Grand Valley Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 13524 Sherman Way, Van Nuys, California 91405
- CMS Provider Number
- 056363
- Inspections on file
- 67
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Grand Valley Health Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact decision-making capacity requested that a specific CNA not provide care or be present in her room. Despite this request being acknowledged by facility staff, the CNA was initially assigned to the room and later entered the room to interact with the resident, causing discomfort and anxiety. This action was contrary to the facility's policy on resident dignity and privacy.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
A resident with paraplegia, morbid obesity, and diabetes was found to have a low air loss mattress set for a much higher weight than their actual weight, contrary to physician orders and facility policy. Both an LVN and the DON confirmed the mattress setting was incorrect, which was identified during observation and record review.
A resident with multiple complex medical conditions received Oxycodone Hydrochloride, a controlled substance, which was signed out and administered by two LVNs but not documented on the MAR as required. The DON confirmed that facility policy mandates immediate documentation of medication administration on the MAR and that the MAR should match the Controlled Drug Record. This failure to document the administration of a narcotic medication resulted in a deficiency.
Two residents were not provided necessary assistance with mobility and getting out of bed, despite being dependent or requiring moderate help for these activities. One resident remained in bed throughout the day, with the assigned CNA admitting to forgetting to offer assistance, while another reported that only the physical therapist, not nursing staff, helped her get out of bed. Facility policy required staff to assist with ADLs, but this was not followed, resulting in prolonged bed rest for both residents.
A resident who was fully dependent on staff for activities of daily living did not receive required oral care, resulting in dry, cracked lips and an unclean tongue with a thick coating. The CNA assigned to the resident did not provide oral care, failed to promptly report the resident's oral condition to nursing staff, and only disclosed the issue after being questioned by a surveyor. Facility staff confirmed that oral care was not provided as required and that the resident's condition was not reported in a timely manner.
The facility did not complete required 72-hour follow-up assessments for two residents with bowel and bladder incontinence issues, resulting in missed opportunities to evaluate their candidacy for retraining programs and to implement appropriate care interventions, as required by facility policy.
Two residents were not informed in advance about the deep cleaning of their rooms, violating their rights to a dignified existence and self-determination. Both residents were informed on the day of cleaning, causing inconvenience and lack of preparation time. The facility's housekeeping schedule was not communicated to nursing staff or residents in advance.
A resident was physically assaulted by another resident, resulting in injuries requiring treatment. The incident occurred while the resident was sleeping, and the aggressor, who had severely impaired cognition and auditory hallucinations, punched the victim multiple times. The facility failed to prevent this altercation, leading to a deficiency in protecting residents from abuse.
A resident with a left hip fracture and dementia did not receive proper follow-up care for their surgical wound. The facility failed to obtain a physician's order to continue monitoring the wound after the initial 14-day period, and licensed nurses stopped documenting the wound's condition. The Treatment Nurse admitted to monitoring the wound without documentation, which is considered as not having been done. The facility's policy requires documentation of wound care, but this was not followed, resulting in a deficiency.
A resident with glaucoma did not receive their prescribed Latanoprost eye drops on the day of admission, yet the MAR inaccurately documented the administration. The LVN admitted to the error, and the DON highlighted the need for accurate documentation and physician notification when medications are unavailable.
The facility failed to ensure proper infection control practices, as a nurse did not perform hand hygiene after checking a resident's blood pressure, and another nurse did not perform hand hygiene between glove changes during wound treatment. Both incidents involved residents requiring assistance with daily activities, and the staff acknowledged the oversight, which was confirmed by the Infection Control Preventionist.
The facility failed to set low air loss mattresses (LALM) correctly for three residents, as per physician orders and guidelines. One resident's LALM was set to 210 lbs instead of their weight of 140 lbs, another's was set to firm despite weighing 132 lbs, and a third's was set to 280 lbs instead of 133 lbs. This non-compliance with LALM settings increased the risk of skin breakdown and pressure ulcers.
The facility failed to label leftover food brought by families with resident identifiers and use-by dates, as observed in three residents' cases. Various food containers in the residents' refrigerator were found without proper labeling, which the Dietary Manager confirmed should be done to prevent foodborne illness. The facility's policy requires perishable food to be labeled and disposed of within two days.
The facility failed to ensure proper infection control practices, including a nurse not wearing a gown while administering medications to a resident on enhanced barrier precautions, a CNA not performing hand hygiene after handling a dirty towel before assisting a resident with lunch, and unlabeled urinals in a resident's room, all of which could increase infection risk.
The facility failed to ensure accessible call lights for two residents, leading to potential delays in care. One resident's call light was out of reach, while another required an adaptive call light due to upper extremity impairments. Both situations were confirmed by staff, highlighting a breach in the facility's call light policy.
A facility failed to inform a resident of their right to formulate an advance directive, as required by the Patient Self-Determination Act of 1990. The resident, who was capable of making and understanding decisions, did not have a signed form acknowledging receipt of this information. This oversight violated the resident's rights and could lead to conflicts with their healthcare wishes.
A resident with severe cognitive impairment and multiple health conditions was found in a room with a temperature of 68°F, below the facility's policy of 70-75°F. The resident expressed feeling cold, and an open window was identified as the cause. The facility's policy requires maintaining a comfortable temperature range for residents.
The facility failed to create person-centered care plans for two residents, one with range of motion limitations and another with bowel and bladder incontinence. Despite documented needs, no care plans were developed, leading to potential gaps in care. The facility's policy on comprehensive care planning was not followed, resulting in deficiencies in addressing the residents' specific needs.
A facility failed to involve a cognitively intact resident in IDT Care Conferences, depriving them of the right to participate in their care plan development. Additionally, the facility did not update another resident's care plan after symptoms of a burning sensation during urination resolved, potentially leading to inappropriate care. These actions were contrary to the facility's policies, resulting in deficiencies in care planning.
A facility failed to assess and provide appropriate equipment for a resident with limited ROM upon readmission. The resident, with conditions like osteomyelitis and diabetic neuropathy, was unable to use the standard call light due to impairments in both upper extremities. The initial nursing assessment and Occupational Therapy Evaluation missed these limitations, leading to the resident's inability to call for assistance, potentially delaying care.
A facility failed to conduct a timely fall risk evaluation for a resident with a history of falls and severely impaired cognition, potentially impacting their care plan. Additionally, an LVN left medications unattended at a resident's bedside, risking unauthorized access. These actions violated the facility's policies on fall risk prevention and medication administration.
An LVN failed to provide adequate respiratory care to a resident by not administering oxygen as ordered, not covering the suction catheter, and not labeling the suction tubing. The resident, with serious health conditions, was found with an oxygen saturation below the prescribed level due to these oversights.
A resident was inappropriately administered hydrocodone-acetaminophen (Norco) despite having a pain level of zero, contrary to the physician's orders which specified its use for severe pain. This occurred on two occasions, as confirmed by a nurse during a review of the Medication Administration Record (MAR). The nurse acknowledged the potential adverse consequences of unnecessary medication use.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, missing vital signs and access site evaluation. The oversight was confirmed by an LVN and the ADON, who stated that licensed nurses are responsible for these assessments. The facility's policy requires documentation of vital signs, access site condition, and additional instructions, which was not followed, placing the resident at risk for complications.
The facility did not meet the federal regulation of providing at least 80 square feet per resident in multiple resident bedrooms, affecting four rooms. Despite this, residents did not express concerns, and observations showed adequate space for movement and care.
A facility failed to implement its policy for an allegation of financial abuse involving a resident with Alzheimer's Disease. The Business Office Manager reported the abuse, but the Administrator did not conduct a formal investigation or document findings. The Director of Nursing was not informed, resulting in no SBAR form completion or monitoring for emotional distress. This failure placed the resident at risk for further abuse.
A facility failed to report the results of a financial abuse investigation involving a resident with Alzheimer's and hydrocephalus. The resident's son, who was the financial POA, used the resident's Social Security checks for personal expenses instead of medical costs. The BOM reported the abuse, but the ADM did not conduct a formal investigation or document findings, violating the facility's abuse reporting policy.
A facility failed to create a care plan for a resident with hydrocephalus and Alzheimer's Disease involved in a financial abuse allegation. Despite the resident's impaired cognition and a significant billing balance, no care plan was developed. The DON was unaware of the abuse report and stated that a care plan would have been created if informed. The facility's policies on care planning and abuse reporting were not followed.
A resident with osteomyelitis and diabetes, requiring assistance with hygiene and mobility, was verbally abused by a CNA after requesting coffee. The CNA responded condescendingly, leading to a heated argument where both exchanged obscene language. An LVN witnessed the incident and reported it, with the facility's administration acknowledging the CNA's behavior as verbal abuse.
A resident with hypothyroidism did not receive Levothyroxine for a month due to the primary care physician's failure to review the medication list upon admission. This oversight led to the resident developing myxedema coma, requiring ICU admission. Interviews confirmed the physician did not adhere to facility policy requiring medication review.
Failure to Honor Resident's Request Regarding Caregiver Assignment
Penalty
Summary
The facility failed to honor a resident's explicit request to not have a specific Certified Nursing Assistant (CNA) provide care or be present in her room upon readmission. The resident, who had diagnoses including a left femur fracture, osteoporosis, rheumatoid arthritis, morbid obesity, and generalized anxiety disorder, had intact cognition and decision-making capacity. Upon readmission, the resident communicated her request to the case manager, who acknowledged it and assured her that the CNA would not be assigned to her care or be present. Despite this, the CNA was initially assigned to the resident's room and, after being informed of the restriction, was reassigned to the roommate but still entered the room and interacted with the resident, including responding to a call light and providing ice water. Interviews with facility staff, including the Assistant Director of Staff Development (ADSD), the case manager, and the Director of Nursing (DON), confirmed that the resident's request was known and that the CNA should not have entered the room or interacted with the resident. The facility's policy on dignity and privacy requires that residents be treated with respect and that their rights and preferences be honored. The DON acknowledged that the CNA's presence in the room had the potential to cause the resident increased anxiety, fear, and discomfort, which was contrary to the facility's stated policy and the resident's expressed wishes.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Incorrect Low Air Loss Mattress Setting for Resident
Penalty
Summary
A resident with multiple medical conditions, including paraplegia, morbid obesity, type 2 diabetes, and a history of poor wound healing, was admitted to the facility and required a low air loss mattress for skin management as per physician orders. Upon review, it was found that the mattress was set for a weight range of 600 to 1000 pounds, while the resident's actual weight was 246 pounds. This incorrect setting was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the mattress should have been set according to the resident's current weight. The facility's policy on the prevention of pressure injuries specifies the use of specialized mattresses as an intervention to prevent skin breakdown. However, the failure to set the mattress correctly for the resident's weight constituted a lapse in following this policy. The deficiency was identified through observation, interview, and record review, and it was confirmed that the mattress setting was not appropriate for the resident's needs at the time of the survey.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain accurate clinical records for one resident by not properly documenting the administration of Oxycodone Hydrochloride on the Medication Administration Record (MAR). Specifically, the Controlled Drug Record showed that Oxycodone was signed out and administered by two different Licensed Vocational Nurses on two occasions, but these administrations were not recorded on the MAR. The Director of Nursing confirmed that medication administration should be documented on the MAR immediately after the medication is given and that the MAR entries should align with the Controlled Drug Record. The resident involved had multiple diagnoses, including a right femur fracture, type 2 diabetes, end stage renal disease, and muscle weakness, and was assessed as having intact cognition and decision-making capacity. Facility policy required that all administered medications be documented on the MAR by the person administering them, and that the MAR be reviewed at the end of each medication pass to ensure accuracy. The failure to document the administration of a controlled substance as required by policy and professional standards constituted the deficiency.
Failure to Assist Residents with Mobility and Getting Out of Bed
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically mobility and getting out of bed, for two residents. One resident, who had diagnoses including traumatic subdural hemorrhage, pneumonia, and epilepsy, was assessed as cognitively moderately impaired and fully dependent on staff for mobility and other ADLs. Observations throughout the day showed this resident remained in bed with the call light within reach, and the gastrostomy tube feeding was alternately on and off. The assigned CNA admitted not offering to get the resident out of bed, citing forgetfulness and the presence of a g-tube, despite acknowledging the importance of mobility for preventing bed sores and maintaining function. The Director of Staff Development confirmed that getting residents out of bed is part of morning care and does not require a physician's order, but stated the facility preferred to keep the resident in bed during feeding times. Another resident, with diagnoses including pneumonia, COPD, and low back pain, was cognitively intact and required partial or moderate assistance for mobility. Observations showed this resident remained in bed throughout the morning and early afternoon, with staff assisting only with lunch. The resident reported that only the physical therapist, not nursing staff, assisted her with getting out of bed, and that nursing staff had not offered to help her transfer to a chair. The Director of Staff Development stated that CNAs are expected to offer and assist all residents with getting out of bed and to report refusals to the charge nurse, emphasizing that this is a standard part of daily responsibilities. A review of facility policies confirmed that staff are required to monitor, assist with, and provide ADLs, including transferring from bed to chair, to ensure residents attain or maintain their highest practicable well-being. Despite these policies, the facility did not ensure that the two residents were offered or provided necessary assistance with mobility and getting out of bed, resulting in prolonged periods spent in bed and potential compromise of dignity, preferences, and functional well-being.
Failure to Provide Oral Care and Timely Reporting for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, and was assessed as having moderately impaired cognition and being fully dependent on staff for personal care. The resident's care plan specifically required staff to assist with personal hygiene and provide oral care. On the day in question, the resident was observed in bed with dry, cracked lips. A CNA assigned to the resident that day initially stated that oral care had been provided, but upon further questioning, admitted that oral care was not given. The CNA described the resident's tongue as unclean, with a thick white and yellow coating, and stated that this condition had persisted for a long time. The CNA also admitted to not reporting the condition to the nurse until prompted by the surveyor and did not provide oral care because the resident began to scream. Interviews with facility staff, including the LVN, Assistant Director of Nursing, and Director of Staff Development, confirmed that oral care was not provided as required and that the condition of the resident's tongue was not reported in a timely manner. Review of facility policies indicated that oral care should be provided at least once per shift and that staff are responsible for monitoring and assisting with activities of daily living, including mouth care, and reporting any changes in resident condition.
Failure to Timely Reassess Bowel and Bladder Function for Two Residents
Penalty
Summary
The facility failed to implement an effective bowel and bladder retraining program for two residents by not ensuring timely reassessment of their bowel and bladder status. For one resident, the initial bowel and bladder assessment indicated functional incontinence and occasional episodes of both bladder and bowel incontinence. The facility's protocol required a follow-up evaluation 72 hours after admission, but this evaluation was not completed until ten days later. The delay was acknowledged by the registered nurse, who confirmed that the late assessment prevented the facility from providing appropriate interventions based on the resident's needs. For another resident, the admission record showed a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, with the resident being dependent on staff for most activities of daily living. The initial bowel and bladder assessment indicated the resident was always continent of bladder but always incontinent of bowel. However, the required 72-hour follow-up evaluation was left blank and not completed. The registered nurse confirmed that the assessment was missing and emphasized the importance of timely completion to ensure proper care planning and interventions. The facility's policy on bowel and bladder retraining, last reviewed in August 2024, specifies that the purpose of the program is to assist incontinent residents in regaining control over excretory functions. The failure to complete timely reassessments as outlined in the policy resulted in missed opportunities to accurately assess residents as candidates for retraining programs and to implement appropriate care interventions.
Failure to Inform Residents of Room Cleaning Schedule
Penalty
Summary
The facility failed to inform two residents, Resident 2 and Resident 3, in advance about the deep cleaning of their rooms, which is a violation of their rights to a dignified existence and self-determination. Resident 2, who was admitted with right knee and ankle fractures and hypothyroidism, was informed on the morning of the cleaning and was not given details about the duration or reason for the cleaning. Resident 2 expressed a desire to be informed at least one or two days in advance to prepare for the inconvenience. Similarly, Resident 3, who was admitted with Guillain-Barre syndrome, was also informed on the day of the cleaning and was not given adequate time to arrange personal belongings. Resident 3 expressed a preference for being informed three days in advance. Both residents were left waiting outside their rooms without clear communication about when they could return. The facility's housekeeping department had a monthly cleaning schedule, but it was not communicated to the nursing staff or residents in advance. The Director of Nursing acknowledged the need for a better system to inform residents about cleaning schedules. The facility's policy on resident rights emphasizes the importance of providing residents with information material to their decisions, which was not adhered to in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. On January 8, 2025, Resident 2 physically assaulted Resident 1 by punching him in the face multiple times. This incident occurred while Resident 1 was trying to sleep, leading to injuries including a left periorbital discoloration, an abrasion on the left eyebrow, and skin tears on the left forearm and dorsal hand. These injuries required first aid and daily wound treatments. Resident 1 was admitted to the facility on December 5, 2024, with diagnoses including cauda equina syndrome, osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb. The Minimum Data Set (MDS) indicated that Resident 1 had intact cognition. In contrast, Resident 2, admitted on December 12, 2024, had diagnoses including chronic obstructive pulmonary disease, unspecified dementia, opioid dependence, and nicotine dependence, with the MDS indicating severely impaired cognition. On the day of the incident, Resident 2 reported hearing voices instructing him to punch his roommate, Resident 1, and was noted to be agitated and experiencing auditory hallucinations. The facility's policy on abuse reporting and prevention mandates the protection of residents' rights and the prevention of resident-to-resident altercations. However, the facility failed to prevent the altercation between Resident 1 and Resident 2, resulting in physical abuse. The incident was confirmed through interviews with staff and residents, and the facility's investigative report corroborated the occurrence of the physical assault. Despite the facility's policy, the actions and inactions leading to this deficiency highlight a failure to adequately protect Resident 1 from harm.
Failure to Monitor and Document Surgical Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following up with the physician to obtain an order to continue monitoring the resident's surgical wound. The resident, who was admitted with a left hip fracture and dementia, had an order to monitor the surgical wound for signs of infection for 14 days. However, after the 14-day period, the licensed nurses stopped documenting the monitoring of the wound, and no follow-up order was obtained from the physician. During an interview, the Treatment Nurse admitted to monitoring the wound but not documenting it, which is considered as not having been done according to the Assistant Director of Nursing. The resident's surgical wound was partially covered with a non-removable dressing and had visible staples, which were not observed the previous day. The facility's policy requires documentation of wound care, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a physician-ordered eye drop medication in the Medication Administration Record (MAR) for a resident diagnosed with glaucoma. The resident was admitted with a physician's order to receive Latanoprost eye drops at bedtime. However, the MAR inaccurately indicated that the medication was administered on the day of admission, despite the medication not being delivered to the facility until the following day. This discrepancy was confirmed during interviews with the resident, the Assistant Director of Nursing (ADON), and the Licensed Vocational Nurse (LVN) responsible for the documentation. The resident, who had intact cognitive skills and required varying levels of assistance with daily activities, reported not receiving the eye drops on the evening of admission. The LVN admitted to incorrectly documenting the administration of the medication in the MAR, acknowledging the importance of accurate documentation to ensure continuity of care. The Director of Nursing (DON) stated that the licensed nurses should have notified the physician about the unavailability of the medication and documented the situation accurately in the MAR. The facility's policy on medication administration emphasizes the need for accurate documentation and appropriate actions when medications are not administered as scheduled.
Infection Control Lapses in Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after checking a resident's blood pressure with bare hands. The resident, who was admitted with diagnoses including glaucoma, required various levels of assistance for daily activities. The LVN admitted to forgetting to wear gloves and perform hand hygiene, acknowledging the risk of cross-contamination. In the second incident, a Treatment Nurse (TN) failed to perform hand hygiene between glove changes while providing wound treatment to another resident. This resident, who had been readmitted with lymphedema, required maximum assistance with dressing and transfer. The TN initially performed hand hygiene and wore gloves but neglected to do so between glove changes during the treatment process. The Infection Control Preventionist confirmed that hand hygiene should be performed before and after wearing gloves and between glove changes to prevent cross-contamination. The facility's policy on infection control and hand hygiene supports these practices.
Incorrect LALM Settings for Residents
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for three residents were set at the correct settings, as per physician orders and the LALM operator's manual. Resident 88, who was admitted with multiple fractures and diabetes, had a care plan indicating high risk for skin breakdown and required a LALM set to their weight of approximately 140 lbs. However, during an observation, the LALM was set to 210 lbs, which was not in accordance with the physician's order or the manual's guidelines. Similarly, Resident 11, admitted with a fracture and requiring maximal assistance for activities of daily living, had a physician's order for a LALM for wound management. Despite weighing 132 lbs, the LALM was observed to be set to firm, or greater than 350 lbs. This setting was inconsistent with the facility's practice of setting the LALM according to the resident's weight to prevent wound development. Resident 196, admitted with osteomyelitis and stage III pressure ulcers, also had a physician's order for a LALM. The mattress was observed to be set at 280 lbs, while the resident's weight was 133 lbs. The Assistant Director of Nursing confirmed that the LALM should be set according to the resident's weight to effectively manage and prevent wounds. The facility's policy and procedure for wound care emphasized the importance of following guidelines to promote healing, which was not adhered to in these cases.
Improper Labeling of Leftover Food Brought by Families
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date. This deficiency was observed in the cases of three residents. During a kitchen observation, various food containers were found in the residents' refrigerator without proper labeling. A red container belonging to one resident had no use-by date, an orange container with food items had no resident name or use-by date, a plastic container belonging to another resident had no use-by date, and a clear plastic container belonging to a third resident also lacked a use-by date. The Dietary Manager confirmed that leftover food from outside should be labeled with a resident identifier and dated to ensure it is discarded by the use-by date. The facility's policy on food brought from outside sources requires that perishable food be stored properly and labeled with the date opened, to be disposed of within two days. The failure to adhere to these procedures had the potential to result in foodborne illness for the residents.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Labeling
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) donned a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). The resident, who was admitted with diagnoses including encephalopathy and gastrostomy status, had severely impaired cognition and required maximal assistance for most activities of daily living. During an observation, the LVN was seen administering medications without wearing a gown, which was confirmed by the LVN in an interview. The Infection Preventionist (IP) stated that proper personal protective equipment (PPE) is necessary to prevent the spread of infection, especially for residents with indwelling medical devices. The facility also failed to ensure that a Certified Nursing Assistant (CNA) performed hand hygiene after picking up a dirty towel from the floor and before assisting a resident with lunch. The resident had intact cognition and required moderate assistance for most activities of daily living. During an observation, the CNA was seen picking up a dirty towel and then assisting the resident with their lunch tray without performing hand hygiene. The CNA confirmed this lapse in an interview, and the IP emphasized the importance of hand hygiene to prevent infection spread. Additionally, the facility did not label a urinal with a resident's name, which is required to prevent cross-contamination. The resident, who had severely impaired cognition and was dependent on assistance for personal care, was observed with unlabeled urinals in their room. The Restorative Nurse Assistant (RNA) and the Assistant Director of Nursing (ADON) confirmed that urinals should be labeled according to facility policy to prevent infection spread.
Failure to Provide Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that Resident 16's call light was within reach while the resident was in bed. Resident 16, who was admitted with diagnoses including chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and hypertension, required substantial assistance with activities of daily living. During an observation, it was noted that the call light was hanging behind the bed and out of reach, which the resident confirmed they were unaware of its location. Both a Certified Nursing Assistant and the Assistant Director of Nursing acknowledged that the call light should always be within reach to prevent delays in care. The facility also failed to provide an adaptive call light for Resident 28, who was readmitted with conditions such as osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, and congestive heart failure. Resident 28 had impairments in both upper extremities, making it impossible to use the standard push-button call light provided. During observations, it was confirmed by both the Treatment Nurse and a Registered Nurse that Resident 28 was unable to press the call light button due to contracted wrists and hands, necessitating an adaptive call light to prevent delays in care. The facility's policy on call lights, last reviewed in August 2024, mandates that call lights be accessible to residents in various locations, including in bed, and that residents should be able to demonstrate how to use them. The failure to adhere to this policy for both residents resulted in the potential for delayed care, as neither resident could effectively signal for assistance when needed.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that an advance directive was discussed and written information was provided to a resident, identified as Resident 6, or their responsible parties. This deficiency was identified during a review of Resident 6's admission records and Minimum Data Set (MDS), which indicated that the resident had the ability to make self-understood decisions and understand others. Despite this, the facility did not have a signed Patient Self-Determination Act of 1990 form for Resident 6, which is meant to inform residents of their right to formulate an advance directive. The Assistant Director of Nursing (ADON) confirmed that the absence of a signature on the form indicated that Resident 6 was not informed of their right to formulate an advance directive. This oversight violated the resident's right to be fully informed of their healthcare options and could potentially lead to conflicts with their healthcare wishes. The facility's policy, last reviewed in August 2024, mandates that all residents and their representatives be presented with written information about their rights to accept or refuse medical treatment and to formulate an advance directive upon admission.
Failure to Maintain Safe Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature level for a resident, identified as Resident 30, which had the potential to result in loss of body heat and risk of hypothermia. Resident 30 was initially admitted on February 22, 2024, and readmitted on August 30, 2024, with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity, degenerative disease of the nervous system, and repeated falls. The resident had severely impaired cognition and was dependent on assistance for daily activities. During an observation on November 4, 2024, Resident 30 was found in his room, covered with a blanket, and expressed feeling cold. The Maintenance Supervisor Assistant measured the room temperature at 68 degrees Fahrenheit, which was below the facility's policy range of 70-75 degrees Fahrenheit. The Maintenance Supervisor later identified an open window in the bathroom as the cause of the low temperature. Interviews with the Maintenance Supervisor and the Assistant Director of Nursing confirmed that the temperature should be maintained within the specified range to ensure resident comfort. The facility's policy, last reviewed on August 15, 2024, indicated that room temperatures should be maintained at a comfortable level for residents, generally between 70-75 degrees Fahrenheit.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 28, who was readmitted with multiple diagnoses including osteomyelitis, diabetes with neuropathy, and congestive heart failure, exhibited significant range of motion (ROM) limitations in the upper extremities. Despite being alert and oriented, Resident 28 was unable to move his arms without assistance and could not use the call light button, which was confirmed by both the resident and Treatment Nurse 1. The facility's records showed no care plan addressing these ROM limitations, as confirmed by Registered Nurse 1 and the Assistant Director of Nursing, indicating a failure to document and plan for the resident's needs. Similarly, the facility did not develop a care plan for Resident 50's bowel and bladder incontinence. Resident 50, who was readmitted with conditions such as gastroesophageal reflux disease and dysphagia, was frequently incontinent of bowel and bladder, requiring moderate assistance for daily activities. Despite these needs being documented in the Minimum Data Set, there was no corresponding care plan to address the incontinence, as confirmed by Registered Nurse 2. This lack of a care plan meant that the resident's care needs might not be adequately met, potentially leading to further complications. The facility's policy on comprehensive care planning, which mandates the development of a person-centered care plan with measurable objectives and timetables based on resident assessments, was not adhered to in these cases. The policy requires regular review and revision of care plans to reflect any changes in the resident's condition, but this was not done for Residents 28 and 50, resulting in a failure to provide necessary care and services.
Deficiencies in Resident Involvement and Care Plan Updates
Penalty
Summary
The facility failed to involve Resident 50 in two quarterly Interdisciplinary Team (IDT) Care Conferences, despite the resident having intact cognitive skills and no appointed representative. The care plan conferences were attended by representatives from various departments and a family member via telephone, but there was no documentation that the resident was invited or refused to attend. This omission deprived the resident of the right to participate in developing a resident-centered care plan, which is crucial for addressing the resident's needs effectively. Additionally, the facility did not revise the care plan for Resident 30 after the resident's symptoms of a burning sensation during urination resolved. The resident, who had severely impaired cognition and was dependent on assistance for daily activities, initially complained of pain during urination. A urinalysis and urine culture were conducted, revealing a significant bacterial presence. However, the resident's symptoms resolved within three days, and no new antibiotic orders were received. Despite this, the care plan was not updated to reflect the resolved symptoms, potentially leading to inappropriate care. The facility's policies and procedures emphasize the importance of involving residents and their representatives in care planning and ensuring care plans are based on comprehensive assessments. However, in these cases, the facility did not adhere to its policies, resulting in deficiencies in care planning for both residents. The lack of resident involvement and failure to update care plans as needed were identified as deficient practices during the survey.
Failure to Assess and Provide Equipment for Resident's Limited ROM
Penalty
Summary
The facility failed to comprehensively assess the limited mobility and range of motion (ROM) for Resident 28 upon readmission. Resident 28, who was readmitted with conditions including osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and abnormalities of gait and mobility, was not provided with the appropriate equipment to maintain their maximum practicable independence. The resident was observed to have impairments in both upper extremities, with the right wrist contracted and the left hand mostly closed, rendering them unable to use the standard call light provided by the facility. Interviews and record reviews revealed that the initial nursing assessment failed to note the resident's upper extremity ROM limitations. The Occupational Therapy Evaluation also missed the left hand's ROM limitations, despite the resident's inability to push a call button. The facility's policy on call lights, which requires accessibility and the ability for residents to demonstrate usage, was not adhered to, resulting in the resident's inability to call for assistance, potentially delaying care.
Deficiencies in Fall Risk Evaluation and Medication Administration
Penalty
Summary
The facility failed to ensure a fall risk evaluation was completed after a fall incident involving a resident. The resident, who had a history of repeated falls and severely impaired cognition, was found on the floor and sent to a hospital for evaluation. Despite the fall, the facility did not conduct a fall risk evaluation immediately after the incident, and the subsequent evaluation inaccurately reported no falls in the past three months. This oversight had the potential to negatively impact the resident's care plan and the delivery of necessary services. Additionally, the facility did not adhere to medication administration protocols, as observed with a licensed vocational nurse (LVN) who left prepared medications unattended at a resident's bedside. The resident, who had severely impaired cognition and required maximal assistance for daily activities, was left with medications within reach while the LVN retrieved a stethoscope. This practice posed a risk of unauthorized access to medications by other residents, potentially leading to adverse effects or allergic reactions. The facility's policies on fall risk prevention and medication administration were not followed, as evidenced by the lack of timely fall risk assessments and the improper handling of medications. These deficiencies highlight lapses in the facility's adherence to its own procedures, which are designed to ensure resident safety and proper care management.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to provide necessary respiratory care to a resident, identified as Resident 242, in accordance with professional standards and physician orders. The deficiencies included not covering the suction catheter with a sleeve when not in use, not administering oxygen as per the physician's order, and not labeling the suction tubing with the date it was last changed. These actions were observed during a review of Resident 242's records and an observation on November 4, 2024, where the resident was found without the prescribed continuous oxygen administration, and the suction equipment was improperly maintained. Resident 242 had been admitted with serious health conditions, including malignant neoplasm of the colon, acute systolic heart failure, acute respiratory failure, and pleural effusion. The resident's physician had ordered continuous oxygen administration at 2 liters per minute via nasal cannula to maintain oxygen saturation above 94%. However, during an observation, the resident's oxygen saturation was found to be at 93% due to the oxygen not being administered. Additionally, the suction catheter was improperly stored, and the tubing was not labeled, increasing the risk of respiratory infection. The facility's policies required adherence to physician orders and proper maintenance of medical equipment, which were not followed in this instance.
Inappropriate Administration of Pain Medication
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician for a resident, identified as Resident 6. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and muscle weakness. According to the physician's orders, the resident was prescribed hydrocodone-acetaminophen (Norco) to be administered orally every four hours as needed for severe pain, with a pain level of 7-10 on a numerical scale. However, a review of the Medication Administration Record (MAR) revealed that the resident was administered Norco on two occasions when their pain level was recorded as zero. During an interview and record review, Registered Nurse 2 confirmed that the medication was administered inappropriately on these occasions, as the resident's pain level did not warrant the use of Norco. The nurse acknowledged that administering the medication without the appropriate pain level could lead to unnecessary use and potential adverse consequences such as constipation, respiratory depression, and sedation, which could increase the risk of falls and injury. The facility's documentation on medication issues for older adults also highlighted the potential adverse effects of opioid analgesics like hydrocodone.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. The resident, admitted with end-stage renal disease and dependent on dialysis, had moderately impaired cognition and required substantial assistance with daily activities. On a specific date, the post-dialysis assessment was not completed, and there was no documentation of vital signs or assessment of the dialysis access site. This oversight was confirmed during a review with a Licensed Vocational Nurse, who acknowledged the missing documentation and stated that charge nurses are responsible for completing the assessment upon the resident's return to the facility. The Assistant Director of Nursing confirmed that licensed nurses are responsible for completing the post-dialysis assessment, which should include vital signs and signs of bleeding to ensure the resident's stability. The facility's policy on dialysis care, last reviewed in August 2024, requires the completion of a post-dialysis checklist, including documentation of vital signs, access site condition, skin condition, and any additional instructions from the dialysis unit. The failure to complete this assessment placed the resident at risk for complications associated with dialysis.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed in four of the 38 resident rooms (Rooms 1, 3, 9, and 11). Each of these rooms contained two beds, but the floor area per resident was below the federal regulation requirement. Specifically, Room 1 had 73 square feet per resident, Room 3 had 77.5 square feet, Room 9 had 71.5 square feet, and Room 11 had 75.5 square feet. The minimum required square footage for a two-bed room is 160 square feet, which these rooms did not meet. Despite the deficiency in room size, during a resident council meeting, no concerns were raised by the residents regarding the size of the rooms. Additionally, general observations conducted on two consecutive days indicated that residents had ample space to move freely within their rooms. There was sufficient space for residents' freedom of movement and for nursing staff to provide care, as well as adequate space for beds, side tables, and resident care equipment.
Failure to Investigate Financial Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for an allegation of financial abuse concerning a resident. The Business Office Manager (BOM) reported the financial abuse to the Social Security Administration (SSA) after discovering that the resident's son, who was the financial power of attorney, was using the resident's Social Security checks for personal expenses instead of paying the resident's share of cost for medical services. Despite this report, the Administrator (ADM) did not conduct a formal investigation or document the findings, as required by the facility's policy. The facility's policy mandates that the ADM, as the abuse coordinator, thoroughly investigate any alleged violations and report the results to the appropriate agencies within five working days. However, the ADM only engaged in informal conversations with the resident's son and did not document any investigation or conclusions. Additionally, the Director of Nursing (DON) was not informed of the financial abuse allegation, which resulted in the nursing department not completing an SBAR form or monitoring the resident for emotional distress or negative outcomes. The resident involved had moderately impaired cognition due to Alzheimer's Disease and hydrocephalus, making them vulnerable to financial abuse. The facility's failure to follow its abuse reporting and prevention policy, including conducting a thorough investigation and ensuring proper communication and monitoring, placed the resident at risk for further abuse and potential emotional distress.
Failure to Report Financial Abuse Investigation Results
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically financial abuse, in accordance with Section 1150B of the Act. This deficiency involved a resident who was diagnosed with hydrocephalus and Alzheimer's Disease, and had moderately impaired cognition. The resident's financial power of attorney, their son, was receiving the resident's Social Security checks but was not paying the resident's share of cost for medical expenses. Instead, he used the funds for his daughter's school expenses, which was identified as financial abuse by the Business Office Manager (BOM). The BOM reported the financial abuse allegation to the State Survey Agency (SSA) on behalf of the resident. However, the Administrator (ADM), who is the abuse coordinator, did not conduct a formal investigation or document the findings. Despite being aware of the facility's policy and the requirement to report the investigation results within five working days, the ADM only engaged in informal conversations with the resident's son and did not complete a conclusion letter. This lack of formal documentation and reporting constituted a failure to comply with the facility's abuse reporting policy.
Failure to Develop Care Plan for Financial Abuse Allegation
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident involved in an allegation of financial abuse. The resident, who had diagnoses including hydrocephalus and Alzheimer's Disease, was found to have a significant outstanding balance on their billing statement. Despite the resident's moderately impaired cognition and the presence of a financial power of attorney, no care plan was developed to address the financial abuse allegation. Interviews with the Medical Records Director and the Director of Staff Development confirmed the absence of a care plan related to the financial abuse. The Director of Nursing was unaware of the financial abuse report and stated that if informed, a care plan would have been developed, including interventions such as reporting to the physician and monitoring the resident for emotional distress. The facility's policy on comprehensive care planning requires the development of a care plan with measurable objectives and timeframes, which was not adhered to in this case. Additionally, the facility's abuse reporting policy mandates initiating a care plan in response to abuse allegations, which was not followed.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a verbal altercation between the CNA and a resident, who was admitted with osteomyelitis and type two diabetes mellitus with a foot ulcer. The resident, who was cognitively intact and required assistance with personal hygiene and mobility, requested a cup of coffee from the CNA. The CNA responded in a condescending manner, leading to an argument where both parties exchanged heated words. During the altercation, the resident and the CNA were heard yelling at each other, with the CNA using obscene language in response to the resident's provocation. A Licensed Vocational Nurse (LVN) witnessed the exchange and reported it to a Registered Nurse (RN). The facility's Administrator and Director of Nursing acknowledged the CNA's behavior as verbal abuse, although the Administrator noted it was not abusive. The facility's policy on abuse reporting and prevention defines verbal abuse as the use of derogatory language, which was violated in this incident.
Failure to Review Medication List Leads to Severe Health Decline
Penalty
Summary
The facility failed to ensure that the primary care physician (PMD 1) for a resident with a history of hypothyroidism reviewed the resident's progress notes and medication list upon admission. The resident was admitted to the facility with a diagnosis of hypothyroidism and had been taking Levothyroxine as a routine home medication. However, PMD 1 did not review the resident's home medication list and consequently did not prescribe Levothyroxine during the resident's stay at the facility. As a result of this oversight, the resident did not receive 30 doses of Levothyroxine over a period of one month. This led to the resident experiencing a severe health decline, culminating in a myxedema coma, a life-threatening condition associated with severe hypothyroidism. The resident was subsequently transferred to a hospital and admitted to the ICU for critical care. Interviews with PMD 1 and the Director of Nursing confirmed that the physician did not review the resident's medication list, which was a critical component of the resident's care plan. The facility's policy required physicians to review and sign off on all medications and treatments, but this was not adhered to in this case, resulting in significant harm to the resident.
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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