Laurel Park Behavioral Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 1425 Laurel Avenue, Pomona, California 91768
- CMS Provider Number
- 05A137
- Inspections on file
- 44
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Laurel Park Behavioral Health Center during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
A resident with a history of paranoid schizophrenia and another resident, both cognitively intact and independent, were involved in an incident where one shoved the other in the hallway after a disagreement. Staff and care records indicated a known history of boundary issues between the two, and the facility's policy defined such physical contact as abuse. The event was reported and confirmed by staff interviews, resulting in a deficiency for not protecting residents from physical abuse.
A resident in an LTC facility did not receive orthostatic blood pressure monitoring as ordered by the physician. The resident, with diagnoses including schizophrenia and major depressive disorder, was on antipsychotic medications requiring monitoring for hypotension. On a specified date, only two blood pressure readings were taken, and they were in the wrong sequence, with no standing reading recorded. This was confirmed by interviews with an LVN and the DON, who acknowledged the failure to follow the physician's order.
The facility failed to obtain informed consents for two residents regarding antipsychotic medications. One resident's consent for Clozapine lacked frequency details, while another resident's consent for an increased Olanzapine dose was missing. Staff acknowledged these oversights, which violated facility policies requiring informed consent before administering such medications.
The facility failed to develop and implement individualized care plans for two residents, leading to unmet needs. One resident refused to use a recommended walker after falls, and the facility did not create a care plan to address this refusal. Another resident required supervision during smoking breaks, but no care plan was documented to ensure safety interventions. These deficiencies resulted in unmet needs and potential negative impacts on the residents' well-being.
The facility failed to follow physician orders and medication management policies for two residents. One resident did not have orthostatic blood pressure monitored as ordered, and another missed doses of Propranolol due to a failure to reorder the medication in a timely manner. These deficiencies were due to lapses in following established procedures for physician orders and medication management.
The facility failed to properly dispose of expired medications for three residents, as expired antibiotics were found in the medication cart during an inspection. The medications, including Sulfamethoxazole-Trimethoprim and Amoxicillin, were not disposed of until after their expiration dates, contrary to the facility's policy. This oversight was confirmed through the Medication Disposition Record and staff interviews, highlighting a lapse in procedure adherence.
A facility failed to accurately document a resident's assessment, leading to a discrepancy in the resident's ability to hear and communicate. The resident was incorrectly noted as nonverbal and deaf, despite being able to communicate verbally. This error was due to a mix-up by an NP, potentially affecting the resident's care plan.
A resident with schizophrenia and substance abuse issues experienced a fall, but the facility failed to update the care plan with new interventions as required by policy. Staff interviews confirmed the oversight, which could impact the resident's well-being.
A facility failed to ensure a CNA completed the required annual skills training, which is necessary for maintaining competencies in resident care. The CNA was hired and completed initial training in 2023 but lacked documentation of skills training in 2024. Despite this, the CNA continued to provide direct patient care, as confirmed by timecards and assignment sheets. The Director of Staff Development acknowledged the oversight, noting that the CNA should not have been caring for residents without updated training, contrary to the facility's policy requiring annual in-service training.
The facility did not have a full-time DON, with the role temporarily filled by multiple RNs. The Administrator confirmed the absence of a DON, and an RN highlighted the importance of having a DON for proper oversight of resident care. An employment letter indicated a future start date for a new DON, while facility policy required a full-time DON to oversee nursing standards.
A facility failed to monitor the use of haloperidol for a resident with schizoaffective disorder and anxiety. The PRN order for haloperidol lacked an end date, contrary to the facility's policy of limiting such orders to 14 days. The resident's anxiety behaviors and potential side effects of the medication were not monitored, as required by the facility's policy.
The facility failed to label a bowl of cottage cheese in the kitchen refrigerator with the date of preparation and expiration, violating their food storage policy. This oversight was discovered during a kitchen tour, where a staff member confirmed the labeling requirement. The unlabeled food could potentially lead to foodborne illness if consumed.
The facility did not have an employed Director of Nursing (DON) present at the Quality Assurance Performance Improvement (QAPI) meetings, as required by their policy. The absence of a DON, who oversees nursing services and direct patient care, was confirmed by the Administrator during a review of meeting attendance records.
Two residents were involved in a physical altercation where one punched the other, leading to a retaliatory push. Both residents have mental health diagnoses and were generally calm before the incident. The facility's policy on preventing abuse was not effectively implemented, resulting in the altercation.
The facility failed to meet the minimum space requirements for 15 out of 19 resident rooms, with nine rooms housing two residents each and seven rooms housing three residents each, all below the required 80 square feet per resident. Despite a waiver request indicating adequate space, surveyors noted potential impacts on care provision. Observations showed rooms were uncluttered, and a CNA confirmed sufficient space for care duties.
Two residents were involved in a physical altercation after one elbowed the other, leading to retaliation and a bloody nose. Staff witnessed the incident but did not immediately separate the residents, contrary to the facility's abuse prevention policy. The residents involved had histories of mental health issues, and the incident occurred during a period of agitation for one of them.
The facility failed to appoint a full-time DON after the previous DON resigned, leaving the facility without proper oversight for nursing care in September and October 2024. Interviews and record reviews confirmed the absence of a DON, with staff emphasizing the importance of this role for smooth operations and resident safety. The Acting DON, an LVN, primarily served as an infection control nurse, not fulfilling the DON responsibilities.
A resident was physically assaulted by another in the dining room, resulting in a skin tear and scratch. The incident occurred after one resident accused the other of taking an apple, leading to multiple punches. The assaulted resident had moderate cognitive abilities and was independent in daily activities, while the aggressor had schizophrenia and drug-induced akathisia.
A resident with schizophrenia reported feeling unsafe after another resident placed their hand on his crotch without consent. Both residents were assessed to have intact cognitive status, but the incident was classified as sexual abuse by facility staff. The facility's policies emphasize the right of residents to be free from abuse, which was violated in this case.
A resident in an LTC facility was physically abused by another resident, who intentionally hit them on the arm, knocking a drink from their hand. Both residents had schizophrenia, with the aggressor also having moderate cognitive impairment and a history of physical behavioral symptoms. The facility's policies prohibit such abuse, but the incident was not prevented, resulting in a deficiency.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours on one day, as required by their policy. This was confirmed during a review of the nurse staffing sign-in sheet and interviews with the Administrator and Director of Staff Development (DSD). The absence of an RN on duty was acknowledged as a failure to meet the facility's policy, which mandates RN coverage for at least eight hours every day.
The facility failed to prevent physical and verbal abuse when one resident hit another on the head and verbally abused her. Despite being aware of ongoing tension and previous verbal altercations between the two residents, the facility's measures to keep them apart were insufficient, leading to the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident shoved another in the hallway. Resident 1, who had a diagnosis of paranoid schizophrenia but was cognitively intact and independent in self-care and mobility, reported being shoved by another resident (Resident 2) during a conversation about arcade games. Resident 2, also cognitively intact and independent, admitted to shoving Resident 1 in the chest after becoming upset. Both residents had a documented history of boundary issues and previous play fighting. The incident was reported to staff, and interviews confirmed that the shove was deliberate and caused distress to Resident 1. Facility records, including care plans and interdisciplinary notes, indicated awareness of ongoing boundary issues between the two residents. Staff interviews revealed that the facility's policy defines such physical contact as abuse, regardless of intent to harm. The facility's abuse prohibition policy was reviewed, which states that any willful infliction of injury or physical contact such as hitting or shoving constitutes abuse. The incident was recognized by staff and administration as a violation of this policy, resulting in a deficiency for failing to ensure residents were free from physical abuse.
Failure to Monitor Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and general anxiety, was prescribed antipsychotic medications that required monitoring for side effects related to hypotension. The physician's order specified that orthostatic blood pressure readings should be taken in three positions: lying, sitting, and standing, to monitor for orthostatic hypotension. On January 15, 2025, the facility did not perform the orthostatic blood pressure monitoring as ordered. The records showed that only two blood pressure readings were taken, and they were done in the wrong sequence. The sitting blood pressure was recorded at 10:30 a.m., followed by the lying blood pressure at 10:33 a.m., with no standing blood pressure reading taken within minutes of the other two. This failure to follow the physician's order was confirmed during interviews with the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the resident was not monitored for orthostatic hypotension as required. The facility's policy and procedure documents indicated that all physician orders should be complete and accurate, and that treatment orders should include a description of the treatment, frequency, and duration. Despite these guidelines, the facility did not adhere to the physician's order for orthostatic blood pressure monitoring, which could have potentially resulted in adverse effects for the resident, such as hypotension, dizziness, and falls.
Failure to Obtain Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain informed consents for two residents, Resident 7 and Resident 18, regarding the administration of antipsychotic medications. For Resident 7, the informed consent for Clozapine did not include the frequency of administration, which is a required element. The Licensed Psychiatric Technician (LPT) and Registered Nurse (RN) involved acknowledged that the informed consent was incomplete and should have included all necessary information, such as medication, dosage, frequency, diagnosis, and manifestation. This oversight was identified during a review of the resident's Medication Administration Record and informed consent documentation. For Resident 18, the facility did not obtain informed consent before increasing the dose of Olanzapine from 25 mg to 30 mg. The resident's cognition was intact, and they were independent with activities of daily living. Despite this, the required informed consent for the dosage increase was not found in the records. The RN and Health Information Manager (HIM) confirmed that the informed consent was likely not obtained, as it could not be located during the review. The facility's policies and procedures require that informed consent be obtained and verified by a licensed nurse before administering antipsychotic or psychotropic medications. These deficiencies indicate a failure to adhere to the facility's guidelines for informed consent, which are intended to ensure that residents or their conservators are fully informed about the treatments they receive, including the risks, benefits, and alternatives.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. For Resident 17, the facility did not timely develop a care plan to address the resident's refusal to use a front wheel walker (FWW) after experiencing several falls. Despite a physical therapy evaluation recommending the use of a walker as a fall prevention measure, the resident refused to use it, citing feelings of aging. The facility did not create a care plan to address this refusal, which could have helped in developing strategies to mitigate fall risks while respecting the resident's autonomy. For Resident 24, the facility did not implement a care plan to address the need for supervision during smoking breaks, as required by the facility's policy. The resident's smoking evaluation indicated a need for supervision due to an inability to light a cigarette independently. However, there was no smoking care plan documented in the resident's medical record. This lack of a care plan meant that necessary interventions for the resident's safety, such as proper handling of cigarettes and compliance with smoking policies, were not ensured. The facility's policies require that individualized comprehensive care plans be developed for each resident, including measurable objectives and timetables to meet their medical, physical, mental, and psychosocial needs. The failure to develop and implement these care plans for Residents 17 and 24 resulted in unmet individualized needs and had the potential to negatively affect their physical and psychosocial well-being.
Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, Resident 24 and Resident 39, as per the physician's orders and facility policies. For Resident 24, the facility did not follow the physician's order to monitor orthostatic blood pressure (OBP) from February 2024 to December 2024. Despite the order being active since March 2023, the facility's records did not indicate any OBP measurements were taken during this period. Interviews with Registered Nurses (RN) confirmed that the OBPs were not carried out as required, and there was no documentation to suggest otherwise. The failure to follow the physician's order was acknowledged by the nursing staff, who emphasized the importance of adhering to such orders to ensure patient safety and correct treatment. For Resident 39, the facility failed to reorder Propranolol, a medication used to treat severe restlessness and agitation, resulting in the resident missing five doses. The Medication Administration Record (MAR) indicated that the medication was unavailable on several occasions in December 2024. Interviews with nursing staff revealed that the medication should have been reordered when it was first identified as unavailable on December 13, 2024. However, there was no documentation to confirm when the medication was reordered, and the pharmacy records showed that the refill request was only made on December 17, 2024. The lack of timely reordering and documentation was noted as a significant issue by the nursing staff, who highlighted the importance of maintaining an adequate medication supply and proper documentation to ensure effective communication and resident care. The facility's policies and procedures for physician orders and medication management were not followed, leading to these deficiencies. The policy for physician orders required complete and accurate documentation, which was not adhered to in the case of Resident 24. Similarly, the policy for medication ordering and receiving from the pharmacy required medications to be reordered five days in advance, which was not followed for Resident 39. These lapses in following established procedures resulted in incorrect treatment and had the potential to impact the residents' physical and mental well-being.
Failure to Properly Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications for three residents, as per their Policy and Procedure on Disposal of Medications and Medication-Related Supplies. During a medication cart inspection, three blister packs of expired antibiotics were found, which included Sulfamethoxazole-Trimethoprim for one resident and Amoxicillin for two other residents. These medications had expiration dates ranging from December 2, 2024, to December 16, 2024, but were not disposed of until December 18, 2024. This oversight had the potential to result in the accidental use of ineffective medications, posing a risk of bacterial growth and physical decline for the residents involved. The facility's Medication Disposition Record/Pass Log confirmed the expiration and delayed disposal of these medications. Interviews with the registered nurse and licensed psychiatric technician revealed that expired medications were supposed to be recorded in a log and disposed of in a locked bin, separate from current medications. However, the expired medications were found in the medication cart, indicating a lapse in following the facility's procedures. The facility's policy stated that discontinued medications should be destroyed within 90 days, but this was not adhered to in this instance.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in the assessment entry of a resident's History and Physical (H&P) exam, which led to a discrepancy in the resident's ability to hear and communicate. The resident, who was admitted with diagnoses including schizophrenia, moderate intellectual disabilities, and chronic obstructive pulmonary disease, was incorrectly documented as nonverbal, deaf, and using sign language. This error was identified during a review of the resident's Minimum Data Set (MDS), which indicated the resident had adequate hearing and clear speech, and was independent in activities of daily living and mobility. An observation confirmed the resident was able to verbally communicate without difficulty. The error was attributed to Nurse Practitioner 1, who admitted to mixing up the resident's information with another patient during documentation. The facility's policy and procedure guidelines emphasize the importance of concise, accurate, and complete charting and documentation. The inaccurate assessment had the potential to negatively affect the resident's plan of care and delivery of necessary services, as it provided the foundation for proper diagnosis and treatment. Interviews with facility staff highlighted the critical nature of accurate assessments in ensuring appropriate care and avoiding potentially harmful consequences.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for Resident 36 after the resident experienced a fall on October 30, 2024. Resident 36, who was admitted on March 26, 2024, with diagnoses including schizophrenia and psychoactive substance abuse, had a care plan initiated on May 3, 2024, for being at risk for falls. The care plan included interventions such as obtaining orthostatic blood pressure and providing verbal cues for safety. However, after the fall on October 30, 2024, the care plan was not updated to include new interventions, despite the facility's policy requiring such updates after a fall. Interviews with staff, including a Licensed Psychiatric Technician and a Registered Nurse, confirmed that the care plan was not revised following the fall. The staff acknowledged that care plans should be updated after each fall to address specific risk factors and prevent future incidents. The facility's policies on care plan comprehensive and fall management also indicated that care plans should be reviewed and revised when there is a significant change in a resident's condition, such as a fall. The failure to update the care plan had the potential to result in unmet individualized needs for Resident 36 and affect the resident's physical and psychosocial well-being.
Failure to Ensure Annual Skills Training for CNA
Penalty
Summary
The facility failed to ensure that one of four Certified Nursing Assistants (CNA 3) had completed the required annual skills training, which is necessary to maintain competencies for safe resident care. CNA 3 was hired on 5/2/2023 and completed initial trainings on 5/2/2023, 5/3/2023, and 5/5/2023. However, there was no documentation indicating that CNA 3 completed any skills training in 2024. Despite this, CNA 3 continued to provide direct patient care, as evidenced by timecards and assignment sheets showing work on 12/7/2024 and 12/8/2024. The Director of Staff Development acknowledged the lack of updated skills training and stated that CNA 3 should not have been caring for residents without it. The facility's policy requires all staff to participate in initial orientation and annual in-service training, which was not adhered to in this case.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a full-time Director of Nursing (DON) was employed, which is a requirement for proper oversight of nursing practices. During an interview, the Administrator confirmed that the facility currently had no DON, and the role was being filled by multiple Registered Nurses (RNs). This was corroborated by an interview with an RN who emphasized the importance of having a DON onsite due to their greater knowledge, training, and experience in handling resident treatments and medications. A review of the facility's employment letter indicated that a full-time DON position was offered and accepted, with a start date set for a future date. The facility's policy and procedure document stated that the DON should be employed full-time and responsible for overseeing nursing practice standards.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychotropic medication, specifically haloperidol, for one resident. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar type, and anxiety disorder, was prescribed haloperidol on a PRN basis for anxiety. However, the facility did not adhere to its policy of limiting PRN orders for psychotropic drugs to 14 days. The medication administration record lacked an end date for the haloperidol order, which could lead to its administration beyond the intended period. Additionally, the facility did not monitor the resident's anxious behaviors or the side effects of haloperidol, as required by their policy. Interviews with nursing staff revealed that the resident's anxiety manifested through pacing, fidgeting, and verbalization of anxiety, but these behaviors were not documented or monitored. The staff acknowledged that the order should have included the manifestation of anxiety and the duration of the order to ensure proper understanding and management of the resident's condition. The facility's policy required monitoring for efficacy, risks, benefits, and adverse consequences of psychotropic medications, but this was not done for the resident in question.
Failure to Label Food in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling of food items in the kitchen, which is a violation of their food storage policy. During a kitchen tour, a Styrofoam bowl wrapped in plastic was found in the reach-in refrigerator without a date label. The bowl contained a white substance, later identified as cottage cheese, intended for a resident's breakfast. However, the resident did not consume it. The staff member acknowledged that all food in the refrigerator should be labeled with the name of the item, the date of preparation, and the date of expiration. The facility's policy, titled Healthcare Services Group (HCSG) Policy 019: Food Storage - Cold Foods, mandates that all Time/Temperature Control for Safety (TCS) foods must be stored in accordance with the U.S. Food and Drug Administration (FDA) Food Code. This includes being wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination. The failure to label the bowl with the date of preparation and expiration could potentially lead to foodborne illness if consumed, as stated by the staff member.
Lack of Director of Nursing in QAPI Meetings
Penalty
Summary
The facility failed to have all required members of the Quality Assessment and Assurance committee present, specifically lacking an employed Director of Nursing (DON). During a review of the Quality Assurance Performance Improvement (QAPI) Meeting attendance records for meetings held on 9/20/2024 and 10/24/2024, it was found that the DON was not present. The Administrator confirmed that the facility did not have a DON employed at the time, which is crucial as the DON oversees nursing services and the direct care provided to patients. The facility's policy and procedure document, revised in March 2020, specifies that the Director of Nursing Services is a required member of the committee.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect two residents, Resident 2 and Resident 15, from physical abuse, as outlined in their Abuse Prohibition Policy and Procedure. On December 11, 2024, an altercation occurred between the two residents, where Resident 2 punched Resident 15 in the chest after being called a name, and Resident 15 retaliated by pushing Resident 2 to the ground. This incident was documented in Resident 2's progress notes and was reported in the Confidential Adverse Incident Initial Reporting Form. Resident 2, who has a history of schizophrenia, moderate intellectual disabilities, and chronic obstructive pulmonary disease, was admitted to the facility in 2011 and readmitted in 2014. The Minimum Data Set (MDS) for Resident 2 indicated that their cognition was moderately intact, and they were independent in activities of daily living and mobility. Resident 15, admitted in 2020, has diagnoses including schizoaffective disorder, hypertension, and anemia, with their MDS also indicating moderately intact cognition and independence in daily activities and mobility. Interviews with staff and residents revealed that the altercation was not witnessed from the beginning, but CNA 1 and Resident 8 provided accounts of the incident. CNA 1 noted that neither resident showed signs of aggression prior to the altercation, and both residents were generally calm. The facility's policy emphasizes the need for adequate supervision to prevent resident-to-resident altercations, which was not effectively implemented in this case, leading to the physical abuse incident.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 15 out of 19 resident rooms met the minimum requirement of 80 square feet per resident in rooms with more than one resident. Specifically, nine rooms housed two residents each, and seven rooms housed three residents each, all of which were below the required space per resident. This deficiency was identified through a review of the facility's Client Accommodation Analysis (CAA) and was confirmed during an observation and walk-through of the facility. The rooms in question were found to be uncluttered, and residents were able to move freely without expressing concerns about the room sizes. Despite the facility's room waiver request letter indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy, the surveyors noted the potential for insufficient space to impact the ability of nursing staff to provide resident hygiene care and for residents to reside comfortably. During an interview, a Certified Nursing Assistant (CNA) stated that there was enough space in each resident's room to perform care duties, such as helping residents and changing bed sheets. However, the facility's failure to meet the minimum space requirements for resident rooms was documented as a deficiency.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in an altercation between them. Resident 1, who has a history of schizophrenia, autism, and hypertension, was involved in an incident where they elbowed Resident 2, who has paranoid schizophrenia and other conditions. This led to Resident 2 retaliating by hitting Resident 1, causing a bloody nose and pain rated 5 out of 10. The incident was witnessed by staff, but they did not immediately separate the residents, which could have prevented the escalation. Resident 1's cognitive status was moderately impaired, and they exhibited behaviors such as hallucinations and delusions. On the day of the incident, Resident 1 was reportedly agitated and had a history of striking out when frustrated. Resident 2, whose cognitive status was intact, reacted to being elbowed by Resident 1 by hitting them back. Interviews with staff and residents confirmed the sequence of events, and it was noted that Resident 1 had been cycling through a period of agitation. The facility's policy on abuse prevention requires staff to immediately separate residents upon witnessing abuse to ensure their safety. However, in this case, the staff did not act quickly enough to prevent the physical altercation. The facility's administrator acknowledged that staff should have redirected Resident 1 and separated the residents to prevent the incident from escalating. The deficiency highlights a failure to adhere to the facility's abuse prevention policy, resulting in harm to Resident 1.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as a full-time Director of Nursing (DON) to oversee nursing service personnel for the months of September and October 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility had been without a DON since the resignation of the former Director of Nursing in May 2024. The facility's RN schedules for September and October 2024 did not indicate the presence of a DON, although several RNs were scheduled to work. Interviews with staff, including a Licensed Psychiatric Technician and an RN, confirmed the absence of a DON and highlighted the importance of having a DON for smooth operations, resident assessments, and staff oversight. The Acting Director of Nursing, who was a Licensed Vocational Nurse, primarily served as an infection control nurse and did not fulfill the role of a DON. The facility's policy and procedure indicated that the nursing services department should be under the direct supervision of a registered nurse employed full-time, which was not adhered to, leaving the facility without proper clinical oversight for resident care.
Resident Assault in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in an incident where one resident was physically assaulted by another. On 9/12/24, Resident 1 was hit by Resident 2, leading to a skin tear on the left hand and a scratch on the right lower leg of Resident 1. The incident occurred in the dining room after dinner, where Resident 2 accused Resident 1 of taking an apple from Resident 2's drawer and subsequently punched Resident 1 multiple times. Resident 1, who was admitted to the facility with a history of myopia and COVID-19, was found to have moderate cognitive abilities and was independent in all activities of daily living. Resident 2, who was admitted with schizophrenia and drug-induced akathisia, was involved in the altercation. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The policy specifies that physical abuse includes actions such as hitting and slapping. During interviews, Resident 1 confirmed the details of the incident, showing the surveyor the injuries sustained, while Resident 2 admitted to hitting Resident 1 but did not provide further details. The facility's failure to prevent this altercation highlights a deficiency in protecting residents from physical abuse.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who has multiple diagnoses including schizophrenia and hypothyroidism, reported feeling unsafe after Resident 2 placed Resident 1's hand on Resident 2's crotch without consent. Resident 1's medical records indicated a history of hallucinations and delusions, and the resident expressed feeling bad and unsafe following the incident. Resident 2, who also has a diagnosis of schizophrenia, was reported to have engaged in non-consensual acts with Resident 1. According to the facility's records, Resident 2 admitted to placing Resident 1's hand on his groin and acknowledged that the act was not consensual. Both residents were assessed to have intact cognitive status, but Resident 1 reported feeling threatened and unsafe around Resident 2. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that the incident was classified as sexual abuse. The facility's policies and procedures clearly state that residents have the right to be free from abuse, and the incident violated these rights. The facility's Abuse Prohibition Policy emphasizes the importance of providing a safe and secure environment for all residents, which was not upheld in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident hit another on the arm. The incident involved two residents, both with schizophrenia and other diagnoses. The resident who was hit had no cognitive impairments and was independent in daily activities, while the resident who hit was moderately impaired in cognitive skills and exhibited physical behavioral symptoms. The incident occurred when the two residents were walking past each other, and one resident intentionally hit the other, knocking a drink from their hand. The facility's policies and procedures prohibit abuse, including physical abuse such as hitting or slapping. Despite this, the incident was not prevented, and the resident experienced physical aggression from a peer. Interviews and record reviews confirmed that the resident who hit admitted to doing so intentionally after being bumped into. The facility's documentation, including progress notes and care plans, reflected the occurrence of the physical aggression, but the facility failed to prevent the abuse as required by their policies.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours on one day, specifically on 4/29/2024. This deficiency was identified during an interview and record review conducted on 5/9/2024 with the Administrator and the Director of Staff Development (DSD). The nurse staffing sign-in sheet for 4/29/2024 confirmed the absence of an RN on duty for the required duration. Both the Administrator and the DSD acknowledged the importance of having an RN on duty to oversee the safety and care of residents, as well as to conduct resident assessments and care. The facility's policy and procedure, revised in August 2022, mandates that an RN must provide services for at least eight consecutive hours every 24 hours, seven days a week.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from physical and verbal abuse when Resident 2 hit the back of Resident 1's head and verbally abused her. Both residents had a history of verbal altercations, and the facility staff were aware of the tension between them. Despite this knowledge, the facility's measures to keep the residents apart were insufficient, leading to the incident where Resident 2 physically and verbally abused Resident 1. Resident 1 was admitted to the facility with multiple diagnoses, including schizophrenia and psychoactive substance dependence, and was cognitively intact and independent in daily activities. Resident 2, who also had schizophrenia and diabetes, was similarly cognitively intact and independent. On the day of the incident, Resident 2 admitted to intentionally hitting Resident 1 and throwing water at her due to ongoing verbal provocations from Resident 1. Interviews with various staff members, including the Primary Counselor, Licensed Vocational Nurse, Administrator/Abuse Coordinator, Director of Nursing, and a Certified Nurse Assistant, revealed that the facility was aware of the ongoing tension and had instructed staff to monitor and separate the residents. However, these measures were not effectively implemented, resulting in the physical and verbal abuse of Resident 1 by Resident 2. The facility's policies and procedures on abuse prohibition and resident rights were not adequately followed to prevent this incident.
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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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