility failed to provide adequate communication devices for two residents who spoke Cantonese/Mandarin, leading to potential communication barriers and unmet needs. One resident lacked a communication board, and staff were not always available to speak the resident's language. Another resident had a limited communication board, and staff relied on body language, which was insufficient. The facility's policy required communication boards, but no additional interpretation services were available, affecting the residents' quality of life.
The facility failed to label and date opened food containers and did not discard expired refrigerated food, as required by its P&P. Additionally, two staff members with facial hair did not wear beard nets in the kitchen, contrary to the facility's policy, increasing the risk of food contamination.
The facility failed to ensure its binding arbitration agreements included a convenient venue for three residents, risking unjust arbitration. A resident with dementia, another with metabolic encephalopathy, and a third with renal dialysis dependence had agreements lacking details on a neutral arbitrator and venue, contrary to facility policy.
A facility failed to complete a quarterly MDS assessment on time for a resident with dementia and malnutrition. The assessment was not completed as of the required date, and the MDS Coordinator acknowledged missing the deadline. Facility policy mandates submission within 14 days of the MDS Completion Date.
A resident with hearing difficulties and severe cognitive impairment did not have a specific care plan developed to address their needs. Despite being assessed for hearing issues and requiring maximal assistance, the facility failed to create a person-centered care plan, as observed during staff interactions where the resident indicated hearing problems.
A resident with lung cancer and dysphagia had an IV site that was not labeled with the date of insertion, contrary to professional standards and facility policy. This oversight was confirmed by the MDS Coordinator, who noted the importance of labeling for infection control. The facility's policy required labeling to ensure timely changes of the IV site.
A facility failed to follow its Enhanced Barrier Precaution (EBP) protocol when a nurse did not wear personal protective equipment (PPE) while taking the blood pressure of a resident in an EBP room. The nurse admitted to not wearing a gown and gloves, which are required for close contact activities to prevent the spread of multidrug-resistant organisms (MDRO). The Infection Prevention Nurse confirmed the necessity of PPE in such situations, as outlined in the facility's policy.
The facility did not post actual nurse staffing data at the beginning of each shift in the lobby and nursing station on two occasions. Observations showed that the Posted Nurse Staffing Information (PNSI) forms were incomplete, and interviews with the DON and RN Supervisor confirmed the oversight. The facility's policy requires posting staffing numbers within two hours of each shift's start, which was not followed.
Failure to Readmit a Hospitalized Resident to First Available Semi-Private Bed
Penalty
Summary
The facility failed to permit a resident to be readmitted to the first available bed in a semi-private room following hospitalization and transfer to a long-term acute care hospital (LTACH), as required by its own bed-hold and return policy. The resident had a history of hemiplegia and hemiparesis following cerebral infarction and dementia, with documentation showing severe cognitive impairment and a lack of capacity to make decisions. The resident was originally admitted and later readmitted to the facility, then transferred to a general acute care hospital (GACH) via 911 for altered mental status, increased respirations, and oxygen desaturation, and subsequently admitted to an LTACH for further evaluation and therapy. At the LTACH, documentation indicated that the resident’s discharge goal/plan included transfer back to a SNF, and a psychiatric consultation noted that the resident was calm, quiet, and manageable with the current treatment plan. The LTACH case manager reported that a psychiatric consultation report addressing behavioral issues was completed and sent to the facility. Despite this, when the LTACH inquired about readmission, the facility’s Admission Coordinator Director and DON stated that the facility refused to readmit the resident, initially citing that behavioral issues had not been addressed or evaluated in the LTACH records. Further review showed that the facility had multiple available female beds in semi-private rooms on the dates in question. The DON acknowledged that the facility received the psychiatric consultation report from the LTACH and still refused readmission, and also stated that the resident should be accepted for readmission if there were no behaviors that would endanger the health or safety of the resident or others, and that the facility could provide the care and meet the resident’s needs. The facility’s written policy on bed-holds and returns required that residents be allowed to return to their previous room if available, or to the first available semi-private bed, provided they still required facility services and were eligible for Medicare or Medicaid services, and that residents be evaluated based on their current condition following hospitalization. The facility did not follow this policy in the resident’s case.
Failure to Provide Required Transfer/Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to complete the required transfer/discharge notification process for one sampled resident when the resident was transferred to a general acute care hospital. The resident had a history of hemiplegia, hemiparesis following cerebral infarction, and dementia, and was documented as lacking capacity to understand and make decisions, with an MDS showing severely impaired cognitive skills and need for partial/moderate assistance with most ADLs. On the day of transfer, a physician’s telephone order directed that the resident be transferred to a hospital via 911 due to altered mental status and desaturation, and progress notes documented that the resident was transferred by 911 for altered mental status, increased respirations, and desaturation. Record review showed that there was no Notice of Transfer or Discharge (NTD) in the resident’s medical record related to this hospital transfer. In a telephone interview, the RN who received the transfer order stated that they should have completed the NTD form and faxed it to the ombudsman after the resident was transferred. The ADON, after reviewing the medical record, confirmed that no NTD form could be found and stated that the NTD is important to inform the resident and family of the transfer or discharge and to fax to the ombudsman prior to transfer or discharge. The facility’s policy titled “Transfer or Discharge, Facility-Initiated” indicated that the NTD should be given as soon as practicable but before transfer or discharge when an immediate transfer is required by urgent medical needs, that notice is to be provided to the resident, representative, and LTC ombudsman when practicable, and that nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.
Failure to Ensure Call Lights Were Accessible and Functional
Penalty
Summary
The facility failed to ensure that call lights were within reach and functioning properly for two residents, resulting in the potential for delayed or unmet care needs. For one resident with hemiplegia, impaired vision, and severe cognitive impairment, the call light was observed to be placed on a rolling table approximately three feet away from the bed, making it inaccessible. Both the LVN and ADON confirmed that the call light was not within reach and should have been placed closer to the resident's functional side to allow for timely assistance, as outlined in the resident's care plan. Another resident, assessed as high risk for falls due to impaired mobility and vision, reported that their call light had not been working for two days despite notifying staff. The resident stated that no staff responded to the call light and had to leave the room to seek assistance. The facility's policy required staff to ensure call lights were functional and to answer them promptly, but this was not followed, as evidenced by the resident's experience and staff interviews.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information reflecting the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for three consecutive days. Observations and interviews revealed that the required staffing information for the night and day shifts was not completed and was not posted in visible areas such as the nurses' station. The Case Manager acknowledged that the staff posting was incomplete and stated that actual hours would be posted the following day, rather than as required. Further interviews with the Assistant Director of Nursing confirmed that staffing hours should be posted at the beginning of each shift and should reflect actual hours worked. Record review showed that the posted nurse staffing information was not completed for all three shifts on the specified dates. The facility's policy and procedure require that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing staff and their actual hours worked be posted in a prominent location accessible to residents and visitors.
Deficient Food Storage, Labeling, and Equipment Maintenance in Dietary Services
Penalty
Summary
The facility failed to adhere to its own food storage and handling policies by not removing expired food items from the refrigerator and failing to label food items with the required information, such as the food item name and use by or expiration date. During multiple kitchen observations, surveyors found expired prunes, puree food, and sandwiches in the refrigerator, as well as numerous unlabeled or undated items including grapes, fruit cups, applesauce, peppers, fortified milk, sweetener, thickener, raw chicken, and pastrami meat. Staff interviews confirmed that these items should have been labeled and expired food should have been discarded, as per facility policy. Staff acknowledged that the lack of proper labeling and removal of expired food could result in serving unsafe food to residents. Additionally, the facility failed to maintain a functional convection steamer in the kitchen. During an observation, a staff member was injured when a tray of green beans fell from the steamer due to missing supporting rails. The equipment had been known to be in disrepair, and maintenance staff were aware of the issue but had not yet completed repairs. This malfunction led to delays in meal preparation and service, as food had to be remade and staff were diverted to address the injury. Review of the facility's policies and procedures confirmed that all food items are required to be labeled and dated, and that equipment must be maintained in good working order with regular inspections. The observed deficiencies in food labeling, storage, and equipment maintenance were not in accordance with these established policies, as confirmed by staff and policy review.
Inaccurate MDS Discharge Coding for Resident
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's discharge destination in the Minimum Data Set (MDS) assessment. Specifically, a resident who was admitted with diagnoses including hyperlipidemia and type 2 diabetes mellitus was discharged home per their request after dialysis treatment. However, the MDS assessment incorrectly documented the discharge destination as a short-term general hospital. This error was identified during a review of the resident's admission record, physician's order, and discharge summary, all of which confirmed the resident was discharged home. Interviews with the MDS Coordinator and the Assistant Director of Nursing confirmed that the resident was not discharged to a hospital, and both acknowledged the necessity for accurate MDS coding. The facility's policy and procedure on the MDS and Resident Assessment Instrument (RAI) process indicated that all members of the Interdisciplinary Team share responsibility for the accurate completion of the RAI, with the RN MDS Coordinator responsible for reviewing and signing off on the assessment. Despite these procedures, the MDS was not coded accurately, resulting in incorrect information being reported to CMS.
Failure to Provide Required Two-Person Assistance During ADLs Resulted in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including osteoarthritis, osteoporosis, morbid obesity, generalized muscle weakness, and lack of coordination, was not provided adequate supervision during activities of daily living (ADLs). The resident was assessed as being dependent on staff for all ADLs and required the assistance of two or more staff members for tasks such as turning, repositioning, and personal care. Despite this documented need, a certified nursing assistant (CNA) provided care alone, during which the resident slid off the bed while being turned for a diaper change. The CNA was unable to prevent the fall due to the resident's weight and called for assistance after the incident occurred. Interviews with staff, including the CNA involved, a licensed vocational nurse (LVN), and the assistant director of nursing (ADON), confirmed that the resident should have received two-person assistance for all ADLs to ensure safety and prevent falls. Documentation and care plans also indicated the requirement for two-person assistance. The facility's policy on ADL support emphasized providing appropriate care and assistance for residents unable to perform ADLs independently. The failure to follow these protocols resulted in the resident falling from the bed and being sent to the emergency room, although no fractures were found.
Failure to Secure Foley Catheter Tubing as Required by Care Plan and Policy
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, urinary retention, and dementia, who was admitted with an indwelling Foley catheter, was observed to have the catheter tubing unsecured on their thigh. The resident's care plan specifically required the catheter tubing to be secured to the leg to prevent pulling or trauma. During observation, the resident was seen in a wheelchair with the Foley catheter tubing not secured, and the attending LVN confirmed this was not in accordance with proper procedure. Interviews with both the LVN and the Assistant Director of Nursing confirmed that all indwelling catheters should be properly secured to prevent injury during movement or transfers. Review of the facility's policy and procedure for catheter care also indicated that leg straps should be used to attach catheter tubing to the resident's leg to avoid tension. The failure to secure the catheter tubing as required by the care plan and facility policy constituted the deficiency.
Failure to Label Nasal Cannula Tubing for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of congestive heart failure, cirrhosis of the liver, and obstructive sleep apnea was observed receiving oxygen therapy via nasal cannula (NC) at 2 liters per physician order. During observation and interview, it was noted that the NC tubing in use was not labeled with a date to indicate when it was last changed. The Certified Nurse Assistant confirmed that the tubing was not labeled, and the Assistant Director of Nursing stated that NCs and other respiratory tubing should be labeled with the date for infection control purposes. A review of the facility's policy and procedure for oxygen administration indicated that nasal cannula tubing should be labeled and dated, and changed every 7 days by licensed nurses. The failure to label the NC tubing as required by facility policy was observed and confirmed through staff interviews and record review, resulting in a deficiency related to safe and appropriate respiratory care and infection control practices for the resident.
Failure to Obtain Physician Order and Informed Consent for Siderail Use
Penalty
Summary
The facility failed to obtain a physician's order and informed consent prior to the installation of bilateral one-fourth siderails/bedrails for a resident. The resident, who had diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, was severely cognitively impaired and dependent on staff for all activities of daily living. During observation, the resident was found in bed with both siderails up, and review of the medical record confirmed that neither a physician's order nor informed consent had been documented before the siderails were installed. Interviews with facility staff, including the Minimum Data Set Coordinator and the Assistant Director of Nursing, confirmed that the required physician's order and informed consent were missing. The facility's policies and procedures specify that informed consent and a physician's order are necessary before siderails are used, especially when they may function as a physical restraint. The absence of these steps placed the resident at risk for entrapment and injury associated with siderail use.
Damaged Side Rail Pads Not Replaced for Dependent Resident
Penalty
Summary
The facility failed to ensure that both side rail pads on a resident's bed were free from damage, wear, and tear. Observation revealed that the resident, who was admitted with diagnoses including unspecified dementia and senile degeneration of the brain, was lying in bed with half-length bilateral side rails that had ripped and damaged pads. The resident's care plan required the use of padded side rails as an enabler for bed mobility and to minimize the risk of bruising or skin tears, with instructions for nursing staff to periodically check the side rails for safety and refer to maintenance as needed. A physician's order also specified the use of padded side rails to prevent skin injury. Record review indicated that the resident was severely cognitively impaired and fully dependent on staff for all activities of daily living. During an interview, the ADON acknowledged that the side rail pads needed to be changed and should not be ripped or damaged to maintain the resident's safety and dignity. The facility's policy required staff to report any defective equipment to supervisors and document it in the maintenance request log, but this was not followed in this instance.
Medication Administered Without Physician Order
Penalty
Summary
A licensed vocational nurse (LVN) administered Zofran 4 mg to a resident without first verifying the presence of a current physician's order in the Medication Administration Record (MAR). The LVN obtained the medication from the medication cart, which was labeled with the resident's name, and gave it to the resident after the resident experienced a small amount of emesis. After administering the medication, the LVN attempted to document the administration in the MAR but discovered there was no active order for Zofran for the resident. Interviews with the LVN, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that facility policy requires staff to check the MAR and verify physician orders before administering any medication. The facility's policy and procedure on Medication Administration states that medications are to be administered only as prescribed and in accordance with written orders from the attending physician. The failure to follow this process resulted in the administration of medication without a physician's order.
Incomplete Assessment and Documentation of Resident's Change in Condition
Penalty
Summary
The facility failed to follow its own policy and procedure for charting and documentation by not completing a thorough assessment and documentation of a resident's change in condition. The resident, who had a history of a right femur fracture, dementia, and difficulty walking, was observed by a CNA to be moaning and expressing pain when repositioned, which was unusual for this resident. The CNA reported these observations to the LVN, who, along with an RN, checked on the resident but did not perform a full assessment of the resident's lower extremities or document any findings related to possible pain or swelling. The LVN did not note any abnormalities or changes in the resident's condition in the medical record at that time. Subsequent documentation revealed that the resident continued to exhibit signs of pain and was later found to have swelling in the right knee. A radiology report confirmed a fracture of the proximal lateral tibia. Interviews with staff confirmed that the LVN did not evaluate or document the condition of the resident's legs, and the facility's policy required documentation of all changes in a resident's condition. The lack of complete assessment and documentation resulted in incomplete information regarding the resident's condition.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to potential delays in receiving necessary care. Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, had severely impaired cognition and required maximal assistance with daily activities. The care plan for Resident 20 included keeping the call light within reach, but during an observation, the call light was found hanging on the side of the bed, caught between the bed and bedrails, making it inaccessible. Similarly, Resident 27, who had osteoarthritis and a history of falls, was observed with the call light on the floor by the wall, out of reach. Despite having intact cognition and requiring moderate assistance, the resident's care plan also specified that the call light should be within reach. Interviews with staff, including LVNs and the DON, confirmed that the call lights should be accessible to residents to ensure their needs are promptly met. The facility's policy also stated that call lights should be repositioned within residents' reach at all times.
Failure to Include Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that the Advance Directive/Preferred Intensity of Care Documentation form (AD) was included in the medical records of two residents, which could lead to care being provided against their wishes. Resident 35, who was admitted with renal dialysis dependence and a leg fracture, had an AD form indicating a preference for no resuscitation and no tube feeding. Despite having intact cognition and the ability to communicate, the AD form was missing from the medical record, as confirmed by the Admission Coordinator. This omission meant that staff might not be aware of the resident's treatment preferences during an emergency. Similarly, Resident 2, admitted with dementia, hypertension, and type 2 diabetes, also lacked an AD Acknowledgement Form in their medical record. The resident's cognition for daily decision-making was severely impaired, making the presence of the AD form crucial for guiding care decisions. Both a Licensed Vocational Nurse and the facility's Case Manager confirmed the absence of the form, and the Director of Nursing acknowledged the necessity of having the AD form in the resident's chart to honor their wishes. The facility's policy mandates recording residents' wishes in their medical records to ensure their rights are respected.
Communication Barriers for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication devices for two residents, leading to potential communication barriers and unmet needs. Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, spoke Cantonese/Mandarin and was at risk for social isolation. The care plan for Resident 20 included the use of a communication board and translation services, but during an observation, it was noted that no communication board was present in the room, and Cantonese/Mandarin-speaking staff were not always available. This lack of effective communication tools hindered the ability of staff to meet Resident 20's needs. Similarly, Resident 34, who preferred to communicate in Mandarin, faced challenges due to limited communication options. Although an English-Chinese communication board was available, it did not cover all necessary care areas, and staff primarily relied on body language to communicate. This inadequacy was confirmed by interviews with staff, who acknowledged the difficulty in understanding and meeting Resident 34's needs due to the language barrier. The facility's policy indicated that communication boards should be available for non-verbal and non-native speaking residents, but the implementation was insufficient. Staff interviews revealed that there were no additional interpretation services available, which further exacerbated the communication challenges faced by non-English speaking residents. This deficiency in communication support had the potential to delay care and affect the quality of life for the residents involved.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the proper labeling and dating of opened food containers, as well as the storage of refrigerated food. During an observation, it was noted that a bottle of salad dressing, a carton of milk, and several canisters of seasonings were opened without being labeled with the date of opening. Additionally, a tray of nourishments containing yogurt, prunes, and cottage cheese was found in the refrigerator with a date of 6/12/2024, which should have been discarded after three days according to the facility's P&P. Interviews with the Dietary Supervisor and another staff member confirmed that the lack of labeling and failure to discard expired food could lead to foodborne illnesses. Furthermore, the facility did not comply with its Hair Net Policy for kitchen workers. During an observation, two staff members with facial hair were seen working in the kitchen without wearing beard nets. The Dietary Supervisor acknowledged this oversight and stated that beard nets are necessary to prevent hair from contaminating the food. The facility's P&P clearly requires kitchen workers with facial hair to wear beard nets, but this policy was not followed, increasing the risk of food contamination.
Deficient Arbitration Agreements in LTC Facility
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included the selection of a venue convenient to both the facility and the resident or the resident's responsible party for three sampled residents. Resident 16, who was admitted with diagnoses including dementia, hypertension, and diabetes, had an arbitration agreement signed by their responsible party that did not specify a neutral arbitrator or a convenient venue. The facility's policy required that the venue be agreed upon by both parties and be convenient for the resident, but this was not reflected in the agreement. Similarly, Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, signed an arbitration agreement that also lacked information about a neutral arbitrator and a convenient venue. Despite Resident 20's lack of capacity to understand and make decisions, the agreement was signed without these critical details. Resident 35, who was cognitively intact and admitted with renal dialysis dependence and a leg fracture, also had an arbitration agreement that did not provide for a convenient venue. These omissions in the arbitration agreements placed the residents at risk for unjust arbitration processes.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed within the required time frame for a resident diagnosed with dementia and malnutrition. The resident was admitted on September 16, 2022, and the quarterly MDS assessment was not completed as of June 8, 2024. This delay in completing the MDS assessment was identified during a review of the resident's admission record and the Center for Medicare and Medicaid Services (CMS) Submission Report, which indicated that the assessment was completed more than 14 days after the assessment reference date. During an interview and record review with the MDS Coordinator, it was confirmed that the quarterly MDS for the resident was missed and not submitted on time. The facility's policy and procedure for the MDS and Resident Assessment Instrument Process requires that all assessments be submitted within 14 days of the MDS Completion Date, and quarterly assessments are due every quarter unless the resident is no longer in the facility. The MDS Coordinator acknowledged the importance of timely completion and submission of the MDS to provide accurate information to CMS.
Failure to Develop Care Plan for Resident with Hearing Difficulties
Penalty
Summary
The facility failed to develop a specific and individualized person-centered care plan for a resident with hearing difficulties. The resident, who was admitted with diagnoses including metabolic encephalopathy and Parkinson's disease, was assessed to have severely impaired cognition and required maximal assistance with daily activities. Despite these assessments, the facility did not initiate or develop a care plan to address the resident's hearing difficulties, as observed during interactions with staff where the resident indicated difficulty hearing. During observations and interviews, it was noted that the resident primarily spoke Cantonese and had trouble hearing in both ears. Licensed Vocational Nurses communicated with the resident by speaking loudly, but there was no documented care plan to guide staff in addressing the resident's hearing impairment. The facility's policy requires the development of a comprehensive care plan upon admission and during changes in condition, but this was not adhered to in the case of this resident.
Failure to Label IV Site
Penalty
Summary
The facility failed to adhere to professional standards of practice by not labeling and dating the intravenous (IV) site for a resident, which is essential for infection control. The resident, who was admitted with diagnoses including dysphagia and lung cancer, had a peripheral IV line inserted on their left hand for continuous infusion of 0.9% Normal Saline at a rate of 60 ml/hr. During an observation, it was noted that the IV dressing lacked a label indicating the date of insertion, which is a critical step to ensure timely changes of the IV site to prevent infection. The Minimum Data Set Coordinator confirmed that the IV site was not labeled and emphasized the importance of labeling for infection control, stating that the IV access should be changed every 72 hours. The facility's policy on Short Peripheral Catheter Insertion, revised in 2015, also required the dressing to be labeled with the date and time of insertion, catheter gauge and length, and the nurse's initials. The failure to label the IV site as per the facility's policy and professional standards posed a risk of infection for the resident.
Failure to Follow Enhanced Barrier Precaution Protocol
Penalty
Summary
The facility failed to adhere to its Policy and Procedure on Enhanced Barrier Precaution (EBP) for infection control, specifically in the case of Resident 35. During an observation, Licensed Vocational Nurse 7 (LVN 7) entered Resident 35's EBP room without donning personal protective equipment (PPE) and proceeded to take the resident's blood pressure. LVN 7 acknowledged the failure to wear a gown and gloves, which are required when in close contact with residents in EBP rooms, as per the facility's policy. This oversight was identified as a potential risk for the transmission of multidrug-resistant organisms (MDRO) to other residents. The Infection Prevention Nurse (IPN) confirmed that EBP is implemented to reduce the transmission of MDROs, with signs posted outside rooms of residents who require such precautions. These residents may have conditions such as open wounds, gastrostomy tubes, foley catheters, or be on dialysis. The IPN emphasized that taking blood pressure is considered a close contact activity, necessitating the use of PPE. A review of the facility's undated P&P on Enhanced Barrier Precaution reiterated the requirement for staff to wear gowns and gloves during tasks with a high risk of MDRO contamination.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post actual nurse staffing data at the beginning of each shift daily in two sampled locations, the lobby and nursing station, on specific dates. On 6/18/2024, during an observation at 10:24 am, it was noted that the Posted Nurse Staffing Information (PNSI) form did not reflect the actual number of nursing staff present for the morning shift. This oversight was confirmed during an interview with the Director of Nursing (DON) on 6/20/2024, who acknowledged that the PNSI form should be completed at the start of each shift to inform residents and visitors of the staffing levels. Further observations on 6/20/2024 at 11:35 am revealed that the PNSI form at the nursing station was also incomplete, lacking the actual number of staff working. The Registered Nurse Supervisor (RN Sup 1) admitted responsibility for updating the form and confirmed that it was not completed for that day. The facility's policy, revised in 8/2022, mandates that the charge nurse or designee must compute and post the staffing numbers within two hours of each shift's start. The failure to adhere to this policy potentially affected the transparency of staffing information available to residents and their families.
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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