Fireside Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 947 3rd Street, Santa Monica, California 90403
- CMS Provider Number
- 555039
- Inspections on file
- 50
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Fireside Health Care Center during CMS and state inspections, most recent first.
A resident who was dependent for personal care and had multiple medical conditions was subjected to aggressive perineal care by a family member, despite expressing pain and asking for it to stop. The CNA reported the suspected abuse to the RN, who was unfamiliar with the reporting process and delayed notifying the appropriate authorities, including APS, the Ombudsman, and law enforcement, as required by facility policy.
Surveyors found that the facility did not display the current Administrator's license, instead posting the license of a former Administrator. The current Administrator reported not having a copy of his license due to it being mailed to the wrong address and lacking the means to print another copy. The facility also lacked a policy for the Administrator's license.
Two residents reported missing personal property, including a damaged cell phone and various clothing items, and stated that repeated requests to speak with the social worker were ignored. Staff failed to complete required inventory lists upon admission and did not investigate the reports of missing property, contrary to facility policy.
A resident with a history of alcohol abuse and medical conditions eloped from the facility due to inadequate supervision and non-functional alarm systems on exit doors. The resident was cognitively intact but required assistance with daily activities. The facility failed to conduct an elopement assessment upon admission and did not include specific interventions in the care plan. The alarm system on several exit doors was either non-functional or not activated, leading to a delayed response from staff. The resident was found the following day, highlighting lapses in supervision and safety protocols.
A facility failed to properly waste an Ativan 0.5 mg tablet according to its controlled narcotic protocol, resulting in an inaccurate medication count for a resident with multiple diagnoses. The LVN admitted to giving one tablet and failing to document it, as well as dropping another tablet during the count, which was not wasted as per protocol. The waste was not properly documented or witnessed by two licensed nurses, as required by the facility's policy.
A resident with a history of cervical disc disorder and other conditions experienced unmanaged pain due to the facility's failure to administer prescribed oxycodone-APAP for 18 out of 54 days. The medication was not available because the pharmacy did not receive authorization from the physician, and the facility did not follow up to resolve the issue. This resulted in the resident experiencing significant pain and frustration, as well as an inability to participate in activities.
A facility failed to obtain and maintain a PASRR level I screening for a resident with mental health diagnoses, including bipolar disorder and dementia. The absence of this screening was identified during a review of the resident's admission records and interviews with staff, revealing a lack of adherence to the facility's policy. The Social Services Director and Admissions Director were unaware of the PASRR process, and the Director of Nursing acknowledged the missing documentation, which is crucial for addressing the resident's mental health needs.
A resident with a displaced fracture of the second cervical vertebra was observed without a neck brace, contrary to the physician's order to wear it at all times. The neck brace was found next to the resident, and both a PT and RN confirmed the requirement for the brace to prevent further injury and pain. The facility's policy supported the need for adherence to the physician's order.
A resident with chronic respiratory failure reported that her Bipap machine was not cleaned daily as required by physician orders. Facility staff, including the DSD and LVNs, lacked proper training and documentation on the cleaning and operation of the Bipap machine, leading to potential respiratory infection risk for the resident.
The facility failed to ensure staff competency in operating and cleaning Bipap machines and maintaining current CPR certification. A resident with chronic respiratory failure reported that their Bipap machine was not cleaned daily. The DSD admitted to a lack of structured training and materials for staff. Additionally, five staff members lacked current CPR certification, and some were unable to demonstrate basic CPR skills. The facility's policies required proper training and certification, but these were not adhered to, posing potential harm to residents.
A resident with multiple health conditions experienced significant discomfort due to a malfunctioning bed and a worn-out mattress. Despite reporting the issue to the Maintenance Supervisor, no corrective action was taken. Observations confirmed the bed's malfunction and the poor condition of the mattress, posing risks of injury and infection. The facility's policy for regular bed inspections was not followed.
A facility failed to complete a required PASRR Level II assessment for a resident with major depressive disorder and PTSD, as indicated by a positive Level I screening. The resident was admitted and readmitted with these diagnoses, and the oversight was confirmed during an interview with the DSD. The facility's policy requires a Level II review within 40 days of admission, which was not followed.
Two residents' room entrance was obstructed by wheelchairs filled with boxes, creating a safety hazard. One resident was cognitively intact but needed assistance with daily activities, while the other had severe cognitive impairment and was fully dependent on staff. The obstruction could delay emergency access, violating the facility's policy for a safe environment.
A resident with an indwelling catheter showed signs of a UTI, such as cloudy urine with sediments, but the facility staff failed to monitor and report these signs to a physician. Despite the resident's care plan requiring such monitoring, no change of condition was noted, leading to a delay in treatment. The facility's catheter care policy, which emphasizes checking urine for unusual appearance, was not followed.
A facility failed to label a resident's feeding tube syringe with the date it was opened, as observed during a survey. The resident, who had multiple medical conditions and was dependent on staff, was at risk of infection due to this oversight. The facility's policy required labeling to prevent contamination, which was not followed.
The facility failed to maintain infection control measures, with deficiencies observed in resident rooms lacking proper sanitation facilities, improper handling of urinals and commodes, and inadequate cleaning of a resident's Bipap machine. Staff and visitors used restrooms intended for residents, and a garbage can for waste was improperly stored in a shower room. Staff lacked training on Bipap machine maintenance, posing infection risks.
A facility failed to ensure a Restorative Nurse Assistant (RNA) was properly certified and trained before providing care. The RNA's CNA, CPR, and RNA training certificates were missing from their file, violating facility policy. The Director of Staff Development acknowledged the oversight and expressed concern about potential harm to residents due to inadequate training in therapeutic rehabilitation techniques.
The facility failed to meet the required 80 square feet per resident in 28 out of 32 rooms, including 2-bed, 3-bed, and 4-bed rooms. Despite observations that nursing staff had adequate space to provide care and residents did not express concerns, the rooms did not meet the minimum square footage requirements. A room waiver request was submitted, acknowledging the deficiency.
A resident with severe cognitive impairments was discharged from an LTC facility without receiving the necessary hospice information as ordered by the physician. The family member reported that no hospice options were provided while the resident was in the facility, leading to confusion and a tedious discharge process. The facility's social worker and administrator acknowledged the lapse, with the hospice information being provided only after the resident's discharge.
The facility failed to manage medications for discharged or transferred residents, leaving multiple medications in the storage room accessible to staff. Medications were not returned or destroyed per policy, as observed in four residents' cases. Staff interviews revealed a lack of adherence to medication destruction procedures, with some staff unaware of the facility's policies.
A facility failed to secure controlled substances of a discharged resident and did not store discontinued controlled substances per policy. A resident's medications, including Hydromorphone and Morphine, were found unsecured in the medication storage room. Additionally, the DON had a cabinet with controlled substances that were not double-locked as required. The facility's policy mandates monthly monitoring by a pharmacist, but the last waste of narcotics was in August, with a missed waste in September due to an unavailable interim DON.
The facility failed to ensure the Medical Director's application was filed with the State Licensing and Certification department, resulting in the MD not being listed in the Electronic Licensing Management System. Interviews confirmed the presence of a Medical Director, but the application was still being prepared for submission. The MD was not part of the governing body but participated in Quality Assessment and Assurance meetings.
A resident with cognitive impairment and significant care needs was transferred to another SNF without receiving the required advance notice. The Social Services Director acknowledged informing the resident of the discharge only an hour before it occurred, without notifying the Ombudsman, contrary to the facility's policy requiring a 30-day notice unless urgent circumstances exist.
A facility failed to develop an individualized discharge care plan for a resident with hemiplegia, PTSD, and major depressive disorder, leading to confusion and anxiety. Despite the resident's moderate cognitive impairment and need for substantial assistance, no discharge plan was initiated, as confirmed by the SSD and DON. The facility's policy requires such plans, but it was not followed.
A resident with severe cognitive impairment was physically abused by a caregiver due to the facility's failure to implement its abuse prevention policies. The caregiver, hired privately by another resident's family, had not undergone required orientation or background checks. The resident was left alone with the caregiver despite a verbal altercation, leading to the abuse. The facility lacked proper supervision and documentation, contributing to the incident.
A resident with cognitive impairment was allegedly slapped by a caregiver during a heated conversation. The incident was reported to the administrator and police, but the facility failed to notify the State Survey Agency within the required two-hour timeframe, as per their abuse prevention policy.
A resident was issued a 30-day discharge notice due to alleged aggression, but the facility failed to provide necessary physician documentation to support the discharge. The resident's appeal was granted as the facility did not have the attending physician assess the resident or document that the resident's presence endangered safety, as required by policy.
A resident with mild cognitive impairment alleged that a CNA attempted to hit him during a disagreement over breakfast service. The CNA denied the allegations, and the LVN, who was informed of the incident, did not report it to the ADON or Administrator as required by facility policy. The incident was not reported until a surveyor's interview, highlighting a failure in mandatory reporting procedures.
A facility failed to develop and implement a proper discharge plan for a resident with terminal cancer, resulting in the resident not receiving necessary hospice care. The Social Services Director referred the resident to a hospice agency without a contract or detailed service documentation, and the family was not provided with written information about the agency.
Failure to Timely Report Suspected Abuse to Proper Authorities
Penalty
Summary
The facility failed to report an allegation of suspected abuse involving a resident within the time frame specified by facility policy. The incident involved a female resident with multiple medical conditions, including spinal stenosis, chronic kidney disease, and chronic lymphocytic leukemia in remission, who was dependent on staff for toileting and personal hygiene. During a shift, a Certified Nursing Assistant (CNA) observed that the resident did not want her family member (FM) to perform perineal care, but the FM insisted and proceeded to do so aggressively, causing the resident pain and distress. The resident verbally requested the FM to stop, but the FM refused, and the CNA noted redness and irritation in the perineal area, suspecting abuse. The CNA reported the incident to the Registered Nurse (RN), who attempted to report the suspected abuse to Adult Protective Services (APS) and the Ombudsman but was unable to reach them immediately. The RN subsequently reported the incident verbally and in writing to APS the following day and informed the Director of Nursing (DON). However, the RN was unfamiliar with the facility's reporting process and did not know the identity of the abuse coordinator, leading to further delays in proper notification. The Director of Social Services (DSS) and the Administrator were not immediately informed, and the police were not contacted as required by facility policy. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that all staff are mandatory reporters and must report suspected abuse immediately, but no later than two hours after forming a suspicion, to the state survey agency, APS, law enforcement, and the Ombudsman. The policy also specifies that the Administrator or designee is responsible for reporting and that failure to report within the required time frames may result in disciplinary action. In this case, the facility did not adhere to its own policy, resulting in a delay in reporting the suspected abuse to the appropriate authorities.
Failure to Display Current Administrator's License
Penalty
Summary
The facility failed to display and provide a copy of the current Administrator's license as required by regulation. During an unannounced visit, surveyors observed that the license posted was for a former Administrator, and there was no license displayed for the current Administrator. The current Administrator, who had been employed for one month, stated in an interview that he did not have a copy of his license because it was mailed to the wrong address and he had no way to print another copy. He acknowledged awareness that the license should be posted from the first day of employment. Additionally, the Director of Medical Records confirmed that the facility did not have a policy regarding the Administrator's license.
Failure to Address Resident Grievances and Missing Property
Penalty
Summary
The facility failed to honor residents' rights to voice grievances and did not take appropriate corrective action regarding reports of missing personal property for two residents. One resident, who had an intact cognitive status and required moderate to maximal assistance with activities of daily living, reported that a certified nursing assistant accidentally sent his cell phone to the laundry with the bed linens, resulting in damage to the phone. This resident also reported multiple missing items, including clothing, shoes, and eyeglasses, and stated that repeated requests to speak with the social worker about these issues were ignored for several days. Review of the resident's medical chart revealed that no inventory list was created upon admission, as required by facility policy. Another resident, who was the roommate of the first, also reported missing several items of clothing and stated that he had been requesting to speak with the social worker for over a month without response. This resident expressed anger over the missing items and the lack of follow-up, which also affected his ability to attend follow-up medical appointments. Interviews with facility staff, including the Director of Social Services, Administrator, and Director of Nursing, revealed that they were not aware of the missing property or the residents' grievances, and that required inventory lists had not been completed for either resident upon admission. Facility policies reviewed indicated that staff are required to inventory and document residents' personal belongings upon admission and to promptly investigate any reports of lost or stolen property. However, the facility did not follow these procedures, as evidenced by the lack of inventory documentation and failure to investigate or address the residents' complaints about missing property.
Resident Elopement Due to Inadequate Supervision and Non-Functional Alarm System
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including epilepsy, a cardiac pacemaker, and hypertension, was cognitively intact but required substantial assistance with activities of daily living. Despite having a history of alcohol abuse and withdrawal, which could increase the risk of elopement, the facility did not conduct an elopement assessment upon admission or include specific interventions in the resident's care plan to prevent elopement. On the day of the incident, the resident was last seen in the facility lobby by a CNA. The resident managed to leave the facility unsupervised through the main door, which was not properly monitored. The facility's alarm system on several exit doors was either non-functional or not activated, failing to alert staff of the resident's departure. The staff's response was delayed, and the resident was not found until the following day, highlighting a significant lapse in supervision and safety protocols. Interviews with facility staff revealed that the door alarms were not regularly checked for functionality, and there was no documented evidence of routine maintenance or testing. The facility's policies required daily testing of the alarm system and immediate reporting of any malfunctions, but these procedures were not followed. The lack of a functional alarm system and the absence of a specific care plan for the resident's elopement risk contributed to the resident's unsupervised exit and the subsequent search efforts by the facility staff.
Failure to Properly Waste Controlled Medication
Penalty
Summary
The facility failed to properly waste an Ativan 0.5 mg tablet according to its controlled narcotic protocol, resulting in an inaccurate medication count for a resident. The resident, who was admitted with multiple diagnoses including Parkinson's disease, COPD, epilepsy, and dementia, was prescribed Ativan 0.5 mg to be administered four times a day for anxiety. During a review, it was found that the medication count was incorrect, with 31 pills present instead of the expected 33. The licensed vocational nurse (LVN) admitted to giving one tablet that morning and failing to document it, as well as dropping another tablet during the count with an off-going nurse, which was not wasted as per protocol. The LVN later signed the medication count sheet and had another charge nurse co-sign it, but the waste was not properly documented or witnessed by two licensed nurses as required. The Director of Nursing confirmed that narcotic waste should be witnessed and signed by two licensed nurses, and the LVN should have reported the incident to the DON. The facility's policy and procedures for medication administration and discarding medications were not followed, leading to this deficiency in handling controlled substances.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 2, who required oxycodone-APAP for moderate to severe pain. Despite a physician's order for the medication, the facility did not administer it for 18 out of 54 days. Resident 2, who had a history of cervical disc disorder, non-Hodgkin lymphoma, and a rotator cuff tear, experienced significant pain levels ranging from 4/10 to 8/10 during this period. The resident reported frustration and an inability to participate in activities due to the unmanaged pain. The deficiency was attributed to the facility's failure to ensure the medication was available and administered as prescribed. The Licensed Vocational Nurse (LVN) confirmed that the pharmacy did not send the medication because they had not received authorization from the ordering physician. There was no documented evidence that the physician was informed about the medication shortage, and the facility did not follow up to ensure the authorization was completed. This oversight resulted in Resident 2 experiencing unnecessary pain and a lack of participation in activities. Interviews with the nursing staff, including the Registered Nurse Supervisor and the Director of Nursing, revealed that the facility did not adhere to its policy and procedures for pain management. The staff acknowledged that medications should be ordered before the current stock runs out and that the prescribing physician should be contacted immediately if there are issues with medication authorization. The facility's failure to administer the prescribed pain medication led to Resident 2 suffering from unmanaged pain, as confirmed by the Medication Administration Record and staff interviews.
Failure to Obtain and Maintain PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a pre-admission screening Resident Review level I (PASRR) was obtained and maintained in the resident's chart for one of the sampled residents. This deficiency was identified during a review of the admission records and interviews with facility staff. Resident 61, who was admitted with diagnoses including bipolar disorder, dementia, and major depressive disorder, did not have a PASRR level I on file. The absence of this screening could potentially impact the appropriateness of care and services provided to the resident. Interviews with the Social Services Director (SSD) and the Admissions Director (AD) revealed a lack of awareness and adherence to the facility's policy regarding PASRR screenings. The SSD admitted to not being familiar with the PASRR process, while the AD confirmed that the PASRR should have been obtained from the hospital prior to admission. The Director of Nursing (DON) also acknowledged the missing PASRR and its importance in addressing the resident's mental health needs. The facility's policy mandates that all applicants be screened for serious mental disorders or intellectual disabilities, and a record of the prescreening should be maintained in the resident's medical chart.
Failure to Ensure Resident Wore Neck Brace as Ordered
Penalty
Summary
The facility failed to ensure that Resident 122 wore a neck brace at all times as per the physician's order. Resident 122 was admitted with a displaced fracture of the second cervical vertebra and had a care plan indicating the need to wear a cervical collar due to this condition. During an observation, it was noted that the resident was lying in bed without the neck brace, which was found next to the resident instead of being worn. This observation was made in the presence of a physical therapist and a registered nurse, both of whom acknowledged that the resident was supposed to wear the neck brace at all times to prevent further injury and pain. The facility's policy and procedures on cervical collars, dated January 25, 2022, stated that the purpose of the collar is to treat an acute injury or prevent potential cervical spine fracture or cord damage. The policy also indicated that the wearing schedule of the cervical collar is based on the physician's order. Despite these guidelines, the facility did not adhere to the physician's order for Resident 122, as evidenced by the resident not wearing the neck brace during the observation. This failure had the potential to cause further injury and pain to the resident.
Failure to Clean Bipap Machine as Required
Penalty
Summary
The facility failed to provide proper respiratory care for a resident by not cleaning the Bilevel Positive Airway Pressure (Bipap) machine as required. Resident 8, who was admitted with diagnoses including generalized muscle weakness, morbid obesity, and chronic respiratory failure, reported that the facility staff did not clean her Bipap machine daily, as per the physician's orders. The orders specified that the Bipap/CPAP filter should be washed with warm soapy water, rinsed, and air-dried daily, while the mask, tubing, humidifier container, and headgear should be cleaned weekly. During an observation, the Bipap machine was found on the nightstand next to the resident's bed, and the resident expressed frustration and nervousness about the lack of daily cleaning. Interviews with facility staff revealed a lack of proper training and documentation regarding the cleaning and operation of the Bipap machine. The Director of Staff Development (DSD) admitted that the last in-service on Bipap operation was conducted without a lesson plan or materials, and staff did not perform return demonstrations to assess competency. Licensed Vocational Nurses (LVNs) confirmed they had not received training on Bipap machine use and were unaware of the last cleaning date for Resident 8's machine. The facility's policy indicated that cleaning instructions should be obtained from the manufacturer, but this was not followed, leading to the potential risk of respiratory infection for the resident.
Deficiencies in Staff Competency and Certification
Penalty
Summary
The facility failed to ensure that staff were competent in operating and cleaning a Bilevel Positive Airway Pressure (Bipap) machine, which is crucial for residents with respiratory issues. Resident 8, who was admitted with conditions such as generalized muscle weakness, morbid obesity, and chronic respiratory failure, reported that the Bipap machine was not being cleaned daily, causing frustration and nervousness. The Director of Staff Development (DSD) admitted that there was no structured in-service training or materials available for staff on the operation and maintenance of the Bipap machine, and no return demonstrations were conducted to assess staff competency. Additionally, the facility did not ensure that five staff members, including a registered nurse supervisor, a licensed vocational nurse, and certified nursing assistants, had current Cardiopulmonary Resuscitation (CPR) certification. The Director of Nursing (DON) and DSD acknowledged that employee files were incomplete, lacking documentation of current CPR certification and annual competencies. Interviews with staff revealed a lack of training on the Bipap machine and CPR, with some staff unable to demonstrate basic CPR skills or knowledge of emergency procedures. The facility's policies and procedures indicated that only qualified and properly trained personnel should operate Bipap machines and that CPR certification was mandatory for key clinical staff. However, the facility failed to adhere to these policies, as evidenced by missing certifications and inadequate training. This lack of compliance had the potential to cause physical harm to residents, particularly those dependent on Bipap machines and in need of emergency CPR intervention.
Failure to Provide Functional Bed and Mattress
Penalty
Summary
The facility failed to provide a functional bed and a comfortable mattress for a resident, leading to significant discomfort and distress. The resident, who was admitted with conditions including generalized muscle weakness, morbid obesity, and chronic respiratory failure, required extensive assistance with daily activities. Despite having the cognitive capacity to understand and make decisions, the resident was unable to adjust the bed height, which was necessary for both comfort and care. The mattress was found to be worn out, with holes and covered with duct tape, and the bed was not operating properly. The resident reported the issue to the Maintenance Supervisor a week prior, but no action was taken to replace the bed or mattress. Observations confirmed the bed's malfunction and the poor condition of the mattress. Interviews with the Maintenance Supervisor and a Registered Nurse highlighted the potential risks of injury to staff and the resident, as well as the possibility of infection and bed sores due to the unclean and damaged mattress. The facility's policy required regular inspections and maintenance of beds, which was not adhered to in this case.
Failure to Complete PASRR Level II Assessment
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II assessment for one resident, identified as Resident 27, as required by the PASRR Level I assessment. This oversight was discovered during a review of Resident 27's records, which indicated that the resident was admitted and readmitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). The PASRR Level I screening conducted on January 25, 2024, indicated the need for a Level II mental health evaluation, which was not completed. The deficiency was further highlighted during an interview with the Director of Staff Development (DSD), who confirmed that the Level II assessment should have been completed promptly following a positive Level I screening. The DSD emphasized the importance of the Level II evaluation in developing appropriate care plans and interventions. The facility's policy, revised on June 22, 2023, mandates that a Level II resident review be completed within 40 calendar days of admission, which was not adhered to in this case.
Obstructed Room Entrance Poses Safety Hazard
Penalty
Summary
The facility failed to ensure a hazard and clutter-free environment for two residents, leading to a deficiency in maintaining a safe and accessible living space. During a facility tour, it was observed that the entrance to the shared room of two residents was obstructed by two wheelchairs, each containing boxes. One wheelchair held a facility supply of nasal cannulas, while the other contained personal belongings of one of the residents. This obstruction posed a safety and fire hazard, potentially delaying emergency access to the residents. Resident 17, who was cognitively intact and required assistance with certain activities of daily living, and Resident 46, who had severe cognitive impairment and was totally dependent on staff for care, were both affected by this deficiency. The facility's policy on providing a safe and homelike environment was not adhered to, as the cluttered entrance could impede prompt staff access in emergencies, as confirmed by a registered nurse during an interview.
Failure to Monitor and Report Signs of UTI in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident who was incontinent of bowel and bladder. The resident, who had an indwelling catheter, was observed to have cloudy urine with clusters of sediments, which are signs of a urinary tract infection (UTI). Despite these observations, there was no change of condition noted or physician notification made by the staff, as confirmed by the Registered Nurse Supervisor during an interview. This oversight occurred even though the resident's care plan specifically required staff to monitor, record, and report signs and symptoms of a UTI, such as cloudiness and deepening of urine color. The resident, who was admitted and readmitted to the facility with diagnoses including obstructive and reflux uropathy, dementia, and generalized muscle weakness, was dependent on staff for activities of daily living. The facility's policy on catheter care, revised in September 2023, emphasized the importance of checking urine for unusual appearance to prevent catheter-associated urinary tract infections. However, the staff failed to adhere to this policy, resulting in a delay in addressing the resident's potential UTI, as evidenced by the physician's order for Ertapenem sodium only being received the day after the surveyor's observation.
Failure to Label Feeding Tube Syringe
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent complications related to a gastrostomy tube. Specifically, the facility did not label the resident's tube feeding syringe with the date it was opened, which is a necessary step to prevent infection and contamination. This oversight was observed during a survey when the syringe was found hanging from the resident's feeding pole without a date label. The Registered Nurse Supervisor confirmed the deficiency, acknowledging that the syringe needed to be labeled to prevent potential infection. The resident involved in this deficiency was admitted with multiple diagnoses, including diabetes mellitus, cerebral infarction, and pulmonary embolism, and was dependent on staff for activities of daily living due to cognitive impairment. The facility's policy on administration set and tubing changes, revised in December 2024, outlines the need for aseptic procedures to prevent infections, including labeling devices added to tubing. The failure to adhere to this policy had the potential to cause a spread of infection, as noted by the Registered Nurse Supervisor.
Infection Control Deficiencies in Resident Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain proper infection control measures, leading to several deficiencies. During a facility tour, it was observed that resident rooms 15, 17, 22, 23, and 32 did not have toilets or sinks for handwashing, despite being under enhanced barrier precautions due to the risk of spreading multi-drug resistant organisms (MDROs). Certified nursing assistants (CNAs) were found to be improperly handling urinals and bedside commodes, using sinks in restrooms not designated for such purposes, and disposing of waste inappropriately. The facility's policy on bedside commode use was found lacking in specific cleaning instructions, contributing to the potential spread of infection. Additionally, the restroom located between certain rooms was used by staff and visitors, despite being intended for resident use only. This was confirmed through interviews and observations, where it was noted that the restroom lacked proper signage to indicate its intended use. Staff and family members were observed using the restroom sink to rinse urinals, which could lead to cross-contamination. The presence of a large garbage can in the shower room, used for disposing of dirty diapers and commode contents, further compromised the hygiene of the environment, as it was sometimes left in the shower room during resident showers. Resident 8, who required a Bipap machine for chronic respiratory failure, reported that the facility staff were not cleaning the machine daily as required. Interviews with staff revealed a lack of training and in-service education on the proper operation and cleaning of Bipap machines. The Director of Staff Development admitted to not having a lesson plan or materials for training staff on Bipap machine maintenance, and staff members confirmed they had not received adequate training. This oversight in staff education and adherence to cleaning protocols posed a risk of infection to the resident.
Deficiency in Staff Certification and Training
Penalty
Summary
The facility failed to ensure that a Restorative Nurse Assistant (RNA) was properly certified and trained before providing care to residents. During a record review and interview with the Director of Staff Development (DSD), it was discovered that the RNA's Certified Nursing Assistant (CNA) certification, Cardiopulmonary Resuscitation (CPR) certification, and RNA training certificate were missing from the employee file. The DSD acknowledged that these certifications were required for the RNA to perform their duties and stated that the RNA would be removed from their assignment until the necessary certification was obtained. The facility's policy and procedures on credentialing nursing service personnel require that nursing personnel present verification of certification prior to or upon employment and prohibit them from performing direct resident care services until certification is completed. The DSD expressed concern that the RNA's lack of proper training could potentially harm residents, as the RNA might not know the correct techniques for assisting residents with range of motion exercises, which are crucial for maintaining or increasing joint mobility and preventing contractures.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 28 out of 32 rooms met the required 80 square feet per resident in multiple resident rooms. This deficiency was identified through observation, interview, and record review. The rooms in question included twenty-five 2-bed rooms, two 3-bed rooms, and one 4-bed room, all of which did not meet the minimum square footage requirements. Specifically, the 2-bed rooms were required to have at least 160 square feet, the 3-bed rooms at least 240 square feet, and the 4-bed room at least 320 square feet. However, the rooms were found to have less space per resident than required, with the 2-bed rooms having only 140 square feet, the 3-bed rooms having 196 and 217 square feet, and the 4-bed room having 294.5 square feet. During the initial tour, evaluators observed that the nursing staff had enough space to provide care, and privacy was maintained with curtains. Additionally, the rooms had direct access to the corridors. In a group interview with residents, no concerns were raised regarding the room sizes. Despite these observations, the facility's Client Accommodation Analysis confirmed the deficiency, and a room waiver request was submitted, indicating the facility's awareness of the issue.
Failure to Provide Hospice Information During Discharge
Penalty
Summary
The facility failed to follow the physician's orders by not providing a hospice agency for a resident upon discharge, as was ordered. This resulted in the resident receiving incomplete discharge information, causing confusion. The resident, who had severe cognitive impairments and required assistance with most Activities of Daily Living, was discharged to home with hospice care as per the discharge order. However, the family member of the resident reported that no hospice information or options were provided while the resident was still in the facility, leading to a confusing and tedious discharge process. The family member had to call the facility after the resident arrived home without instructions on how to initiate hospice services. The social worker admitted that the hospice information should have been provided during the discharge process for timely initiation of services. The facility administrator confirmed that the hospice information was given over the phone after the resident's discharge, but was unable to provide documentation or the specific date of verification. The facility's policy on transfer and discharge requires complete and appropriate discharge planning, which was not adhered to in this case.
Improper Medication Management for Discharged Residents
Penalty
Summary
The facility failed to properly manage medications for residents who were discharged or transferred, as observed in the cases of four residents. Medications were not returned or destroyed according to policy, resulting in multiple medications being left behind in the medication storage room. These medications were accessible to all staff with access to the room, which is against the facility's policy and procedure for medication management. The report details specific instances where medications were not handled correctly. For example, a resident discharged to another facility had medications left behind, and another resident transferred to a general acute care hospital also had medications that were not returned or destroyed. The facility's policy requires that medications left after a resident's discharge should be either returned to the pharmacy or destroyed, but this was not followed. Interviews with staff revealed a lack of adherence to the facility's medication destruction policy. A Licensed Vocational Nurse admitted that medications were not always destroyed nightly due to busy shifts, and a Registered Nurse Supervisor was unaware of the current status of residents whose medications were left behind. Additionally, the Director of Nursing was unsure of the facility's policy on medication destruction, indicating a lack of proper training or communication regarding medication management procedures.
Failure to Secure and Store Controlled Substances
Penalty
Summary
The facility failed to secure controlled substances belonging to a discharged resident, identified as Resident 4, according to its protocol. Resident 4, a male with a history of cancer-related diagnoses and pain, was admitted to the facility with physician orders for Hydromorphone and Morphine Sulfate ER, both classified as opioids and controlled substances. After leaving the facility against medical advice, Resident 4's medications were found unsecured in a box labeled 'patient's own medications store here' in the medication storage room. The Registered Nurse Supervisor was unaware of Resident 4's current status at the facility. Additionally, the facility did not store discontinued controlled substances per its policy. During an observation, the Director of Nursing (DON) was found to have a cabinet with a single lock containing multiple medication pill packs, including controlled substances, which should have been double-locked. The DON admitted to not knowing the last time the pharmacy had come to destroy these medications and had only recently contacted them for disposal. The facility's policy requires controlled substances to be stored in a double-locked compartment and monitored monthly by a consultant pharmacist. However, the pharmacist reported that the last waste of narcotics was conducted in August, and a scheduled waste in September did not occur due to the unavailability of the interim DON. This lapse in procedure resulted in controlled substances being easily accessible to staff with access to the medication storage room, posing a risk for drug diversion.
Medical Director Application Not Filed
Penalty
Summary
The facility failed to ensure that the Medical Director had filed an application with the State Licensing and Certification department's Centralized Applications Branch (CAB). This resulted in the Medical Director not being listed in the Electronic Licensing Management System (ELMS), which had the potential to affect resident care and medical oversight. On review of ELMS, it was found that the facility did not have a listed Medical Director. Interviews with the Administrative Assistant, a Licensed Vocational Nurse, and the Interim Director of Nursing confirmed the presence of a Medical Director, although the LVN did not know the name. The facility Administrator confirmed the Medical Director's name and stated that the application was being prepared for submission to CAB. The Medical Director was not part of the governing body but participated in Quality Assessment and Assurance meetings. The facility's job description for the Medical Director outlined responsibilities for guiding and overseeing resident care policies and procedures.
Failure to Provide Timely Transfer and Discharge Notification
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer and discharge to a resident, as well as to the resident's representative and the State Long Term Care Ombudsman. This deficiency was identified during a review of the case of a resident who was admitted with conditions including hemiplegia, hemiparesis, PTSD, and major depressive disorder. The resident required significant assistance with activities of daily living and had moderate cognitive impairment. Despite these needs, the facility did not provide the required advance notice of the transfer, which was initiated following a physician's order to discharge the resident to another skilled nursing facility. The Social Services Director admitted to discussing the discharge with the resident only on the day of the transfer, without providing the necessary advance notice or notifying the Ombudsman. The facility's policy requires a 30-day notice for transfers or discharges unless specific urgent circumstances exist, none of which were applicable in this case. The lack of proper notification led to the resident experiencing confusion and distress, as they were informed of the transfer only an hour before it occurred.
Failure to Develop Individualized Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan with measurable objectives, timeframe, and interventions for a resident upon readmission. This deficiency was identified for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, post-traumatic stress disorder, and major depressive disorder. The resident had moderate cognitive impairment and required substantial to maximal assistance for activities of daily living. Despite these needs, the facility did not initiate a discharge care plan, which is crucial for ensuring a smooth and safe transition from the facility to a post-discharge setting. Interviews with the Social Services Director and the Director of Nursing confirmed the absence of a discharge care plan for the resident. The Social Services Director acknowledged the importance of a care plan in facilitating discharge goals, while the Director of Nursing admitted that discharge planning should begin upon admission. The facility's policy and procedure on care planning, revised in October 2022, mandates the development of a culturally competent and trauma-informed comprehensive care plan for each resident, including discharge plans as appropriate. The lack of a discharge care plan resulted in the resident feeling confused and anxious.
Failure to Protect Resident from Abuse Due to Inadequate Caregiver Screening and Supervision
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse, as outlined in their abuse prevention and prohibition program. The deficiency involved a caregiver, hired privately by another resident's family, who physically abused the resident by slapping them twice on the face. The facility did not implement its policies and procedures to screen and train caregivers, as neither of the two caregivers involved had undergone the required orientation or background checks. Additionally, the facility lacked complete identifiable and contact information for the caregivers. On the day of the incident, the resident was left alone on the patio with the caregiver, despite a verbal altercation being overheard by the Activities Director. The Activities Director failed to separate the caregiver from the resident and left the area, allowing the altercation to continue. The Guest Liaison also left the resident alone with the caregiver, who then moved the resident to a secluded area and committed the abuse. The facility's failure to ensure proper supervision and intervention contributed to the occurrence of the abuse. The resident involved had a history of cognitive impairment and was dependent on staff for various daily activities. The incident was witnessed by the Guest Liaison, who reported it to the Administrator, leading to police involvement. The facility's Director of Nursing admitted to not having documented evidence of background checks or orientation for the caregivers, acknowledging a lapse in following the facility's policies. This oversight and lack of proper procedures directly led to the resident being subjected to abuse.
Removal Plan
- The Caregiver for Resident 3 was removed until a background check, orientation, and abuse training could be completed.
- The facility's Nurse Consultant Director Registered Nurse conducted in-service to all schedule staff on types of abuse and screening, and abuse prevention, intervention, investigation, reporting and monitoring.
- The facility created a Caregiver Logbook which was placed at the receptionist desk, whereby all future caregivers will be directed by the receptionist to verify or complete a background check, abuse training, and orientation.
- Social Services shall conduct room rounds 5 days a week, at least 10 residents a day to monitor residents for concerns, grievances, or allegations of abuse.
- AD1 was provided in-service by the Nurse Consultant Director RN by phone regarding abuse prevention and abuse policies including not to leave a resident alone after hearing a verbal altercation and must separate caregiver from resident.
- The Nurse Consultant RN in serviced AD1 regarding not leaving a resident alone during resident-to-resident altercation.
- The Nurse Consultant RN in-serviced to all working and on-coming staff regarding abuse prevention, review of abuse policy, and the caregiver/visitor log.
- An audit was performed by Medical Records Director for all residents to identify any residents utilizing caregivers - none were found.
- The Director of Staff Development (DSD) will provide caregiver training for future caregivers and will be on-going.
- GL1 was in serviced by phone regarding not leaving a resident alone during resident-to-resident altercation.
- The Medical Records Director (MRD) will audit monthly compliance of Caregiver Logbook and Visitor check in and report to the ADM all findings.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate and report an allegation of physical abuse involving a resident and a caregiver to the Department of Public Health, Ombudsman, and local law enforcement within the required timeframe. The incident involved a resident with cognitive impairment and dementia, who was dependent on staff for various activities and used a wheelchair for mobility. The resident was allegedly slapped by another resident's caregiver during a heated conversation in Farsi, which was witnessed by a guest liaison. The guest liaison observed the altercation and reported it to the administrator, who instructed her to inform the social worker. The social worker subsequently contacted the police, who arrived at the facility shortly after. However, the facility did not report the incident to the State Survey Agency within the mandated two-hour window, as the fax confirmation log indicated the report was sent over four hours after the incident occurred. The facility's policy and procedures on abuse prevention and prohibition require immediate reporting of such allegations, but this was not adhered to, resulting in a delay in communication and investigation. The administrator acknowledged the requirement for timely reporting to prevent noncompliance and ensure the safety of the residents involved.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to provide necessary physician documentation to support a facility-initiated discharge for a resident, identified as Resident 1. This deficiency was identified during an interview and record review, where it was found that the facility did not have the attending physician's documentation to justify the discharge. The resident, a male with a history of cerebral infarction, hemiplegia, hemiparesis, and other conditions, was issued a 30-day notice of transfer or discharge due to alleged physical aggression towards staff, which was claimed to create an unsafe environment. The Director of Social Services (DSS) acknowledged that the attending physician was informed of the resident's behavior but did not attend the Interdisciplinary Team (IDT) Care Conference. The DSS was uncertain if the physician agreed with the discharge decision and could not provide any supporting documentation from the physician. Furthermore, the facility's Administrator admitted that although there was an order from the physician indicating the resident could be transferred to a lower level of care, the facility did not have the physician assess the resident or have a psychologist evaluate the resident's behavior before initiating the discharge. The facility's policy on transfer and discharge requires written documentation from the attending physician to support such actions, especially when the safety of individuals in the facility is claimed to be endangered. The resident's appeal against the discharge was granted due to the facility's failure to provide the necessary physician documentation. The facility's policy also outlines that residents should not be transferred or discharged while an appeal is pending unless it is documented that their presence endangers health or safety, which was not adequately documented in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, which was not communicated to the abuse coordinator or the state agency. The incident involved a male resident with a history of hemiplegia, shoulder dislocation, falls, hypertension, and polyneuropathy, who was admitted to the facility in July 2024. The resident, with mildly impaired cognition, alleged that a certified nursing assistant (CNA) attempted to hit him after a disagreement over the delivery of butter during breakfast. The resident felt threatened and angry, although no physical contact occurred. The incident was witnessed by an unidentified staff member who dismissed the resident's claims. The CNA involved in the incident denied the allegations, stating that the butter was placed on the table without any aggressive behavior. The CNA reported the resident's accusations to a Licensed Vocational Nurse (LVN), who checked the breakfast tray and found the food untouched. The LVN suggested that the resident might have been offended by the CNA's tone but did not believe any abuse occurred. The LVN reassigned the CNA but failed to report the incident to the Assistant Director of Nursing (ADON) or the Administrator, who is the designated abuse coordinator. The facility's policy mandates immediate reporting of abuse allegations to the supervisor and the Administrator. However, the LVN did not follow this protocol, and the incident was not reported until a surveyor's interview days later. The Administrator confirmed that the incident should have been reported immediately to allow for proper investigation and notification to authorities. The facility's policy emphasizes mandatory reporting and non-retaliation for staff who report abuse in good faith.
Failure to Implement Proper Discharge Plan with Hospice Care
Penalty
Summary
The facility failed to develop and implement a discharge plan that included visits by an operating hospice agency for a resident with a terminal condition. The resident, who had diagnoses including malignant neoplasm of the left breast, type II diabetes mellitus, and major depressive disorder, was discharged to home with hospice care. However, the facility did not provide the resident's family member with written information about the hospice agency, leading to confusion and difficulty in finding information about the agency. The family member later discovered that the hospice agency was illegible and reported this to the facility administrator. The Social Services Director (SSD) admitted to initiating the referral for the hospice agency through an outside marketer without having a contract agreement or detailed documentation of the services to be provided. The SSD also failed to document the discharge follow-up in the resident's medical record. This lack of proper discharge planning and communication resulted in the resident not receiving the necessary physical, emotional, social, and spiritual support when nearing the end of life, as required by the facility's policy and procedure on transfer and discharge.
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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