Guardian Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manteca, California.
- Location
- 410 Eastwood Ave, Manteca, California 95336
- CMS Provider Number
- 056216
- Inspections on file
- 45
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Guardian Care And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide a safe, clean, and homelike environment when surveyors observed significant environmental deficiencies in a shower room, a main hallway, and a resident room. In a shower room, there was black discoloration on floor tiles and grout, white buildup on the shower head and handle, a mildewed and discolored call light string stuck to the wall, and a rusted soap holder; staff confirmed the room was used for resident bathing and that the conditions were dirty, with the DOM identifying mildew and hard water stains. In a hallway shared by two nursing stations and the kitchen, the baseboard was water damaged, pulling away from the wall, and packed with dust, debris, and cobwebs, a condition present for months and linked to a prior leak behind the wall. In a resident room, the protective wall covering and vinyl baseboard behind a bed were peeling away and collecting dust and debris. The IP stated that mildew in the shower and dust and debris in the hallway and room could make residents sick, and facility policies required a clean, sanitary, and well-maintained environment.
A resident with intellectual disabilities was started on a psychotropic medication for anxiety following evaluation by a mental health NP, but staff did not obtain informed consent from the resident’s responsible party (RP) before adding the drug to the MAR and administering multiple doses. Review of records showed no documented consent, and interviews with an LPN and the Director of Staff Development confirmed that facility policy requires resident/RP involvement and written informed consent for psychotropic medications. The LPN acknowledged that consent had not been obtained and reported that, when later contacted, the RP stated they did not want the resident to receive the medication.
A resident with enterocolitis due to C. diff was on contact precautions with orders requiring appropriate PPE and proper hand hygiene before and after contact with the resident or their environment. A CNA was observed exiting this resident’s room, removing PPE, and using only an alcohol-based hand gel before immediately entering another resident’s room. In interviews, the CNA confirmed using alcohol gel and believed this was appropriate, while the IP and DON stated that soap-and-water handwashing is required for C. diff, consistent with facility policy and CDC guidance that emphasize soap and water as the best method to prevent person-to-person spread of C. diff.
A resident with paraplegia and complete bowel and bladder incontinence did not receive timely incontinence care despite requesting to be cleaned and dressed late in the morning. Observation showed the resident’s brief was heavily saturated with urine. One CNA reported the resident had asked to delay care earlier in the morning and stated another CNA had provided care later, while the second CNA denied providing any care during the shift. Nursing leadership indicated residents are typically changed every 2 hours and that refusals should be addressed and communicated, and the resident’s care plan and the facility’s incontinence policy required regular checks, cleaning with each episode, and timely, individualized incontinence care.
A resident with paraplegia, chronic pain syndrome, major depressive disorder, and a history of polysubstance abuse, who was on chronic methadone, repeatedly tested positive for cocaine and cannabis over several months. Despite MD notes directing behavior monitoring and documenting ongoing drug use and behavior issues, the facility did not maintain a behavior monitoring log, did not revise the care plan after subsequent positive drug screens, and did not implement consistent supervision when the resident left the premises or received visitors. Staff acknowledged that residents with drug-seeking behavior should be monitored and that visitors and unsupervised outings could facilitate illicit drug use, yet no structured monitoring, psychological evaluation for substance use, or documented visitor controls were put in place, allowing continued access to illicit substances within and outside the facility.
A resident with multiple medical conditions, including dementia and a recent femur fracture, was found with a call light out of reach, hanging from the bed rail to the floor. The resident could not access the call light to request assistance, and both CNA and nursing staff confirmed the device was not properly placed, in violation of the care plan and facility policy.
A resident with multiple serious diagnoses, including dementia and Parkinson's disease, was found on the floor and later diagnosed with a subacute femoral neck fracture. The DON did not submit the required summary of investigation to the Department within the mandated timeframe, despite being aware of this requirement.
Surveyors found that kitchen staff failed to properly clean food-contact equipment, with four sheet pans stored as clean but visibly soiled with dark brown buildup, and also failed to label a pie in the freezer with a required use-by or expiration date. Dietary and nursing staff confirmed these lapses, which did not follow facility policy or FDA Food Code requirements.
Two residents with physician orders for oxygen therapy were observed receiving oxygen via concentrator without 'Oxygen in Use' signage posted on their doorways, as required by facility policy. Nursing staff and leadership confirmed the absence of signage and acknowledged it was their responsibility to ensure proper posting to maintain safety.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, failing to meet required safety standards.
Two residents did not receive care in accordance with their assessed needs: one resident with face and neck swelling did not have a care plan addressing the issue, and another resident with multiple sclerosis requiring two-person assistance for ADLs was turned by only one CNA, contrary to the care plan. These failures were confirmed by both staff and residents, and were not in line with facility policy.
A resident receiving palliative care reported being verbally and physically abused by a CNA. The facility's investigation was incomplete, as only the resident and the alleged CNA were interviewed, and the CNA's prior history of similar infractions was not reviewed, contrary to facility policy requiring a comprehensive investigation.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A dumpster lid was found propped open with a stick, as confirmed by the DSS during an observation. Staff interviews, including with the DON, acknowledged that dumpster lids should always be closed to prevent pest and infection risks. Facility policies and the FDA Food Code require closed, tight-fitting lids on outside refuse containers, but this was not followed.
Staff did not follow a resident's care plan requiring a mechanical lift for transfers and instead manually lifted the resident from a shower chair to bed, resulting in a right leg fracture and skin breakdown. The resident had significant mobility limitations and a history of bone weakness, and staff acknowledged the transfer method used was unsafe and not in accordance with facility policy.
A resident with a history of diabetes and mental health issues refused medications, blood sugar tests, and physical therapy multiple times. The facility failed to notify the resident's physician and Responsible Party (RP) of these refusals, contrary to policy. The Director of Nursing acknowledged the lapses in communication and documentation, which left the RP uninformed and unable to participate in medical decisions.
A resident was discharged from the facility following a hospital admission for surgery, but the required documentation specifying the basis for discharge and the unmet needs was not included in the medical record. The DON and Social Services Director completed and served a discharge notice, but both the Administrator and DON confirmed that the medical record lacked details as required by facility policy.
A resident's responsible party and the LTC ombudsman were given a discharge notice that listed incorrect appeal information, directing them to the CDPH instead of the appropriate Office of Administrative Hearings and Appeals. The Social Services Director and DON confirmed they were unaware of the correct process, resulting in the responsible party not being properly informed of how to appeal the facility-initiated discharge.
A resident was not permitted to return to the facility after a hospital stay, even though their bed and personal belongings remained in place and the facility had available capacity. The facility cited the expiration of the bed-hold period and served discharge paperwork, but did not follow policy allowing return to the previous room or first available bed.
A facility failed to ensure LNs had the necessary skills to perform the milking technique for a resident's leg edema, despite multiple physician orders. The resident reported being denied treatment, and staff interviews revealed a lack of knowledge and experience in performing the procedure. Medical professionals confirmed the importance of following the orders, but the treatment was not consistently administered.
A resident with multiple medical conditions, including heart failure and atrial fibrillation, refused critical medications over two months. The facility failed to notify the medical doctor of these refusals, leading to the resident's hospitalization due to worsening symptoms. Interviews with staff revealed a lack of adherence to protocols for notifying medical professionals about ongoing medication refusals.
The facility failed to provide training and establish a policy for the use of continuous glucose monitoring (CGM) devices for nine residents. A licensed nurse admitted to not knowing how to change the CGM sensor, and the Director of Staff Development confirmed that no training was provided. The Consultant Pharmacist noted issues with sensor replacements and the absence of a policy, while the Director of Nursing acknowledged the lack of training and procedures for staff and residents.
The facility failed to ensure proper medication labeling and storage, including undated medications and improper storage of hazardous drugs. A resident's chemotherapy medication was not labeled or stored as hazardous, and inhalers and CGM Readers lacked proper identification, risking misuse and incorrect dosing.
A resident with lung cancer was not assessed for the ability to safely self-administer her prescribed inhaler, which was found at her bedside without proper labeling or instructions. The facility's process, requiring a physician's order, an assessment, and an IDT meeting, was not followed, leading to potential unsafe medication practices.
A resident's POLST form was found incomplete due to the absence of a physician's signature, despite being marked for a trial period of artificial nutrition. Facility staff, including the MDSC, LN, and DON, confirmed the missing signature, which is crucial for validating the document and ensuring the resident's medical wishes are honored. The facility's policy underscores the importance of a complete POLST form to record treatment wishes.
A facility failed to provide a complete SNFABN to a resident, omitting the estimated cost of services not covered by Medicare. The resident was informed that Medicare coverage would end, but the SNFABN lacked cost details, leaving the resident uninformed about potential financial liabilities. Staff interviews revealed that the BOM expected the form to include private pay rates, while the MDSC did not fill in the cost, directing inquiries to the business office instead.
A licensed nurse violated privacy protocols by using a personal smartphone to photograph a resident's medication labels, which included the resident's name and drug information, during a medication pass. This action breached the facility's confidentiality policy, as confirmed by the DON.
A resident reported a loss of $25, but the facility failed to investigate the incident. Staff did not follow proper procedures for reporting theft, as the Social Services Director was not informed. Interviews revealed inconsistencies in the reporting process, and a binder at the nurse's station lacked specific instructions for handling such incidents. The facility's policy requires prompt investigation of theft, which was not followed in this case.
A resident reported $200 missing from her purse, suspecting a CNA of theft. The LN informed the charge nurse and left a note for the social worker but did not follow up, resulting in a delay in reporting the incident to the Department. The SSD was unaware of the theft and stated she would have taken action if informed. The Administrator confirmed the incident should have been reported within 24 hours as per policy.
A resident with respiratory failure and quadriplegia refused to wear a smoking apron, but the facility failed to update the care plan or educate the resident on the risks. Despite the resident's ability to understand, staff did not revise the care plan or document the refusal, as confirmed by the Director of Nursing.
A facility failed to provide a resident with activities that met their needs and interests. The resident, with a history of stroke and failure to thrive, did not attend group activities and was infrequently offered in-room activities. Staff interviews revealed inaccuracies in activity documentation, with the resident participating in activities on only three days in June. The DON expected consistent activity offerings to prevent depression, but the facility's policy was not effectively implemented.
A resident with a Foley catheter for urinary retention had their catheter drainage bag improperly maintained, as it was found resting on the floor. This was confirmed by a CNA, who noted the risk of infection, and further supported by the IP, LN, and DON, who all emphasized the importance of keeping the bag off the floor to prevent infection and other complications.
A resident receiving enteral nutrition through a gastrostomy tube was not provided appropriate care when their feeding was not discontinued five hours past its expiration. The feeding bag was observed to be past its expiration time, and staff confirmed it should have been changed earlier. The DON stated that expired feeding could risk health infections and improper digestion.
A resident receiving oxygen therapy was at risk for infection due to the facility's failure to label and change the nasal cannula and humidifier bottle as required. The resident, with lung cancer and COPD, required continuous oxygen, but the equipment lacked date labels, contrary to professional standards. Staff confirmed the oversight and acknowledged the infection risk.
A facility failed to ensure safe use and accountability of controlled narcotic medications for a resident. Norco was removed from the Controlled Drug Record (CDR) without corresponding documentation in the Medication Administration Record (MAR) on multiple occasions. The Director of Nursing (DON) confirmed the discrepancies, and the nurse responsible was no longer employed at the facility. The facility's Consultant Pharmacist had conducted a random audit of narcotic use.
The facility failed to ensure safe use of psychotropic medications for two residents. One resident's bipolar disorder diagnosis was not properly documented, leading to inappropriate use of risperidone. Another resident's frequent use of PRN alprazolam was not reassessed, contrary to policy. These lapses could lead to adverse consequences and medication dependence.
The facility failed to ensure safe food storage for 92 residents, as several food items in the kitchen were not labeled with use-by dates, and thawing bacon trays lacked date and time labels. This oversight was confirmed by the Dietary Supervisor and Registered Dietitian, who emphasized the importance of labeling to prevent serving expired food and potential exposure to foodborne illnesses.
The facility failed to follow infection prevention practices by placing a dirty cup on a cart with clean water pitchers and not labeling a resident's urinal. Staff acknowledged these actions as inappropriate, highlighting the risk of cross-contamination and infection. The facility's policy and USDA guidelines emphasize the importance of preventing such contamination.
A resident's wallet containing money and personal cards was taken without consent by a CNA, causing emotional distress. The CNA was observed leaving the facility after the incident, and the theft was confirmed by the Director of Staff Development. The resident's money was later reimbursed.
Environmental Cleanliness and Maintenance Deficiencies in Shower Room, Hallway, and Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a census of 99 residents, as evidenced by multiple areas of uncleanliness and disrepair. In shower room [ROOM NUMBER], surveyors observed black discoloration on the floor tiles, grout, and in the cracks where the floor met the wall, as well as white discoloration on the shower head and handle, brown and pink discoloration on the emergency call light string that was stuck to the wall, and rust on the metal soap container. A CNA confirmed the shower room was used to bathe residents and agreed the room was dirty. The Director of Maintenance (DOM) scraped the black substance and stated it appeared to be mildew, identified the white stains as likely hard water deposits, confirmed the rust on the soap holder, and stated the call light string appeared mildewed and should be replaced. The Infection Preventionist (IP) stated the mildew in the shower room could get residents sick. In the hallway shared by station 1, station 2, and the kitchen, the baseboard was pulling away from the wall, appeared water damaged, and was compacted with dust, debris, and cobwebs. The Maintenance Assistant attributed the condition to a prior leak from the kitchen garbage disposal and stated the area was difficult to clean, while the DOM reported the wall and baseboard had been in that condition for approximately six months and acknowledged that breathing dust and debris was not good for residents. In room [ROOM NUMBER], behind bed B, the plastic protective wall covering and vinyl baseboard were peeling and pulling away from the wall, with gaps containing dust and debris; the DOM confirmed this accumulation and stated it was not good for the resident. The DOM reported that maintenance relied on repair books at each station, checked three times daily, and weekly room rounds to identify needed repairs, but suggested the area behind bed B may have been missed because the resident was in bed at the time. Facility policies on a homelike environment and maintenance services required a clean, sanitary, orderly environment and building maintenance in good repair and free from hazards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident’s responsible party (RP) prior to initiating and administering a psychotropic medication. The resident, who had diagnoses including unspecified intellectual disabilities, was seen by a mental health nurse practitioner on 2/27/26, and an order was written to start buspirone twice daily for anxiety disorder. Nursing documentation indicated that the orders were noted and carried out, and the medication was added to and administered per the Medication Administration Record (MAR). Review of the electronic health record showed no documentation that informed consent for the psychotropic medication had been obtained from the resident’s RP before the medication was started. The MAR showed that buspirone was administered on multiple occasions, including doses on 2/28/26 and several dates in early March, totaling seven doses. During interviews, a licensed nurse confirmed that informed consent was required before administering buspirone due to the nature of the medication and its potential side effects, and acknowledged that consent had not been obtained from the RP prior to administration. The nurse further stated that when the facility did contact the RP, the RP stated they did not want the resident to receive the medication. The Director of Staff Development stated that facility practice required informed consent from the resident or RP before adding a psychotropic medication to the MAR, and facility policies on Resident Rights and Psychotropic Medication Use indicated that residents and their representatives must be informed of and participate in treatment decisions and that written informed consent must be obtained for psychotherapeutic drugs.
Failure to Use Soap-and-Water Hand Hygiene for C. diff Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to care of a resident with Clostridioides difficile (C. diff). The resident was admitted in February 2026 with diagnoses including enterocolitis due to C. diff and a urinary tract infection, and had physician orders for contact precautions, including use of gown and gloves when entering the room and ensuring proper hand hygiene before and after contact with the resident or their environment. The facility’s own C. diff policy directed frequent handwashing with soap and water by staff and residents, and the Infection Preventionist (IP) and Director of Nursing (DON) both stated that proper hand hygiene for C. diff required soap and water because alcohol-based hand gel would not kill C. diff bacteria. During observation on Hall 400, a CNA was seen entering the C. diff resident’s room wearing appropriate PPE. Upon exiting the room, the CNA removed PPE and performed hand hygiene using an alcohol-based sanitizing gel located outside the room, then immediately proceeded down the hall and entered another resident’s room. In a subsequent interview, the CNA confirmed using alcohol-based gel and stated she believed she had done appropriate hand hygiene before moving to the next resident, despite the resident’s known C. diff infection. The IP and DON both indicated their expectation that staff wash hands with soap and water after caring for a C. diff resident, and the DON stated the risk was the spread of infection to other residents. CDC guidance cited in the record indicated that washing hands with soap and water is the best way to prevent the spread of C. diff from person to person.
Failure to Provide Timely Incontinence Care per Care Plan and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in accordance with professional standards and the resident’s care plan for one resident with paraplegia and complete bowel and bladder incontinence. The resident reported around midday that she had not received care since 6:30 AM and had requested to be cleaned and dressed at 11 AM. During observation, her incontinence brief showed a blue line indicating wetness and appeared heavily saturated with urine. The resident stated she would be unable to go to the dining room for lunch because she had not been cleaned and expressed concern about her risk for urinary tract infection if she was not changed when needed. CNA 1 stated she attempted to provide care at 7 AM, but the resident asked her to return at 11 AM. CNA 1 did not provide care at 11 AM because she went to lunch and stated that CNA 2 had changed the resident instead. CNA 2 later stated he did not provide care to the resident at 11 AM or at any other time during the shift. LN 2 stated her expectation was that the resident would receive timely incontinence care or that CNAs would inform her if they were unable to provide care. The DON stated residents were usually changed every two hours, that refusals would be care planned, and that CNAs should continue to attempt care and notify the nurse if refusals continued. The resident’s care plan documented that she was always bowel and bladder incontinent, with goals to remain free from skin breakdown due to incontinence and interventions including cleaning the perineal area with each incontinence episode, checking every 2–3 hours and as required, and monitoring for signs and symptoms of UTI. The facility’s incontinence care policy required timely, appropriate, individualized care at routine intervals per the care plan and as requested by the resident.
Failure to Monitor and Control Illicit Drug Use for a Resident on Chronic Opioid Therapy
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain effective preventive measures and monitoring for a resident with known drug-seeking behavior and repeated positive urine drug screens for illicit substances. The resident, admitted in 2013 with paraplegia, chronic pain syndrome, and major depressive disorder, had a history of polysubstance abuse and was on chronic methadone therapy for pain. Urine drug screens showed a positive result for cocaine and cannabis on 7/18/25 and additional positive results for cannabis on 8/21/25, 9/25/25, and 12/6/25. Despite these findings and multiple office visit notes from the MD documenting polysubstance abuse, opiate dependence, behavior issues, and instructions to monitor behavior, the facility did not implement ongoing, structured behavior monitoring or revise the care plan in response to the repeated positive tests. The resident reported using marijuana for many years while residing at the facility and admitted to sniffing cocaine when stressed. He stated that he went alone to a nearby park, where a friend supplied him with cocaine and marijuana, and that he informed facility staff that a friend had given him cocaine. He also stated that he was never supervised by staff when leaving the premises and was allowed to go to the park by himself, and that after his positive drug test in July 2025 he stopped going to the park following a doctor’s order of no more day passes. The resident further reported that a visitor brought him marijuana brownies during visits in August, September, and December 2025, and that he brought a marijuana cartridge into the facility but was only told he could not smoke marijuana in the facility. He stated that no one at the facility had discussed substance use treatment services with him. Staff interviews and record reviews showed that, although a care plan for history of substance use disorder and drug-seeking behaviors was initiated on 7/23/25, it was not revised after subsequent positive cannabis tests. The DON stated that behavior monitoring was documented in progress notes for only 72 hours after the 7/18/25 positive test and that no daily behavior tracking was implemented for drug-seeking behavior or drug use. LNs 1, 2, 3, and 4 confirmed there was no ongoing behavior monitoring log for drug use, no psychological evaluations documented for drug use, and no regular drug behavior monitoring despite continued positive urine drug screens and documented behavior issues such as agitation and yelling at staff. CNA 2 acknowledged that residents with a history of drug-seeking behavior should be monitored regularly and that unsupervised residents could go outside and consume illicit substances or be influenced by visitors. The facility’s visitation policy allowed for supervised visitation or denial of access for individuals with a history of bringing illegal substances, but there was no documentation that such measures were applied in this case, even though the IDT investigations repeatedly documented the resident’s continued cannabis use and refusal to stop.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency occurred when a resident's call light was not within reach, as observed during a survey. The call light was found hanging from the left side of the bed rail down to the floor, making it inaccessible to the resident. The resident reported being unable to find the call light and expressed concern that staff would not be able to respond promptly if assistance was needed. Both a CNA and a licensed nurse confirmed the call light was not in the proper place and acknowledged that the resident would not be able to get help right away, which created a safety risk. The Director of Nursing also confirmed that call lights should always be within reach and that failure to do so placed the resident at risk for a fall. The resident involved had multiple diagnoses, including senile degeneration of the brain, Parkinson's disease with dyskinesia, unspecified dementia, chronic obstructive pulmonary disease, palliative care, depressive disorder, and a recent fracture of the right femur. The resident's care plan specifically included interventions to keep the call light within reach, particularly due to a history of an unwitnessed fall and the femur fracture. Facility policy also required that call lights be accessible to residents when in bed, but this was not followed in this instance.
Failure to Timely Submit Investigation Summary After Resident Fracture
Penalty
Summary
The facility failed to submit a summary of investigation of an alleged unusual incident/injury report to the Department within five working days, as required, following a fracture incident involving a resident. The resident, who was admitted under hospice care with multiple diagnoses including senile degeneration of the brain, Parkinson's disease with dyskinesia, unspecified dementia, COPD, depressive disorder, and a right femur fracture, was found sitting on the floor with no visible injury noted upon assessment. Subsequently, the resident complained of right hip pain and an X-ray revealed a subacute fracture of the right femoral neck. Despite being aware of the requirement, the DON acknowledged during interviews that she forgot to submit the summary of investigation for the incident. The facility's policy requires prompt initiation and documentation of investigations for accidents or incidents, but this was not followed in this case. The lack of timely submission of the investigation summary meant that the Department was not informed within the mandated timeframe following the incident.
Deficient Food Storage and Equipment Sanitation in Dietary Services
Penalty
Summary
The facility failed to ensure proper food storage and maintenance of kitchen equipment in accordance with professional standards for food safety, affecting all 93 residents who consumed facility-prepared meals. During an initial kitchen tour, surveyors observed four large sheet pans stored on the clean rack with dark brown buildup on their raised rims. The Dietary Supervisor confirmed the pans were not properly cleaned and acknowledged that this was unacceptable, as it could expose residents to foodborne illness. Dietary staff interviews further confirmed that improper cleaning of pans could result in old food particles contaminating meals, and that the dishwashing process was intended to remove all food residue, but expectations were not met in this instance. Additionally, a food item (pie) was found in the freezer with an open date but missing a use-by or expiration date. The Dietary Supervisor confirmed the pie was leftover from a recent event and acknowledged it should have been labeled with a use-by date. Staff interviews indicated that all food items were required to be labeled with open, preparation, use-by, and expiration dates to ensure safety, but this procedure was not followed for the pie. The Assistant Director of Nursing also confirmed that improper labeling of food items could result in foodborne illness. Review of the facility's policies and procedures revealed requirements for all utensils, counters, shelves, and equipment to be kept clean and maintained in good repair, and for all food items in storage to be labeled and dated. These policies were not followed, as evidenced by the unclean sheet pans and the improperly labeled pie. The FDA Food Code was also referenced, which requires food-contact surfaces to be clean to sight and touch and free of encrusted grease deposits and other soil accumulations.
Failure to Post Oxygen in Use Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that supplemental oxygen was administered in accordance with professional standards of practice for two residents who were receiving oxygen therapy. Both residents had active physician orders for oxygen to be administered via nasal cannula as needed for shortness of breath or comfort, and both were observed receiving oxygen through concentrators in their rooms. However, during multiple observations, there was no 'Oxygen in Use' signage posted on the doorways of either resident's room, as required by facility policy and procedure. Interviews with nursing staff, including licensed nurses and certified nurse assistants, confirmed that the residents were receiving oxygen therapy and that the required signage was not posted. Staff members acknowledged the importance of posting 'Oxygen in Use' signs to alert staff, residents, and visitors to the presence of oxygen and to prevent fire hazards. The staff also confirmed that it was their responsibility to ensure the signage was in place whenever a resident was receiving oxygen therapy. A review of the facility's policy and procedure for oxygen administration, as well as interviews with the Director of Staff Development and the Assistant Director of Nursing, further confirmed that the expectation was for nursing staff to post the appropriate signage immediately upon initiation of oxygen therapy. The Assistant Director of Nursing acknowledged that the facility's policy was not followed in these instances, as the required signage was not posted for either resident while they were receiving oxygen.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. One resident, admitted with chronic and abdominal pain, experienced face and neck swelling. Despite reporting the swelling and requesting interventions such as ice application, there was no care plan addressing this issue, and progress notes only documented the complaint and a general ongoing plan of care. The Director of Nursing confirmed the absence of a care plan for the swelling, acknowledging its importance for proper treatment. Another resident with multiple sclerosis, requiring two-person assistance for activities of daily living (ADLs), was turned in bed by a single CNA, contrary to the care plan's specified intervention. Both the resident and the CNA confirmed that care was provided by only one staff member. The Director of Staff Development verified this deviation from the care plan and emphasized the necessity of following prescribed interventions to ensure proper care. Facility policy also required staff to check care plans for specific positioning needs and the number of staff required.
Failure to Thoroughly Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with palliative care needs. The resident reported that a staff member used foul language and physically slapped her. Documentation in the resident's progress notes confirmed that the allegation was reported, and monitoring for distress was initiated. However, the investigation into the incident was limited in scope. The Social Services Director (SSD) only interviewed the resident and the alleged perpetrator, CNA 8, without interviewing other staff or residents who may have had relevant information. The SSD also did not review the employee file of CNA 8, which contained prior incidents of poor communication and inappropriate behavior. The Director of Nursing (DON) confirmed that a more comprehensive investigation should have included interviews with other staff and residents and a review of the employee's history. Facility policy required a thorough investigation, including interviews with all relevant parties and review of all events leading up to the incident, which was not followed in this case.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Dumpster Lid Left Open, Violating Infection Control and Sanitation Policies
Penalty
Summary
A deficiency was identified when one of two outside dumpster lids was observed to be propped open with a stick, rather than being properly closed. This observation was made during a walkthrough of the facility's dumpster area with the Dietary Services Supervisor (DSS), who confirmed the lid was intentionally left open. Multiple staff interviews, including with the DSS and the Director of Nursing (DON), confirmed that dumpster lids are required to be closed at all times to prevent exposure to pests and to maintain infection control standards. Staff acknowledged that leaving the dumpster open could allow animals and pests to access the garbage and potentially spread disease. A review of facility policies indicated that garbage and trashcans must be inspected daily to ensure lids are closed and the surrounding area is free of debris. The facility's infection prevention and control policy also requires maintaining a safe and sanitary environment. Additionally, the FDA Food Code 2022 specifies that outside receptacles for refuse containing food residue must have tight-fitting lids. The failure to keep the dumpster lid closed was contrary to both facility policy and federal guidelines.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
Staff failed to use safe and appropriate transfer methods for a resident with significant physical limitations and a history of muscle weakness and bone density disorders. The resident's care plan specified the use of a mechanical lift for all transfers due to his inability to stand and the presence of bilateral plantar flexion contractures. Despite this, staff transferred the resident from a shower chair to his bed manually, with three to four staff members lifting him instead of using the mechanical lift as required by his care plan and facility policy. During the transfer, the resident reported hearing a crack and experienced pain in his right leg. Subsequent assessments by nursing staff documented discoloration, pain, and later, the development of blisters and cellulitis on the right lower leg. An x-ray confirmed a minimally displaced fracture of the right proximal tibia. Interviews with staff, including the ADON and CNAs involved, confirmed that the mechanical lift was not used because the resident often refused it, and staff attempted a manual transfer instead, which was acknowledged by staff as unsafe. The facility's policy on safe lifting and movement of residents required the use of appropriate devices and techniques to ensure safety, and manual lifting was to be eliminated when feasible. Both the Director of Staff Development and the physical therapist stated that more than two staff members should not perform a manual transfer and that the mechanical lift was always the safest option for this resident. The failure to follow the care plan and facility policy directly preceded the resident's injury.
Failure to Notify Physician and Responsible Party of Resident's Treatment Refusals
Penalty
Summary
The facility failed to report a change in condition and medical treatment to the physician and the Responsible Party (RP) for a resident who refused medications, fingerstick blood sugar monitoring (FSBS) tests, and physical therapy treatments on multiple occasions. The resident, who had a history of intertrochanteric fracture, diabetes mellitus, and delusional disorders, was noncompliant with her treatment plan. Despite the refusals, the facility did not consistently notify the resident's physician or RP, which resulted in the RP being uninformed of the resident's change in condition and unable to participate in medical decisions. Interviews and record reviews revealed that the resident refused numerous doses of various medications, including those for diabetes, cholesterol, and blood pressure, over a period of three months. Licensed nurses documented the refusals in the progress notes but failed to notify the RP or the physician consistently. The Director of Nursing (DON) acknowledged that the facility's policy was not followed, as the refusals should have been documented in a Change in Condition (CIC) form and communicated to the RP and physician. Additionally, the resident refused FSBS tests and physical therapy sessions multiple times. The facility's policy required notification of the physician and RP after two consecutive refusals of treatment or medications, but this was not adhered to. The Physical Therapist and Director of Nursing confirmed that the resident's refusals were not communicated to the RP, and there was no specific policy for handling physical therapy refusals. The lack of communication and documentation led to the resident's physician and RP being unaware of the extent of the refusals, potentially impacting the resident's health management.
Failure to Document Basis for Facility-Initiated Discharge
Penalty
Summary
The facility failed to properly document the required information prior to discharging a resident. The resident had been at the facility since the spring of 2024 and left for a scheduled medical appointment, after which they were admitted directly to the hospital for surgery. Subsequently, the hospital sent a request for the resident's re-admission to the facility. The facility then completed a NOTICE OF TRANSFER OR DISCHARGE, stating that the resident's needs could not be met in the facility, and served this notice to the resident's responsible party while the resident was still hospitalized. Upon review, it was found that there was no documentation in the resident's medical record specifying the basis for the discharge or detailing the needs that could not be met by the facility. The facility's own policy requires that the specific resident needs that cannot be met, as well as the facility's attempts to meet those needs, be documented in the medical record when a facility-initiated transfer or discharge occurs. Both the Administrator and the DON confirmed the absence of this required documentation.
Failure to Provide Correct Appeal Information in Discharge Notice
Penalty
Summary
The facility failed to provide the required information regarding appeal rights in the discharge notice given to a resident's responsible party and the long-term care ombudsman prior to a facility-initiated discharge. The discharge notice, completed by the Social Services Director (SSD) and the Director of Nursing (DON), included the contact information for the California Department of Public Health (CDPH) as the entity to which appeals should be sent. However, this was incorrect, as appeals should be directed to the Office of Administrative Hearings and Appeals (OAHA), as specified by the Department of Health Care Services (DHCS). During interviews, the SSD confirmed that the facility had been using the CDPH contact information on all discharge and transfer paperwork and was unaware that this was not the correct entity for appeals. The facility's policy required that residents be provided with accurate information on how to appeal a transfer or discharge, including the correct entity's contact details and instructions for obtaining and submitting an appeal form. As a result of this error, the resident's responsible party was not properly informed of how to appeal the facility's decision to discharge the resident.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to ensure a resident's right to return after hospitalization was protected. The resident, who had been living at the facility since Spring 2024, was sent to the hospital for a scheduled appointment and subsequently admitted for surgery. Upon the hospital's request for re-admission, the facility did not allow the resident to return, citing that the seven-day bed hold had expired. Despite this, the resident's bed and personal belongings remained in place, and the facility had available capacity, with the resident's previous room and bed still unoccupied. The facility completed and served a Notice of Transfer or Discharge to the resident's responsible party, stating the reason for discharge was the facility's inability to meet the resident's needs. However, the Administrator indicated that the paperwork was served only as a formality due to the expired bed hold. Observations confirmed that the resident's personal items were still present in the assigned room, and staff verified that the bed remained available. Facility policy indicated that residents should be allowed to return to their previous room if available or to the first available bed after the bed-hold period, but this was not followed in this case.
Failure to Perform Milking Technique for Resident's Edema
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs) possessed the necessary competencies and skills to provide appropriate treatment for a resident, specifically in performing the milking technique for lymphatic drainage on the resident's right leg. This deficiency was identified through observations, interviews, and record reviews, revealing that the milking was not consistently performed by the licensed staff, despite multiple physician orders indicating its necessity. The resident, who was admitted with conditions requiring such treatment, reported being denied the milking treatment multiple times without explanation. The resident's medical records showed several physician orders for milking the right leg, alongside the use of compression stockings, ice, and elevation, which were not consistently followed. Interviews with the facility staff, including LNs and a physical therapist, highlighted a lack of knowledge and experience in performing the milking technique. The physical therapist noted that while milking was part of their training, it was not routine, and the responsibility lay with the nursing staff. Despite the orders, the staff expressed discomfort and lack of experience in performing the procedure, leading to its omission. Further interviews with medical professionals, including a nurse practitioner and a medical doctor, confirmed the importance of following the physician's orders for the resident's edema management. The medical doctor emphasized that the order was reasonable and should have been accommodated, while the nurse practitioner noted that the facility staff had requested the discontinuation of the milking order, which was not approved. The Director of Nursing confirmed that the order for milking was only added to the treatment administration record shortly before the resident's discharge, indicating a delay in addressing the resident's needs.
Failure to Communicate Medication Refusals
Penalty
Summary
The facility failed to ensure that ongoing medication refusals by Resident 16 were communicated to the medical doctor in a timely manner. Resident 16, who had multiple medical diagnoses including heart failure, atrial fibrillation, hypothyroidism, and depression, was documented to have refused several critical medications over June and July 2024. These medications included Furosemide, Paroxetine, Apixaban, and Levothyroxine, which are essential for managing her heart conditions, depression, and thyroid function. Despite these refusals, there was no documentation indicating that the medical doctor was notified of the refusals during this period. Interviews with facility staff, including Licensed Nurse 14 and the Director of Nursing, revealed that the workflow for handling medication refusals involved offering the medication three times before documenting the refusal in the Medication Administration Record (MAR). However, the staff acknowledged that the medical doctor should have been informed of refusals, especially for critical medications. The Director of Nursing confirmed that Resident 16 was sent to the hospital due to excessive swelling in her lower extremities, which was attributed to her refusal to take Lasix, a medication critical for managing her heart failure. The facility's Consultant Pharmacist and Medical Doctor also confirmed that they were not informed of the ongoing medication refusals. The Consultant Pharmacist noted that the refusal of medications could have contributed to the resident's worsening condition, including the need to increase the dosage of Levothyroxine due to low thyroid hormone levels. The facility's policy on administering medications did not address the need to notify the medical doctor of ongoing refusals of high-risk medications, contributing to the deficiency in care for Resident 16.
Lack of Training and Policy for CGM Devices
Penalty
Summary
The facility failed to ensure that licensed staff received appropriate training and that a written policy and procedure were in place for the use of continuous glucose monitoring (CGM) devices for nine residents. During an observation and interview, a licensed nurse admitted to not knowing how to change the CGM sensor and confirmed that no training or reading materials had been provided by the facility. The Director of Staff Development (DSD) acknowledged that although diabetes training was conducted, it did not cover the use of CGMs. The DSD also expressed concerns about the lack of training, which could lead to incorrect blood sugar readings. The Consultant Pharmacist (CP) revealed that the facility began using CGMs in March 2024, but was unaware that no written policy and procedure were in place. The CP noted issues with sensor replacements occurring more frequently than intended, leading to potential improper glucose assessments. The Director of Nursing (DON) confirmed the absence of training for both staff and residents on CGM use and acknowledged the lack of a policy and procedure to guide staff in the proper use of the devices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication labeling and storage practices, affecting the safety and efficacy of medication administration. During an inspection, it was observed that the medication refrigerator contained undated lorazepam, a controlled medication, and improperly stored Gvoke HypoPen, which should not be refrigerated. Additionally, the Emergency Kit contained contaminated bottles of SPS Suspension, and the medication cart had undated test strips and control solutions, which should have been dated upon opening. Resident 27's chemotherapy medication, capecitabine, was not labeled or stored as a hazardous drug, posing a risk to staff handling it without proper precautions. The medication was stored with non-hazardous drugs, and staff were unaware of the necessary safety measures, such as wearing gloves during administration. Furthermore, Resident 27's inhaler was not labeled with her name or instructions, increasing the risk of misuse by other residents. Residents 5 and 14's continuous glucose monitoring (CGM) Readers were not labeled with their names, leading to potential confusion and incorrect insulin dosing. The CGM Readers were left unsecured in their rooms, and staff confirmed the lack of identifiers, which could result in serious health issues if the devices were used by the wrong resident.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess Resident 27 for the ability to independently use her prescribed inhaler, which is necessary for safe self-administration of medication. Resident 27, who was admitted with a diagnosis including lung cancer, had an order for Budesonide-Formoterol Fumarate Inhalation Aerosol to be used twice daily. During an observation, the inhaler was found on her bedside table without any labeling, and Resident 27 confirmed she used it on her own without informing the nurse. Licensed Nurse 12 acknowledged the inhaler was at the bedside per physician's order but lacked proper labeling and instructions. The Director of Nurses (DON) and Licensed Nurse 1 explained the facility's process for allowing medications at the bedside, which includes obtaining a physician's order, conducting an assessment for self-administration capability, and holding an Inter-Disciplinary Team (IDT) meeting to discuss the resident's capacity. However, these steps were not completed for Resident 27, as confirmed by the DON. The facility's policy requires an IDT assessment to ensure it is clinically appropriate and safe for residents to self-administer medications, but this was not adhered to, leading to the potential for unsafe medication practices.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) was completed accurately for one resident, identified as Resident 27. The POLST form, which is a legal document that communicates a resident's medical wishes for end-of-life care, was not signed by the physician or their representative. This omission was discovered during a review of Resident 27's Order Summary Report, which indicated that the resident was admitted with a diagnosis of cancer. The POLST form, dated 7/4/24, was marked for a trial period of artificial nutrition, including feeding tubes, but lacked the necessary physician's signature, rendering it incomplete and invalid. Interviews with facility staff, including the Minimum Data Set Coordinator (MDSC), Licensed Nurse (LN) 7, and the Director of Nurses (DON), confirmed the absence of the physician's signature on the POLST form. The MDSC and LN 7 emphasized the importance of the physician's signature to validate the document and ensure that the resident's wishes are honored. The DON stated that without the physician's signature, the facility could not implement the resident's or their representative's wishes regarding medical care and emergency treatment. The facility's policy on Advanced Directives also indicated that the POLST form is designed to record patients' treatment wishes, highlighting the significance of having a complete and signed document.
Failure to Provide Complete SNFABN to Resident
Penalty
Summary
The facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) to one of its residents, identified as Resident 20. The SNFABN, which is meant to inform residents of potential financial liabilities for services not covered by Medicare, was missing the estimated cost of services that Resident 20 might be responsible for. This omission was discovered during a review of Resident 20's records, which showed that she was readmitted to the facility in 2023 and was informed that her Medicare coverage for nursing services would end on January 2, 2024. The SNFABN issued on December 29, 2023, indicated that Medicare would not cover certain skilled nursing services starting January 3, 2024, but failed to provide an estimated cost for these services. Interviews with facility staff revealed a lack of adherence to proper procedures for completing the SNFABN. The Business Office Manager (BOM) acknowledged that the form should have included the estimated cost of services, typically the private pay room and board rate, to inform the resident or their representative of potential financial responsibilities. The Minimum Data Set Coordinator (MDSC) admitted to not filling in the estimated cost on the SNFABN and instead directed residents or their representatives to contact the business office for this information. This practice was contrary to the facility's procedure, which required the SNFABN to include an estimated cost to help beneficiaries make informed decisions about their care and financial responsibilities.
Unauthorized Photography of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy of a resident's medical information during a medication pass. A licensed nurse used a personal smartphone to take a picture of medication labels, which included the resident's name and drug information, to review later. This action was observed during a medication administration session in the hallway of Unit 1. The nurse intended to delete the pictures afterward, but this use of a personal phone for photographing protected medical information violated the facility's policy on confidentiality and personal privacy. The Director of Nursing confirmed that staff were not permitted to use personal phones for such purposes.
Failure to Investigate Resident's Reported Loss of Property
Penalty
Summary
The facility failed to protect the rights of a resident, identified as Resident 45, by not investigating a reported loss of $25. Resident 45, who was admitted to the facility in 2018, reported the missing money during rounds at 5 AM. The staff searched the resident's room but did not find the money and planned to endorse the issue to the next shift nurse for follow-up with Social Services. However, the Social Services Director (SSD) was not informed of the missing item, as the staff did not follow the proper procedure for reporting such incidents. Interviews with various staff members revealed inconsistencies in the reporting process for theft and loss. Licensed Nurse (LN) 1 confirmed that the missing money was not documented on the shift-to-shift endorsement form. LN 2, who documented the complaint in the progress notes, did not recall any training on reporting theft and loss. The Director of Staff Development (DSD) and LN 3 mentioned a binder at the nurse's station with procedures, but it lacked specific instructions for reporting theft and loss. The Director of Nurses (DON) emphasized the importance of reporting missing items to maintain residents' dignity and rights. The facility's policy, revised in April 2021, mandates prompt investigation of theft or misappropriation of resident property, but this was not adhered to in this case.
Failure to Timely Report Alleged Theft
Penalty
Summary
The facility failed to report an allegation of stolen property involving a resident within the required 24-hour timeframe. Resident 22 reported to a Licensed Nurse (LN) that she suspected a Certified Nursing Assistant (CNA) of stealing $200 from her purse during the first week of July. Despite notifying the charge nurse and leaving a note for the social worker, LN 10 did not follow up, and the social worker was not informed of the incident. Consequently, the facility did not report the incident to the Department until 7/19/24, well beyond the mandated reporting period. This delay in reporting resulted in Resident 22 feeling upset and distressed over the loss of her money, which she liked to have for personal purchases. The Social Services Director (SSD) was unaware of the incident and stated that had she been informed, she would have filed a police report and monitored the resident for psychosocial distress. The Administrator confirmed that the missing money was considered abuse and should have been reported to the police, the Department, and the ombudsman within 24 hours, as per the facility's policy on abuse prohibition and prevention.
Failure to Update Resident's Care Plan for Smoking Safety
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was resident-centered and updated in a timely manner. The resident, who was admitted with multiple diagnoses including respiratory failure and quadriplegia, had a care plan that included the use of a smoking apron to prevent burns while smoking. Despite the resident's ability to understand and communicate effectively, as indicated by a BIMS score of 15, the care plan was not revised when the resident refused to wear the smoking apron. Interviews and observations revealed that the resident was not wearing a smoking apron and had not been asked to wear one by the facility staff. The Director of Staff Development was unable to provide evidence that the care plan was updated or that the resident was educated about the risks of not wearing the apron. The Director of Nursing acknowledged that the care plan should have been revised following the resident's refusal. The facility's policy on care plans emphasizes documenting refusals in the resident's clinical record, which was not adhered to in this case.
Deficiency in Meeting Resident's Activity Needs
Penalty
Summary
The facility failed to ensure that a resident received activities that met their interests and needs. The resident, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage and adult failure to thrive, did not attend group activities and was infrequently offered in-room activities. Interviews with staff revealed that the resident did not get out of bed to attend activities, and the activity participation documentation was inaccurate, indicating activities were provided on days when they were not. The Activities Director confirmed that the resident only participated in activities on three days in June 2024, with no documentation of refusals. The Director of Nurses expressed the expectation that activities should consistently be offered to residents unable to leave their rooms, as participation could help prevent feelings of depression. The facility's policy on activity evaluation emphasized the importance of developing an activities plan that reflects the resident's choices and interests to promote their well-being. However, the lack of consistent activity offerings and accurate documentation for the resident highlighted a deficiency in meeting the psychosocial needs of the resident.
Improper Maintenance of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was properly maintained, leading to potential complications. Resident 38, who was admitted with a diagnosis of urinary retention requiring a Foley catheter, was observed with their urinary catheter drainage bag resting on the floor. This was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the bag should not be on the floor due to the risk of infection. The CNA also noted that the bag was full and needed to be emptied. Interviews with the Infection Preventionist (IP), a Licensed Nurse (LN), and the Director of Nurses (DON) further confirmed that the urinary catheter bag should be hung off a non-movable part of the bed to prevent infection and other issues such as dislodgement. The IP and LN both emphasized the infection risk associated with the bag touching the floor, while the DON stated that it was expected for catheter bags to be kept off the floor to avoid such risks.
Failure to Timely Change Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care to a resident who was receiving enteral nutrition through a gastrostomy tube. The resident's enteral feeding liquid nourishment was not discontinued approximately five hours past its expiration time, which increased the potential for complications such as nausea, vomiting, diarrhea, and stomach cramping. The resident was observed in their room receiving enteral feeding through a pump, with the feeding bag labeled with a date and time indicating it should have been changed earlier that morning. Licensed Nurse 3 confirmed that the enteral feeding bag was past its expiration and should have been changed at 4 a.m. The nurse acknowledged that the feeding and pump supplies needed to be replaced to prevent the formula from becoming spoiled. The Director of Nurses stated that enteral feedings, including formula, flush water, and tubing, should be labeled with the resident's name, date, time, and flow rate, and confirmed that expired enteral feeding could put the resident at risk for health infections and improper digestion.
Failure to Label and Change Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 27, who was receiving oxygen therapy. The resident's nasal cannula and oxygen humidifier bottle were not labeled with the date they were last changed, which is a requirement according to professional standards. Resident 27 was admitted with diagnoses including lung cancer and chronic obstructive pulmonary disease, necessitating continuous oxygen therapy at a flow rate of 2-5 liters per minute. The facility's order summary indicated that the nasal cannula and humidifier should be changed every seven days or as needed, but during an observation, it was found that neither the nasal cannula nor the humidifier bottle had a date label. Interviews with facility staff, including a licensed nurse, the infection preventionist, and the director of nurses, confirmed the lack of labeling and acknowledged the risk of infection due to this oversight. The staff members stated that the expectation was for the nasal cannula and humidifier to be labeled with the date of use and changed weekly. The absence of proper labeling and timely changes of the respiratory equipment placed Resident 27 at risk for infection, as confirmed by the staff during the interviews.
Failure in Controlled Narcotic Medication Accountability
Penalty
Summary
The facility failed to ensure the safe use and accountability of controlled narcotic medications, specifically Norco, for a resident. The Controlled Drug Record (CDR) indicated the removal of Norco for PRN use on several occasions, but there was no corresponding documentation in the Medication Administration Record (MAR) for these instances. Specifically, on four occasions, there were discrepancies between the CDR and MAR, with three instances lacking MAR documentation and one instance lacking CDR removal documentation. During the investigation, the Director of Nursing (DON) acknowledged the missing documentation and noted that the nurse responsible for the removal of Norco was no longer employed at the facility and could not be contacted for clarification. The facility's Consultant Pharmacist had conducted a random audit of narcotic use and provided a report to the facility. The facility's policy on controlled substances, which was undated, indicated compliance with laws and regulations related to handling and documentation of controlled medications.
Failure in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for two residents. For Resident 45, there was a discrepancy in the medical records regarding the diagnosis of bipolar disorder, which was used to justify the administration of risperidone. The diagnosis was not reflected in the medical doctor's progress notes and assessments, and there was no physician cosignatory on the nurse practitioner's order. The MDS Coordinator confirmed that the diagnosis was entered based on a nurse's input, which should have been reviewed by the medical doctor and the Interdisciplinary Team. For Resident 92, the facility did not properly evaluate and reassess the use of PRN alprazolam, an anti-anxiety medication, despite its frequent use. The medication was administered nearly daily without a stop date or reevaluation after two weeks, as required by the facility's policy. The Licensed Nurse and the Director of Nursing acknowledged that the PRN order should have been reassessed, and the Consultant Pharmacist noted that the pharmacy provider should have questioned the order during the initial dispensing review. These failures in medication management could contribute to unsafe use of psychotropic medications, potentially putting Resident 45 at risk for adverse consequences and Resident 92 at risk for dependence. The facility's policy on psychotropic medication use was not followed, as medications were not clinically indicated or reassessed as required.
Failure to Ensure Safe Food Storage Practices
Penalty
Summary
The facility failed to ensure safe food storage practices for 92 residents receiving food service from the kitchen. During an inspection, it was observed that several food items in the walk-in refrigerator and freezer were not labeled with use-by dates. Specifically, an opened bottle of minced garlic, a gallon of barbeque sauce, a bag of veggie patties, a box of precut green beans, a spice bottle of rubbed sage, and a bottle of vanilla extract were all found without use-by dates. The Dietary Supervisor confirmed these findings and acknowledged that these items should have been labeled appropriately. Additionally, trays of thawing bacon in the walk-in refrigerator were not labeled with the date or time when the thawing process began. The Registered Dietitian confirmed that all food products should be labeled with use-by dates to prevent serving expired food, which could expose residents to foodborne illnesses. The facility's policies on labeling and dating foods, as well as thawing meats, were reviewed and indicated that all food items should be labeled and dated, but these procedures were not followed.
Infection Control Lapses in Handling of Dirty Items and Resident Urinals
Penalty
Summary
The facility failed to adhere to proper infection prevention practices, as observed during a survey. A Certified Nursing Assistant (CNA) placed a dirty cup on a cart with clean water pitchers, which was acknowledged by the CNA as inappropriate. Interviews with a Licensed Nurse (LN) and the Director of Nursing (DON) confirmed that dirty cups should not be placed with clean items due to the risk of cross-contamination. The facility's policy on water pitchers and guidelines from the USDA emphasize the importance of preventing cross-contamination to maintain food safety. Additionally, the facility did not label a urinal with a resident identifier, which was observed in the case of a resident diagnosed with Alzheimer's disease. The urinal was attached to the bedrail without any labeling, posing a risk of infection if used by another resident. Both a CNA and an LN confirmed the absence of labeling and acknowledged the necessity of labeling to prevent potential contamination. The Infection Preventionist and the DON reiterated the importance of labeling urinals to avoid the risk of infection from shared use.
Misappropriation of Resident's Property by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and personal belongings. A Certified Nursing Assistant (CNA) took the resident's wallet without consent, which contained $160, an ATM card, a health insurance card, and an ID. The incident caused the resident emotional distress and had the potential for further loss or theft of other residents' property. The resident, who was admitted with chronic kidney disease and had an intact memory, reported the theft to staff. The Director of Staff Development confirmed the theft with the resident's family and verified the contents of the wallet. The CNA involved had previously received training on theft and loss but was terminated following the incident. A Licensed Nurse heard the resident screaming for help and observed the CNA leaving the facility. The Social Services Director later confirmed that the resident's money was reimbursed. The facility's policy strictly prohibits exploitation, theft, and misappropriation of resident property.
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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