La Paz Geropsychiatric Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Paramount, California.
- Location
- 8835 Vans Street, Paramount, California 90723
- CMS Provider Number
- 05A355
- Inspections on file
- 42
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at La Paz Geropsychiatric Center during CMS and state inspections, most recent first.
Two residents with schizophrenia and intact cognition exhibited escalating aggressive and confrontational behaviors, including verbal abuse, noncompliance with medications, physical altercations with another resident, and a documented moderate risk for aggression. Despite these behaviors and existing orders for frequent safety checks, staff confirmed that no individualized, person-centered care plans were developed or updated to address the residents’ aggressive behaviors, define specific interventions, or establish measurable goals and monitoring parameters, contrary to facility policy and assessment findings.
A CNA pre-charted Q15 safety observations for multiple residents by recording future time slots after an earlier round, and later backfilled missed observation times for another resident based on a single hallway encounter rather than direct checks at the scheduled intervals. The CNA did not notify other staff when unable to locate a resident at required times and completed the 24-hour observation checklist entries despite not performing the actual observations. Facility leadership and an RN confirmed that this practice violated policies requiring real-time, factual documentation only after direct observation and prohibiting pre-charting or documenting events that did not occur.
Two residents with behavioral health diagnoses engaged in physical altercations with peers, resulting in injuries, after staff failed to follow care plan interventions and did not intervene before escalation. In one case, a resident was pushed and held down during a group activity, and in another, a resident was struck and scratched by her roommate. Facility policies prohibiting abuse were not effectively implemented.
A social worker did not properly report or investigate incidents of inappropriate sexual behavior between residents, assuming nursing staff would handle the reporting. Despite being a mandated reporter, the social worker failed to complete required abuse reports or notify authorities, and the facility did not follow its abuse prevention and reporting policy. Staff interviews confirmed that mandated procedures were not followed and residents were not monitored after the incidents.
A female resident with a history of depression and schizophrenia, who was cognitively intact, experienced a loss of privacy and dignity when a male resident with severe cognitive impairment and poor impulse control entered the restroom while she was urinating. The incident left the resident feeling embarrassed and violated, and the DON confirmed that such events compromise resident dignity.
A resident with a history of severe cognitive impairment and aggressive behavior entered another resident's bathroom while she was using it and punched her in the face after a struggle over a trash can, causing pain and emotional distress. The aggressive resident was known to wander and had previously threatened staff and entered other residents' rooms, yet was unsupervised at the time of the incident.
A male resident with severe cognitive impairment and a history of wandering and poor impulse control entered an occupied female restroom, exposing and physically assaulting a female resident. Staff were not present in the hallway to supervise or prevent the incident, despite facility policy requiring increased observation for residents with aggressive behaviors.
Two residents in an LTC facility experienced delays in receiving Tamiflu due to a medication shortage. The staff failed to notify the physician about the unavailability of the medication, which was intended to treat symptomatic influenza. The facility's policies require resolving medication concerns with the provider, but this was not documented or followed, potentially delaying medical interventions.
The facility failed to implement care plans for several residents by not monitoring vital signs every four hours as required. A resident with respiratory issues and others with similar conditions had care plans that included frequent monitoring due to Influenza, but records showed inconsistencies in following these plans. The DON confirmed the lack of adherence to the care plans, which were meant to ensure proper monitoring and care.
Two residents experienced a delay in receiving Tamiflu due to a medication shortage at the facility. Despite orders being placed, the medication was not administered until days later, as the pharmacy ran out of stock. The facility's policy for timely antiviral treatment was not followed, leading to potential increased flu cases.
The facility failed to enforce its influenza outbreak policy by not retesting contaminated samples and delaying the reorder of test kits for two symptomatic residents. Resident 5 and Resident 4, both with respiratory conditions, had contaminated tests on 12/27/2024 and were confirmed positive for Influenza A on 12/30/2024. The delay in retesting and reordering test kits compromised the facility's infection prevention and control program, as acknowledged by the IPN and ADON. Staff interviews revealed a lack of clarity and communication regarding the retesting process and test kit availability.
The facility failed to honor the rights of nine residents who were smokers by not allowing them to continue smoking in designated areas, as per the facility's policy. Despite the policy stating that current residents should be allowed to smoke, the facility prohibited smoking, affecting residents' quality of life. Some residents expressed dissatisfaction, and the facility did not provide nicotine replacement therapy to all who requested it or monitor withdrawal symptoms.
The facility failed to maintain proper food safety and sanitation practices, as expired bagels were found on shelves, and the kitchen floor had food crumbs and dirt buildup. Additionally, a drain face plate used for multiple kitchen equipment was observed with a slimy black substance. These lapses were acknowledged by the Dietary Supervisor, Infection Preventionist, and Administrator, who noted the potential health risks to residents.
The facility's QAPI program failed to oversee and implement corrective actions for deficiencies in abuse reporting and smoking cessation. An LVN did not report an abuse allegation between two residents, and the facility did not address smoking cessation properly, leading to potential withdrawal symptoms among residents. These failures resulted in repeated deficiencies.
The facility staff failed to ensure call lights were within reach for three residents, each requiring assistance with daily activities. Observations showed call lights on the floor or behind beds, preventing residents from calling for help. Interviews with CNAs highlighted potential frustration and increased fall risk due to this deficiency.
Two residents experiencing tremors affecting their ADLs were not properly monitored or reported to their physicians, as required by facility policy. Despite observations of tremors impacting daily activities, such as eating and writing, the staff failed to document these episodes and notify the physicians, leading to a deficiency in care.
The facility failed to provide individualized activities for three residents, impacting their mental and psychosocial well-being. Despite having no cognitive impairments, the residents were observed sleeping in bed during multiple observations, with no documentation of activities conducted. Staff interviews highlighted the importance of activities for psychological well-being, yet the facility's activity notes lacked evidence of engagement, indicating a failure to implement the facility's policy on program activities.
The facility failed to ensure that three CNAs completed their mandatory dementia and sexual harassment training. The Director of Staff Development lacked an effective tracking system, leading to incomplete training, which posed a potential risk to resident safety.
A resident with schizoaffective disorder and schizophrenia physically assaulted another resident, causing a small cut on the forehead, due to inadequate monitoring and intervention by the facility. Despite known behavioral issues, staff failed to de-escalate the situation, leading to the incident.
A resident with schizoaffective disorder, anxiety, and major depressive disorder did not have a comprehensive care plan addressing these conditions. The facility's ADON/IPN and DON confirmed the omission, acknowledging the need for a care plan to guide staff in providing necessary care. The facility's policy required addressing co-occurring disorders, which was not adhered to.
A resident's care plan for vision was not updated to reflect a diagnosis of cataracts, despite an ophthalmology report confirming the condition. The care plan continued to address suspected glaucoma, which was no longer applicable. Facility staff acknowledged the oversight, noting that the care plan should have been revised to ensure appropriate care and interventions.
The facility's Director of Staff Development (DSD) failed to manage the online education program effectively, resulting in incomplete mandatory training for several CNAs. The DSD lacked training on generating reports to verify staff training completion, leading to significant gaps in required dementia and sexual harassment training. The Administrator confirmed the DSD's responsibility for maintaining the education department, but an ineffective tracking system contributed to the oversight.
A resident was prescribed antibiotics without obtaining necessary cultures or blood tests, contrary to the facility's Antibiotic Stewardship protocol. The resident, who did not meet the criteria for a cellulitis skin infection, was given Bactrim and doxycycline without diagnostic procedures to identify the bacteria being treated. The facility's policy emphasizes evidence-based guidelines and review of culture reports, which were not followed, leading to inappropriate antibiotic use.
The facility was found to be non-compliant with regulations limiting the number of residents per room, as several rooms accommodated more residents than allowed. Despite this, no concerns with privacy, safety, or care were observed, and the Administrator reported no complaints from residents.
A resident with schizophrenia and anxiety was stabbed on the right index finger by another resident with schizophrenia and hearing loss, resulting in a one-inch cut. Both residents were alert and oriented, with varying levels of assistance needed for daily activities. The facility's policy prohibits mistreatment, but the incident occurred, and the reason for the abuse was not established.
The facility failed to protect residents from abuse, resulting in two incidents where residents were physically assaulted by others. A resident with schizophrenia and anxiety disorder exhibited hallucinations and delusions but was not reported to a physician, leading to an assault on another resident. Similarly, another resident with severe cognitive impairment showed agitation and mood swings, which were not communicated to a physician, resulting in an attack on a fellow resident. The facility did not adhere to its policies on abuse prevention and physician notification.
Failure to Develop and Update Person-Centered Care Plans for Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and update person-centered care plans addressing aggressive behaviors for two residents following admission and readmission. For Resident 1, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, the facility readmitted the resident from a general acute care hospital with aggressive behavior identified as a primary concern. Progress notes from 2/6/2026 through 2/8/2026 documented hyperverbal and aggressive behavior, including yelling, pulling down a privacy curtain, refusing oral medications, throwing medications on the floor, refusing an EKG, being verbally abusive and loud to staff and peers, spitting at a peer on the patio, pacing in the hallway while cursing at staff and other residents, and exhibiting intermittent demanding behavior. An order was in place for safety precautions every 15 minutes for 48 hours related to the readmission, and staff interviews confirmed that Resident 1’s behaviors were more severe than in previous admissions and that no care plan was developed or updated to address these increased aggressive behaviors prior to an altercation with another resident. The report further notes that Resident 1 was involved in an incident with another resident (Resident 2), who had diagnoses including schizophrenia and convulsions and was cognitively intact, requiring only setup or cleanup assistance for some ADLs and being independent in eating and toileting hygiene. A post-event assessment documented that a CNA witnessed Resident 1 grabbing Resident 2’s wrists during an altercation. Interviews with nursing staff, including an RN and a CNA, confirmed that Resident 1 had exhibited worsening verbal aggression and demanding behaviors in the days leading up to this incident and that the required person-centered care plan upon readmission, which should guide staff in managing such behaviors, had not been developed or updated. For Resident 6, who had paranoid schizophrenia, intact cognition, and independence in ADLs, psychiatric progress notes dated 1/21/2026 documented that the resident remained oppositional, verbally confrontational with staff, and at moderate risk for aggressive behavior. Staff interviews indicated that this resident was known to be combative and required careful approaches due to safety concerns, and that the resident had a history of aggressive and assaultive behaviors that could result in physical harm to other residents, including neighbors. Despite this, there was no specific care plan developed or updated to address, monitor, or prevent potential future assaultive behaviors. The MDS Coordinator stated that a specific care plan with measurable goals, clearly defined interventions, monitoring parameters, and direction for notifying the physician should have been in place, consistent with the facility’s policy requiring individualized, measurable, resident-centered care plans for behavioral problems.
Inaccurate Q15 Safety Observation Documentation by CNA
Penalty
Summary
The deficiency involves inaccurate and incomplete maintenance of 24-hour observation checklists for residents on every-15-minute safety monitoring. On one date, a CNA documented the 10:00 a.m. and 10:15 a.m. observations for three residents in advance of the scheduled times, after conducting rounds at approximately 9:45 a.m. The CNA acknowledged that documentation was entered before directly observing the residents at the required times. For another resident, the same CNA initially left the 9:45 a.m. and 10:00 a.m. observation entries blank because the resident was not observed at those times. On the following day, review of that resident’s checklist showed that the CNA later completed the previously blank 9:45 a.m. and 10:00 a.m. entries after seeing the resident at approximately 10:14 a.m. in the hallway, despite not having observed the resident at the scheduled times. The CNA stated she had attempted but was unable to locate the resident earlier and did not notify other staff, and that she filled in the missed times because she believed the form could not be left blank. The DSD and an RN stated that staff must directly observe residents before documenting, that pre-charting or documenting without direct observation is not acceptable and may be considered false charting, and that documentation must be accurate, timely, and reflect actual observations in accordance with facility policies on levels of observation and general documentation guidelines.
Failure to Protect Residents from Physical Abuse and Implement Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from physical abuse and did not ensure the implementation of care plan interventions for residents with known behavioral issues. In one incident, a resident with a history of psychotic behavior, verbal aggression, and intrusiveness became agitated during a group activity after another resident blew his nose nearby. The agitated resident expressed discomfort, stood up, and physically pushed the other resident back onto the couch, holding his arm down and verbally instructing him to stop. Staff did not intervene before the situation escalated, and the Rehabilitation Activity Leader left the two residents alone to seek help, during which time the altercation continued. The care plan for the resident with behavioral issues specifically required staff to intervene before agitation escalated, guide the resident away from the source of distress, and engage in calm conversation, but these interventions were not followed. Another incident involved a resident being physically assaulted by her roommate, who grabbed her breast and hit her in the face, resulting in a four-centimeter scratch on the left side of her face. The aggressor admitted to the action, expressing a delusional belief that the other resident had stolen her breast. The incident was discovered by a CNA, who observed the injury and blood on the resident's gown. The residents had no prior history of altercations, and both required varying levels of assistance with activities of daily living due to mental health diagnoses such as schizoaffective disorder and major depressive disorder. The facility's policy on abuse prevention and reporting prohibits any form of mistreatment, including abuse and neglect, and requires timely investigation and reporting of all allegations. Despite these policies, the facility failed to prevent physical altercations between residents and did not ensure staff followed established care plans and interventions designed to de-escalate potentially aggressive behaviors. These failures resulted in residents sustaining physical harm and not being protected from abuse as required.
Failure to Train and Ensure Abuse Reporting by Social Worker
Penalty
Summary
The facility failed to ensure that a social worker received effective training on abuse reporting, specifically regarding the identification and reporting of inappropriate sexual behavior between residents. The deficiency was identified when a social worker did not properly report or investigate incidents involving a resident who engaged in inappropriate touching and kissing of two other residents. The social worker assumed that nursing staff would handle the reporting and did not complete the required abuse report or notify the appropriate authorities, despite being a mandated reporter. The residents involved had various mental health diagnoses, including schizoaffective disorder, paranoid schizophrenia, and anxiety, but were assessed as having clear comprehension and varying levels of independence in daily activities. The incidents included one resident tapping another on the buttocks and kissing a different resident, with staff intervening to separate the individuals. However, the required steps for abuse reporting and investigation were not followed, and the incidents were not reported to the administrator, ombudsman, or Department of Health as required by facility policy. Interviews with facility staff, including the Director of Nursing, confirmed that the abuse prevention and reporting policy was not followed. The facility's policy mandates immediate reporting and investigation of all alleged violations involving abuse, neglect, or mistreatment, but these procedures were not carried out. Additionally, the residents involved were not monitored following the incidents, and the lack of proper reporting and investigation was acknowledged by facility leadership.
Resident Privacy and Dignity Compromised During Restroom Incident
Penalty
Summary
A deficiency occurred when a resident's privacy was not maintained, resulting in a violation of dignity. Specifically, a cognitively intact female resident with a history of major depressive disorder and schizophrenia was using the restroom when another resident, a male with severe cognitive impairment and poor impulse control, entered the restroom while she was urinating with her pants down. The female resident reported feeling embarrassed, bad, and nasty as a result of this incident. The male resident who entered the restroom had a care plan in place to closely monitor and minimize triggers for aggression, and his psychiatric notes indicated resistance to redirection and episodes of poor impulse control. The facility's policy states that residents are to be treated with respect and dignity, and to be free from abuse. The Director of Nursing acknowledged that such an incident could compromise a resident's sense of safety and dignity, especially when a male enters a female restroom.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was cognitively intact and had no behavioral symptoms, was using her bathroom when another resident, who had a history of schizoaffective disorder, severe cognitive impairment, and aggressive behaviors, entered the bathroom uninvited. The intruding resident attempted to take a trash can from the bathroom, and when the first resident intervened, he punched her in the face, leaving a red mark and causing pain. The incident occurred while the resident was sitting on the toilet with her pants down, which left her feeling mad, embarrassed, and violated. Prior to the incident, the resident who committed the abuse had a documented history of psychiatric issues, including disorganized thought processes, aggressive behavior, paranoid delusions, and poor impulse control. Staff interviews and care plan reviews indicated that this resident was known to become easily agitated, had previously threatened staff, and had a pattern of entering other residents' rooms without permission. Despite these known risks, the resident was ambulatory and allowed to walk freely throughout the facility, including unsupervised access to hallways and other residents' rooms. Observations and staff interviews revealed that there was a lack of staff presence in the hallway near the incident location at the time of the event. The facility's policy on abuse prevention and reporting defined resident-to-resident abuse as aggressive or inappropriate behavior, including hitting and threatening gestures. The failure to provide adequate supervision and monitoring allowed the aggressive resident to access another resident's private space and commit physical abuse, resulting in physical and emotional harm.
Failure to Supervise Resident with Wandering and Aggressive Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent a male resident with a history of wandering and severe cognitive impairment from entering an occupied female restroom. The male resident, who had diagnoses including schizoaffective disorder and was noted to be resistant to redirection with poor impulse control, entered the restroom while a cognitively intact female resident was using it. This resulted in the female resident being exposed and subsequently punched in the right cheek by the male resident. Observations on multiple occasions revealed that no staff were present in the hallways near the resident rooms, and interviews confirmed the male resident's history of wandering into other residents' rooms. The facility's policy required increased observation for residents presenting risks such as aggression or assault, but this was not implemented effectively, as staff were not present to monitor or intervene during the incident.
Failure to Notify Physician of Tamiflu Unavailability
Penalty
Summary
The facility staff failed to notify the physician when Tamiflu, a medication used to treat influenza, was unavailable for two residents who were symptomatic. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, was supposed to start Tamiflu on December 28, 2024, but the medication was not available until December 30, 2024. The Assistant Director of Nursing (ADON) confirmed that the medication order was discontinued due to unavailability and that there was no documentation indicating the physician was notified of this issue. Similarly, Resident 4, who had diagnoses including acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also experienced a delay in receiving Tamiflu. The medication was ordered on December 27, 2024, but was not administered until December 30, 2024, due to a shortage. The Director of Nursing (DON) acknowledged that the delay in treatment could have led to more positive flu cases and stated that the doctor should have been notified when the medication was unavailable. Interviews with facility staff, including the Registered Nurse Supervisor (RNS) and ADON, revealed that there was a lack of documentation regarding communication with the physician about the medication shortage. The facility's policy and procedure on medication administration and orders emphasize resolving medication concerns with the provider, but this was not followed in these instances. The failure to notify the physician and document the communication could have delayed medical interventions for the residents.
Failure to Implement Care Plans for Vital Sign Monitoring
Penalty
Summary
The facility failed to implement the care plans for four residents, specifically by not monitoring vital signs every four hours as required. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had a care plan initiated to monitor vital signs and oxygen saturation every four hours due to testing positive for Influenza. However, the records showed that vital signs were not consistently monitored every four hours, as confirmed by the Director of Nursing (DON). Similarly, Resident 4, admitted with acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also had a care plan requiring vital sign monitoring every four hours due to Influenza. The records indicated that the monitoring was not performed consistently every four hours, which was acknowledged by the DON during the review. Resident 3, with diagnoses including acute lower respiratory infection, hypertension, and schizophrenia, had a care plan with the same requirement for monitoring vital signs and oxygen saturation every four hours. The DON confirmed that the interventions were not implemented as per the care plan. The facility's policy and procedure emphasized the importance of individualized care plans based on assessments, but the failure to adhere to these plans was evident in the review.
Delay in Tamiflu Administration Due to Medication Shortage
Penalty
Summary
The facility failed to ensure timely administration of Tamiflu to two residents, leading to a delay in necessary medication. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had an order for Tamiflu on 12/27/2024, which was not administered until 12/30/2024 due to unavailability. The Medical Administration Record indicated that the medication was unavailable on 12/28/2024, and the facility pharmacy confirmed that Tamiflu would be delivered on 12/30/2024. Interviews with the Licensed Vocational Nurse and review of the progress notes revealed that the medication was not available and that the delay could have minimized the spread of symptoms. Similarly, Resident 4, who had acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also experienced a delay in receiving Tamiflu. The order for Tamiflu was placed on 12/27/2024 but was not administered until 12/30/2024 due to a shortage. The Assistant Director of Nursing confirmed that the pharmacy ran out of Tamiflu on 12/27/2024, and most residents did not start receiving the medication until 12/30/2024 or later. The Director of Nursing acknowledged that the delay in receiving Tamiflu could have resulted in more positive flu cases among residents. The facility's policy and procedure for medication orders and influenza outbreak management were not effectively followed, as the antiviral treatment was not started within the recommended timeframe. The pharmacist stated that no orders for Tamiflu were received on 12/27/2024, and the facility did not keep Tamiflu in stock, leading to the delay. The facility's policy indicated that antiviral treatment should be started as soon as possible for residents with suspected or confirmed influenza, but this was not achieved due to the medication shortage and lack of timely ordering.
Failure to Timely Retest and Reorder Test Kits During Influenza Outbreak
Penalty
Summary
The facility failed to enforce its policy related to an influenza outbreak by not retesting contaminated samples and not reordering test kits in a timely manner for two symptomatic residents. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had a contaminated influenza test on 12/27/2024. The retest on 12/30/2024 confirmed Influenza A. Similarly, Resident 4, with acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also had a contaminated test on 12/27/2024 and was confirmed positive for Influenza A on 12/30/2024. The facility's infection prevention and control program was compromised due to the delay in retesting and reordering test kits. The Infection Preventionist Nurse (IPN) and Assistant Director of Nursing (ADON) acknowledged the delay in retesting symptomatic residents and the failure to reorder test kits promptly. The facility had initially ordered 70 test kits on 12/27/2024 but received only 50, and the contaminated samples were not retested until 12/30/2024. The ADON admitted that the facility could have called the lab for a stat order to obtain test kits over the weekend, but this was not done. Interviews with staff, including the Director of Nursing (DON) and Registered Nurse Supervisor (RNS), revealed a lack of clarity and communication regarding the retesting process and the ordering of test kits. The DON and RNS were unsure why the retesting did not occur sooner, and the facility did not have test kits readily available. The facility's policy on influenza disease surveillance and outbreak management was not followed, leading to a delay in identifying and treating the influenza outbreak among residents.
Facility Fails to Honor Smoking Rights of Residents
Penalty
Summary
The facility failed to honor the rights of nine residents who were smokers by not allowing them to continue smoking in designated areas, as per the facility's policy. The policy, approved on January 31, 2024, stated that if the facility changes its policy to prohibit smoking, current residents who smoked should be allowed to continue smoking in an area that maintains their quality of life. However, the facility did not adhere to this policy, resulting in a failure to honor the residents' choices and affecting their quality of life. Several residents expressed their dissatisfaction with the new non-smoking policy. For instance, one resident stated that smoking helped with their mood and relaxation, while another mentioned feeling sick and upset after being prohibited from smoking. The facility had implemented a no-smoking agreement for newly admitted residents and offered nicotine patches or gum to current smokers, but some residents refused these alternatives and expressed a desire to continue smoking. The facility's actions were inconsistent with their policy, as they did not provide nicotine replacement therapy to all residents who requested it, nor did they assess or monitor nicotine withdrawal symptoms. Interviews with residents and staff revealed that the facility had stopped allowing smoking due to health reasons and the COVID-19 outbreak, but this decision was not aligned with the facility's stated policy of maintaining the quality of life for residents who smoked.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices, as observed during a survey. Expired bagels were found on the shelves, indicating a lapse in monitoring and removing outdated food items. The Dietary Supervisor acknowledged the oversight, stating that expired food should not be served to residents due to the potential health risks. Both the Infection Preventionist and the Administrator confirmed that serving expired food poses a risk for foodborne illnesses. Additionally, the kitchen floor was observed to have food crumbs and dirt buildup, particularly along the walls and in the corners. The Dietary Supervisor and Infection Preventionist emphasized the importance of maintaining a clean and sanitary environment to prevent pest infestations and bacterial growth. Furthermore, the drain face plate used for multiple kitchen equipment was found to have a slimy black substance, which could harbor bacteria. The facility's policies on sanitation and infection prevention were reviewed, highlighting the need for regular cleaning to prevent contamination and ensure food safety.
Deficiencies in Abuse Reporting and Smoking Cessation Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) program failed to effectively oversee and implement the plan of correction for deficiencies identified in a previous recertification survey. Specifically, the facility did not ensure proper reporting of an abuse allegation between two residents. A resident reported being hit by another resident, but the incident was not reported by the Licensed Vocational Nurse (LVN) who was informed of the event. The LVN did not believe the incident occurred and failed to report it to supervisors, which was a requirement according to the facility's policy. Additionally, the facility did not adequately address issues related to smoking among residents. Despite a policy that allowed current residents to continue smoking in designated areas, the facility stopped residents from smoking after a COVID-19 outbreak. This decision was not included in the QAPI program, and there was no documented assessment or monitoring of potential withdrawal symptoms from nicotine among residents who used to smoke. The facility's policy required an appropriate care plan for residents recommended for smoking cessation, which was not implemented. The facility's failure to maintain an effective QAPI program and address these issues resulted in repeated deficiencies. The lack of oversight and failure to implement corrective actions for abuse reporting and smoking cessation could potentially violate residents' rights and compromise their quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility staff failed to ensure that the call lights were within reach for three residents, identified as Resident 132, Resident 140, and Resident 141. Each of these residents was observed on multiple occasions with their call lights on the floor, making them inaccessible. Resident 132 and Resident 140 were both admitted with diagnoses including schizoaffective disorder, essential hypertension, and hyperlipidemia, and were noted to have no cognitive impairments but required assistance with some activities of daily living. Resident 141, diagnosed with schizophrenia, also had no cognitive impairments and required similar assistance. Observations on consecutive days revealed that the call lights for these residents were consistently out of reach, either on the floor or behind the bed, preventing them from calling for assistance when needed. Interviews with Certified Nursing Assistants (CNAs) highlighted the potential impact of this deficiency on the residents' well-being. CNA 6 noted that the inability to reach the call light could lead to frustration and affect the residents' psychosocial state, while CNA 5 emphasized the increased risk of falls and injuries due to the residents' inability to call for help. The facility's policy on the nursing call light system mandates that all staff and residents be oriented to its functions, ensuring that residents can notify staff from their bedside, toilet, or shower when they need assistance. However, the observations and interviews indicate that this policy was not effectively implemented for the three residents in question.
Failure to Notify Physicians of Residents' Tremors
Penalty
Summary
The facility failed to notify the physicians of two residents, Resident 14 and Resident 108, who were experiencing tremors that affected their activities of daily living (ADLs). Resident 14, diagnosed with schizophrenia, extrapyramidal and movement disorder, Parkinson's Disease, and chronic diastolic congestive heart failure, was observed to have hand tremors from October 15 to October 17, 2024, which impacted her ability to eat. Despite these observations, there was no documentation in the progress notes, and the physician was not notified, which was against the facility's policy. Resident 108, diagnosed with bipolar disorder and tremor, was also experiencing tremors that affected her ability to write. She had requested a reduction in her lithium dosage due to the tremors. However, the facility staff failed to document these episodes of extrapyramidal symptoms (EPS) in the resident's chart and did not notify the physician, as required by the facility's policy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of proper monitoring and documentation. The facility's policy on monitoring possible side effects from psychotropic medications required licensed nurses to monitor residents every shift for side effects and notify the physician of any positive findings. The policy also required documentation of new or increased EPS in the progress notes. The failure to adhere to these procedures resulted in the deficiency noted in the report, as the residents' conditions were not properly communicated to their physicians, potentially affecting their treatment plans and quality of life.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities that meet the interests of three residents, potentially impacting their mental and psychosocial well-being. Resident 3, who was admitted with diagnoses including paranoid schizophrenia, type II diabetes mellitus, and essential hypertension, was observed sleeping in bed during multiple observations over several days. Despite having no cognitive impairment and requiring supervision for personal hygiene, there was no documentation of Resident 3 engaging in any activities during this period. Similarly, Resident 21, diagnosed with schizoaffective disorder, seizures, and hypotension, was also observed sleeping in bed during various times over several days. The resident's care plan included interventions to encourage participation in group activities, yet there was no evidence of such activities being conducted. Resident 21 required assistance for all activities of daily living and had no cognitive impairment, indicating a need for structured engagement. Resident 104, with diagnoses of schizophrenia, insomnia, and major depressive disorder, was found in bed sleeping during multiple observations. The resident was dependent on assistance for all activities of daily living and had no cognitive impairment. Interviews with facility staff, including a CNA, RN, and the Rehabilitation Director, emphasized the importance of activities in improving residents' psychological well-being and managing mental health challenges. However, the facility's activity notes lacked documentation of any activities for these residents during the observed period, indicating a failure to implement the facility's policy on program activities.
Failure to Complete Mandatory Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) completed their mandatory continuing education requirements. Specifically, CNA 1, CNA 2, and CNA 3 did not complete the required yearly dementia training, with each missing four out of five hours. Additionally, CNA 2 and CNA 3 did not complete the mandatory one-hour sexual harassment training. This lack of training compliance was identified during an interview and record review with the Director of Staff Development (DSD), who acknowledged the absence of an effective tracking system for monitoring training completion. The Administrator confirmed that the DSD was responsible for managing the education department and ensuring that all mandatory training requirements were met. However, the DSD failed to utilize available tools and did not have a system in place to track training completion, leading to the oversight. The facility's policy and procedures outlined the DSD's role in providing and maintaining staff education, including mandatory training required by regulatory agencies. The failure to complete these training requirements posed a potential risk to resident safety, as staff may not be adequately equipped to care for residents.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, specifically Resident 65, who was injured by her roommate, Resident 37. Resident 37, who has a history of schizoaffective disorder and schizophrenia, exhibited delusional behavior and physically assaulted a staff member before hitting Resident 65 with a table, resulting in a small cut on Resident 65's forehead. Despite Resident 37's known behavioral issues, including delusions and aggression, the facility did not adequately monitor or intervene to prevent the escalation of her behavior. Resident 65, who has diagnoses of paranoid schizophrenia and unspecified dementia, was independent in mobility and had intact cognition. On the day of the incident, Resident 65 sought help at the nursing station with a bleeding forehead after being hit by a table thrown by Resident 37. The facility's records indicate that Resident 37 was experiencing delusional thoughts and accused her roommate of causing harm, which led to the aggressive incident. Interviews with staff, including a CNA, RN Supervisor, ADON, and DON, revealed that there were missed opportunities to intervene and de-escalate Resident 37's behavior. Staff acknowledged that Resident 37's behavior was unpredictable and that someone should have checked on her after she hit a staff member and slammed the door. The facility's policy on abuse prevention requires staff to intervene and correct situations where abuse may occur, but this was not effectively implemented in this case.
Failure to Develop Comprehensive Care Plan for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with schizoaffective disorder, anxiety, and major depressive disorder. The resident, who was admitted with these diagnoses, required various levels of assistance from nursing staff for daily activities, as indicated in the Minimum Data Set (MDS). Despite the resident's active diagnosis of schizoaffective disorder, the care plan did not address this condition, which was confirmed during a review by the Assistant Director of Nursing/Infection Preventionist Nurse (ADON/IPN). The ADON/IPN acknowledged that the care plan should have included interventions for schizoaffective disorder to ensure the resident received necessary care and services. The Director of Nursing (DON) also confirmed the need for a care plan to guide nursing staff in providing appropriate care and interventions. The facility's policy and procedure on Individual Plans emphasized the importance of addressing co-occurring disorders in an integrated manner, which was not followed in this case.
Failure to Update Vision Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a care plan for vision was revised and updated for a resident, identified as Resident 108, who was part of a sample of 33 residents. Resident 108 was admitted with diagnoses including bipolar disorder, tremor, pre-glaucoma, and age-related bilateral nuclear cataract. Despite a consultation report from an ophthalmologist indicating that the resident had bilateral cataracts and no evidence of glaucoma, the care plan continued to address suspected glaucoma without updating it to reflect the cataract diagnosis. This oversight was identified during a review of the resident's care plan, which had not been revised since November 2023, even though the ophthalmology consultation in October 2024 confirmed the presence of cataracts. Interviews with the resident and facility staff, including a Registered Nurse Supervisor, Assistant Director of Nursing, and Director of Nursing, revealed that the care plan was outdated and did not include the resident's current diagnosis of cataracts. The staff acknowledged that the care plan should have been updated to reflect the resident's actual condition to ensure appropriate care and interventions. The facility's policy and procedure indicated that individual plans should be reviewed and updated according to changes in treatment needs, but this was not adhered to in the case of Resident 108.
Inadequate Staff Training Management by DSD
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) was competent in managing the online education program used for staff training. During an interview and record review, the DSD admitted to not having received training on how to generate reports to verify staff completion and competency on mandatory in-services. As a result, the DSD was unable to provide data on the completion of mandatory training for staff members, including Certified Nurse Assistants (CNAs). Specifically, CNA 1, CNA 2, and CNA 3 were missing significant portions of their required yearly dementia training, and CNA 2 and CNA 3 were also missing part of their mandatory sexual harassment training. The Administrator confirmed that the DSD was responsible for maintaining the education department and ensuring that staff completed their mandatory training. However, the DSD did not have an effective tracking system in place and relied on checking each staff member individually, which led to the oversight. The facility's policy and procedures outlined the DSD's responsibilities, including maintaining records and reports of all staff education and providing mandatory education required by regulatory agencies. The failure to complete mandatory training was acknowledged as potentially putting resident safety at risk.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement their protocol for Antibiotic Stewardship for one of the sampled residents by not obtaining a culture or blood tests before prescribing antibiotic medication. This deficiency was identified in the case of a resident who was screened for cellulitis but did not meet the criteria for a cellulitis skin infection according to the Healthcare-associated Infections Suggested Definitions of Infections for Surveillance Purposes. Despite this, the resident was prescribed Bactrim and doxycycline for skin infections without diagnostic procedures to determine the actual bacteria being treated. The Assistant Director of Nursing/Infection Preventionist Nurse acknowledged that a culture should have been done for any skin issue or possible infection, but it was not performed for this resident. The Director of Nursing also stated that the goal of Antibiotic Stewardship is to avoid unnecessary antibiotics and follow guidelines, which were not adhered to in this case. The facility's policy on Antibiotic Stewardship emphasizes compliance with evidence-based guidelines and the review of culture and sensitivity reports, which was not followed, leading to the inappropriate use of antibiotics for the resident.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as rooms 12, 13, 20, and 21 were found to accommodate six residents each, and rooms 47 and 48 accommodated five residents each. This was identified during a review of the Client Accommodations Analysis Form completed by the facility on October 15, 2024. Despite these findings, observations made during the annual recertification survey from October 15 to October 18, 2024, did not indicate any concerns with privacy, safety, or residents' care. Additionally, during an interview on October 18, 2024, the Administrator stated that residents' care was not affected, and there were no complaints about room crowding affecting mobility and safety. The facility's policy and procedure titled 'Safe and Comfortable Environment' indicated that no more than four residents should be accommodated in one room.
Resident Stabbed by Another Resident with a Pen
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 1, who has schizophrenia, anxiety, and hypertension, was stabbed on the right index finger with a pen by Resident 2, who also has schizophrenia, hearing loss, and hypertension. The incident resulted in a one-inch cut on Resident 1's finger. Resident 1 was alert and oriented to name only, while Resident 2 was alert and oriented to name, place, and time. The Minimum Data Set (MDS) assessments indicated that both residents required varying levels of assistance with daily activities, but neither required assistance with personal hygiene or toileting. The Director of Nursing (DON) and the Administrator (ADM) confirmed the incident, with Resident 2 admitting to stabbing Resident 1. The facility's policy on abuse prevention and reporting strictly prohibits any form of mistreatment, including physical abuse. Despite this policy, the incident occurred, and the ADM could not establish the reason behind the abuse. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as required by their policies.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, specifically involving two incidents. In the first incident, Resident 1, who was diagnosed with schizophrenia and anxiety disorder, exhibited behaviors such as auditory hallucinations, paranoid delusions, and visual hallucinations. Despite these behaviors being documented in the Medication Administration Record (MAR) over several days, the facility did not inform Resident 1's physician. This lack of communication resulted in Resident 1 entering Resident 2's room and hitting him in the face, driven by delusional beliefs that Resident 2 had raped him. In the second incident, Resident 3, who had severe cognitive impairment and was diagnosed with schizophrenia, exhibited agitation, anxiety, and mood swings. These behaviors were noted in the MAR, but again, the facility failed to inform the physician. Consequently, Resident 3 hit Resident 4 in the face while she was sitting in her wheelchair in the hallway. Resident 4, who had mild cognitive impairment and was diagnosed with schizoaffective disorder and anxiety disorder, was unable to defend herself or call for help effectively. The facility's policy and procedure on abuse prevention and reporting, as well as the notification of physician/prescriber, were not followed. The Director of Nursing acknowledged that the facility did not take action to control Resident 1's behavior until it escalated, and the Director of Rehab noted the lack of staff presence during the incident involving Resident 3 and Resident 4. These failures highlight the facility's inability to protect residents from abuse and ensure timely communication with physicians regarding significant behavioral changes.
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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