Laurel Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Fontana, California.
- Location
- 7509 N. Laurel Ave, Fontana, California 92336
- CMS Provider Number
- 056429
- Inspections on file
- 37
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Laurel Convalescent Hospital during CMS and state inspections, most recent first.
A resident developed pressure injuries, including deep tissue injuries and open wounds, while in the facility. The facility failed to notify the resident's family about the new wounds and treatments. The resident was admitted without wounds, but they developed during the stay, contrary to the facility's policies on pressure injury prevention and family notification.
The facility failed to maintain the kitchen refrigerator temperature at the required 40 degrees Fahrenheit or lower, with observed temperatures reaching 45 and 49 degrees Fahrenheit. Staff interviews confirmed the risk of food-borne illness due to these elevated temperatures, which could affect all residents receiving food from the kitchen.
Two residents in the facility were found with unclean and untrimmed fingernails, despite their care plans requiring assistance with grooming. One resident, dependent on staff for all ADLs, had black and curled nails, while another, with moderate cognitive impairment, had long and dirty nails. Staff acknowledged the oversight, attributing it to communication lapses and the resident's recent admission.
A resident with a history of chronic kidney disease and urinary issues had an unsecured indwelling catheter, contrary to facility policy. Despite orders to secure the catheter every shift, an observation revealed the absence of a securement device. Staff interviews confirmed the expectation for securement, but the device was not in place.
The facility failed to follow its policy on timely response to call lights, affecting two residents. One resident reported long delays in receiving diaper changes, while another experienced waits of up to three hours for assistance. An observation confirmed that a call light went unanswered, with staff failing to check the call light panel as required by policy.
A resident with multiple health issues experienced the reopening of pressure injuries, indicating a failure in the facility's wound care policy. Additionally, a CT scan was ordered for the wrong foot, which could have delayed treatment for a suspected infection.
A resident with partial paralysis and dementia fell out of bed and was roughly handled by a CNA, who pulled the resident by one arm back onto the bed, causing the resident's hip to rub against the footrest. The CNA also verbally abused the resident by saying, 'Stop that! you're being annoying!' This incident was witnessed and overheard by multiple staff members. The facility's policy on abuse and mistreatment was not followed.
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for a resident with a history of multiple medical conditions. Despite initial notification, no follow-up was made to contact an alternative physician or the Medical Director, resulting in a delay in treatment.
A resident with end-stage renal disease missed a scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared and waiting, but the transportation service was unaware of the pick-up. The facility's policy on arranging transportation was not followed, leading to the missed treatment.
A resident with multiple diagnoses experienced a significant drop in blood sugar and oxygen levels. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The DON and Administrator confirmed a delay in treatment and lack of proper documentation and assessment.
The facility failed to document blood sugar results for a resident with type 2 diabetes mellitus, despite orders for regular checks and insulin administration. Inconsistent documentation practices and incorrect order input led to incomplete records in the MAR, as confirmed by nursing staff and the DON.
A resident with multiple serious diagnoses did not receive prescribed IV antibiotics upon admission due to the facility's failure to obtain the medications in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics.
The facility failed to report an allegation of abuse involving a resident within the required timeframe. The incident, which occurred over a weekend, was not reported to outside agencies until two days later due to staff unawareness and miscommunication.
Failure to Prevent Pressure Injuries and Notify Family
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was diabetic, obese, immobile, and at risk for skin breakdown. The resident developed deep tissue injuries on the left heel, left great toe, and first metatarsal, as well as a fluid-filled blister on the right medial foot. Additionally, the resident acquired open wounds on the left elbow and sacral area. The facility did not notify the resident's family about the left elbow and sacral open wounds and the wound treatment. The resident was admitted with no wounds, but the facility's records indicate that the wounds developed during the resident's stay. The Treatment Nurse acknowledged that the family was not notified and that follow-up calls should have been made. The Assistant Director of Nursing confirmed that the wounds developed in the facility and that the family was not notified. The facility's policies on pressure sore management and prevention of pressure injuries emphasize the importance of assessing residents for pressure injury risk factors and notifying families of changes in a resident's condition, which were not adhered to in this case.
Refrigerator Temperature Non-Compliance
Penalty
Summary
The facility failed to maintain the kitchen refrigerator temperature at 40 degrees Fahrenheit or lower, as required by their policy. During multiple observations on 11/11/2024, the refrigerator temperature was recorded at 45 degrees Fahrenheit and later at 49 degrees Fahrenheit. The Dietary Supervisor confirmed the temperature readings and acknowledged that such temperatures could impact food safety. The facility's policy clearly stated that the refrigerator temperature should be 40 degrees Fahrenheit or lower, yet the observed temperatures exceeded this limit. Interviews with facility staff, including the Dietary Supervisor, Regional Dietician, Director of Nursing, and Administrator, revealed a consensus that the refrigerator temperature should not exceed 41 degrees Fahrenheit to prevent food-borne illnesses. The Regional Dietician emphasized the risk of food-borne illness if the temperature remained at 45 degrees Fahrenheit for an extended period. The Administrator acknowledged the discrepancy between the observed temperatures and the facility's policy, which could potentially affect all residents receiving food from the kitchen.
Failure to Maintain Residents' Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that the fingernails of two residents were clean and trimmed, as required by their care plans and facility policy. Resident #2, who has a history of dementia and cognitive impairment, was observed with black and curled fingernails. Despite being dependent on staff for all activities of daily living (ADLs), the necessary grooming was not provided. Certified Nurse Aide (CNA) #1 acknowledged noticing the issue weeks prior and reported it to a nurse, but no action was taken. Registered Nurse (RN) #3 confirmed that the resident's fingernails needed trimming and was unaware of the issue until it was brought to her attention. Resident #136, who has moderate cognitive impairment and requires assistance with personal hygiene, was also found with long and dirty fingernails. The resident expressed a desire to have their nails cut, but this had not been done since their admission. Restorative Nurse Aide (RNA) #5 and RN #3 both acknowledged the resident's nails were in need of care, and RNA #5 attributed the oversight to the resident being newly admitted. The Director of Nursing and the Administrator both stated that they expected residents' fingernails to be clean and trimmed regularly.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was secured with a securement device, as required by their policy. The policy, revised in August 2022, mandates that catheters remain secured to reduce friction and movement at the insertion site. Resident #52, who was admitted to the facility in July 2022, had a medical history that included chronic kidney disease, benign prostate hypertrophy, obstructive and reflex uropathy, and urinary tract infection. The resident's quarterly Minimum Data Set indicated moderate cognitive impairment and the presence of an indwelling catheter. An order from September 2024 directed staff to secure the catheter tubing with an anchor every shift to prevent dislodgement. During an observation in November 2024, it was noted that Resident #52's catheter was not secured with a securement device. Interviews with staff, including an LVN and the Director of Nursing, confirmed that a securement device should have been in place. The LVN was unaware of why the device was missing, while the DON emphasized the importance of having a leg band or anchor device for all residents with catheters. The facility's Administrator also stated that nurse aides were expected to verify the presence of the securement device every shift and notify the nurse if it was absent.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy of answering resident call lights in a timely manner, which compromised the care of two residents. Resident 1, who was admitted with conditions including enterocolitis, muscle weakness, and hypertension, reported that it took hours for the nursing staff to change her diaper regardless of when she activated the call light. Similarly, Resident 2, who had a history of myocardial infarction, muscle weakness, and type 2 diabetes, stated that he sometimes waited up to three hours for assistance, and on occasions, staff would leave without providing the needed help and not return. During an observation, a call light was heard for an extended period without being answered. A Certified Nursing Assistant (CNA) claimed not to have heard the call light, attributing the sound to the Director of Staff Development (DSD) office. However, it was later confirmed that the sound originated from a resident's room. The DSD acknowledged that staff failed to follow the guidelines and policy, which required checking the call light panel to determine the source of the sound. This oversight in responding to call lights placed the residents' psychosocial health and safety at risk.
Pressure Injury Management and CT Order Error
Penalty
Summary
The facility failed to prevent the reopening of two pressure injuries for a resident, which placed the resident's health and safety at risk. The resident, who was admitted with conditions including contracture of the right knee, vascular dementia, and a flaccid neuropathic bladder, experienced a reopening of a Stage 4 coccyx wound and a Stage 3 left hip wound. Despite the facility's policy on pressure injury prevention, the resident's wounds reopened, indicating a lapse in the implementation of the policy. The facility's policy required regular assessment and repositioning of residents at risk for pressure injuries, but the reopening of the wounds suggests these measures were not effectively carried out. Additionally, there was a miscommunication regarding a physician's order for a CT scan. The order was incorrectly placed for the resident's right foot instead of the left, which was the site of concern for potential osteomyelitis. This error was acknowledged by the Assistant Director of Nursing and the Director of Nursing, who confirmed that the order was written for the wrong foot. The Treatment Nurse also noted that the right heel wound had resolved, and the focus was on the left heel, yet the CT order was not corrected before the resident was sent out, potentially delaying appropriate treatment.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical and verbal abuse. Resident 1, who had partial paralysis of the left side of the body following a stroke and dementia, fell out of bed. A Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed, causing the resident's hip to rub against the footrest. During this incident, CNA 1 verbally abused Resident 1 by saying, 'Stop that! you're being annoying!' This was witnessed by a Registered Nurse Supervisor (RNS) and overheard by a Minimum Data Set/Licensed Vocational Nurse (MDS/LVN 1) and a Licensed Vocational Nurse/Infection Preventionist (LVN/IP). The RNS had instructed CNA 1 to wait while she put on gloves, but CNA 1 did not comply and proceeded to handle Resident 1 roughly. The facility's Administrator, who was not in position at the time of the incident, reviewed the records and interviews and concluded that the facility had failed to protect Resident 1 from abuse. The facility's policy and procedure titled 'Abuse and Mistreatment of Residents,' dated May 3, 2023, was not followed. This policy outlines the prevention guidelines and procedures for reporting and addressing concerns of abuse, neglect, and mistreatment, which were not adhered to in this case.
Failure to Promptly Notify Physician for Change of Condition
Penalty
Summary
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for one resident. The resident, who had a medical history including type 2 diabetes mellitus, osteoporosis, hypertension, rheumatoid arthritis, and muscle contracture of the left lower leg, experienced redness, swelling, and tenderness in the left foot. Despite the CNA alerting the nurse and the nurse assessing the resident, the physician was notified but did not respond, and no follow-up was made to contact an alternative physician or the Medical Director as per the facility's policy. The deficiency was identified during a review of the resident's records and interviews with the Registered Nurse Supervisor and the Administrator. The records showed that the physician was initially notified but did not respond, and the follow-up attempts were not made until much later, resulting in a delay in treatment. The facility's policy clearly stated that in the event of a change in condition, the physician should be called promptly, and if unreachable, an alternative physician or the Medical Director should be contacted. The Administrator acknowledged that the staff did not follow this policy, leading to a delay in addressing the resident's condition.
Failure to Provide Transportation for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident was provided transportation for his dialysis treatment appointment. The resident, who had a history of end-stage renal disease requiring hemodialysis, missed his scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared for dialysis and waiting with paperwork and a sack lunch, but the transportation did not arrive. The CNA notified the charge nurse, and it was discovered that the transportation service was unaware of the scheduled pick-up. The dialysis center was contacted to reschedule the appointment for the following day, and the resident's medical director and family were informed. Orders were given to monitor the resident for fluid overload due to the missed dialysis session. During an interview, the Director of Nursing acknowledged that the resident should not have missed his dialysis treatment and that the staff should have called and notified the transportation services upon the resident's return from the hospital. The facility's policy and procedure on transportation, which states that social services will help residents obtain transportation as needed, was not followed. The Administrator confirmed that the staff did not adhere to the facility's policy, resulting in the missed dialysis treatment for the resident.
Failure to Properly Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to properly assess and notify the physician and responsible party of a change in condition for a resident, leading to a delay in treatment and transfer to an acute hospital. The resident, who had multiple diagnoses including encephalopathy, sepsis, type 2 diabetes mellitus, and MRSA, experienced a significant drop in blood sugar levels and oxygen saturation. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The CNA observed the resident's condition deteriorating during breakfast and lunch, noting that the resident was not staying awake and had to have food removed from her mouth. The CNA reported these observations to the LVN, who checked the resident's respirations but did not perform a full assessment or notify the physician. It was only after the resident's family expressed concern in the afternoon that the LVN took further action, resulting in the administration of glucagon and the calling of emergency services. Interviews with the DON and Administrator confirmed that there was a delay in treatment and a lack of proper documentation and assessment. The facility's policy on handling changes of condition was not followed, leading to a failure in providing timely and appropriate care for the resident. The deficiency was acknowledged by both the DON and the Administrator, who agreed that better assessment and documentation were needed.
Failure to Document Blood Sugar Results
Penalty
Summary
The facility failed to continually document blood sugar results in the medical record for a resident with multiple diagnoses, including type 2 diabetes mellitus. The resident was admitted with orders for regular blood sugar checks and insulin administration. However, the Medication Administration Record (MAR) for March and April 2024 lacked complete documentation of blood sugar results, and there was no clarification of a sliding scale for insulin administration. Interviews with various nursing staff revealed inconsistencies in documentation practices, with some nurses documenting results in progress notes instead of the MAR, and others noting the absence of a sliding scale in the orders. The Director of Nursing (DON) acknowledged that the order was input incorrectly, and parameters were not added, leading to the lack of documentation in the MAR. The facility's policy and procedure for obtaining a fingerstick glucose level and charting and documentation were reviewed, indicating that blood sugar results should be documented. Despite this, the resident's blood sugar results were not consistently recorded, and the admitting orders were not properly clarified. The Administrator confirmed the absence of documentation in the medical record for the resident, highlighting a significant lapse in tracking the resident's blood sugar patterns and results, which is crucial for managing diabetes effectively.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received intravenous antibiotic medications as prescribed by the physician. The resident, who was admitted with multiple serious diagnoses including encephalopathy, sepsis, and MRSA, did not receive the prescribed IV antibiotics upon admission. The resident's medical records indicated that the antibiotics were to be administered daily, but the facility did not have the medications available until the day after the resident was admitted. This delay in treatment occurred despite the facility's policy that medications should be administered within one hour of their prescribed time. Interviews with the Registered Nurse Supervisor, Director of Nursing, and Administrator revealed that the facility did not receive the IV medications from the pharmacy in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics. The facility's policy on administering medications was not followed, leading to a delay in the resident's treatment and placing the resident's health and safety at risk.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of abuse to outside agencies within the timeframe specified by the facility's policy and federal regulations. Resident 1, who had diagnoses including heart failure, major depressive disorder, schizophrenia, and monoplegia of the upper limb, reported being hit by another resident on February 10, 2024. The incident was reported to a Licensed Vocational Nurse (LVN 1), who assessed the resident and sent her to the emergency room based on the physician's recommendation. However, the LVN did not inform the facility's abuse prevention coordinator or other relevant authorities about the incident immediately, as required by the facility's policy and federal regulations. The Social Worker (SW 1) confirmed that the incident was not reported to outside agencies until February 12, 2024, two days after the facility staff was made aware of the allegation. The delay occurred because the incident happened over the weekend, and the staff responsible for reporting and investigating abuse incidents were not present. The Director of Staff Development (DSD) acknowledged that the incident should have been reported immediately but cited miscommunication as the cause of the delay. A review of the facility's policies indicated that any suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The LVN involved stated she was unaware of the process for reporting abuse on weekends, which contributed to the delay in reporting the incident involving Resident 1.
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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