Long Beach Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 2615 Grand Avenue, Long Beach, California 90815
- CMS Provider Number
- 056188
- Inspections on file
- 35
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Long Beach Care Center, Inc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and multiple comorbidities, including metabolic encephalopathy, COPD, and type 2 DM, was punched in the face by another cognitively intact resident, causing lip lacerations and abrasions that required first aid and hospital evaluation. A CNA reported seeing the victim waving his hands toward the other resident in the dining room, briefly looking away, and then observing the other resident punch him, after which staff separated and supervised both residents. The resident who struck the other admitted he hit the victim after being startled and stated he did not know why he did it, while the DON confirmed that the facility’s investigation substantiated that one resident hit another despite a policy stating residents must be free from abuse by anyone, including other residents.
A resident with intact cognition and mental health diagnoses was not consistently involved in IDT care conferences or in the development and implementation of her person-centered care plan. Assessment records showed it was very important to her to participate in discussions about her care, and she was documented as capable of making medical decisions. She reported not always being informed when IDT meetings occurred and expressed a desire to participate. Review of records showed one IDT meeting was not rescheduled after she requested postponement due to not feeling well, and the next meeting months later lacked documentation of her participation, despite facility policy and resident rights documents requiring resident involvement in care planning.
A resident with mental health diagnoses and intact cognition reported that several 2025 consultation notes were missing from her medical record after being informed of this by her physician. Review of the chart with the Medical Records Director confirmed that orthopedic and neurology consultant reports had not been placed in or uploaded to the record, despite facility policy requiring complete, accurate, and up-to-date medical records reflecting all care and services. The DON also acknowledged that consultant notes are expected to be included in the resident’s medical record.
A resident with severe cognitive impairment and psychiatric diagnoses kicked another cognitively impaired resident out of bed, then threw a water pitcher and a urine-filled urinal onto the resident, soaking the resident’s face and chest. A CNA witnessed the assault, attempted to intervene but was pushed away, and called for help while the aggressor continued the behavior. Nursing notes documented swelling and redness to the victim’s head, legs, and chest, and ED records later confirmed a left maxillofacial contusion. An LVN found the victim on a fall mattress with fluids on the floor and the aggressor pacing and stating he had beaten the other resident. The DON acknowledged this as physical abuse and stated staff should have separated the residents after the first kick.
A resident with morbid obesity, osteoarthritis, intact cognition, and a documented fall risk slipped on a wet bathroom floor while getting up from the toilet, fell onto the right arm and shoulder, and immediately reported severe shoulder pain. Nursing notes and an LVN confirmed the bathroom floor was wet, and the resident had to scoot to the door to call for help. Over the following months, the resident continued to report frequent severe right shoulder pain and inability to raise the arm. An orthopedic consult and MRI later confirmed a full thickness supraspinatus tendon tear with retraction and associated bursal fluid. Facility policies required a hazard‑free environment and fall prevention, but housekeeping staff only cleaned rooms during daytime hours and janitorial staff did not routinely check resident rooms unless notified, allowing the wet bathroom floor to remain unaddressed.
A resident with a history of aggressive behavior and a care plan requiring one-to-one monitoring was not assigned dedicated supervision. As a result, this resident physically assaulted another resident on the smoking patio. Staff interviews confirmed that the required one-to-one monitoring assignment was missed, leading to the incident.
A resident with schizophrenia and a history of aggressive behaviors was not provided the one-to-one monitoring specified in their care plan. As a result, the resident was able to punch another resident while on the smoking patio, as the only staff present was not assigned as a one-to-one monitor. Staff interviews confirmed the monitoring assignment was missed, leading to the incident.
Facility staff did not notify a physician when a resident missed a scheduled dose of Heparin for DVT prophylaxis and also failed to inform the physician when the resident was not transferred to a hospital as ordered. The missed medication was only discovered after the resident reported it, and the physician was not informed until days later. Additionally, the resident's decision to delay transfer was not communicated to the physician in a timely manner, contrary to facility policy.
A resident with intact cognition and dependent on staff for mobility was physically attacked in his room by another resident with schizophrenia and impaired cognition. The aggressor entered the room, yelled accusations, and struck the resident multiple times with a plastic water pitcher and fists, causing an abrasion and multiple areas of redness that required immediate first aid. Staff and another resident witnessed the incident, and documentation confirmed the injuries and sequence of events.
Staff did not report a resident's allegation of sexual abuse to the state agency as required. A resident with cognitive impairment accused another resident of rape in front of staff, but the CNA omitted this from her report, assuming the RN would handle it. The RN informed the DON, who failed to include the allegation in the report to CDPH. The Administrator was unaware of the allegation and stated it should have been reported.
A resident with cognitive impairment and psychiatric diagnoses accused another resident of rape during a physical altercation, witnessed by staff and another resident. Although the DON was aware of the allegation, no formal investigation or documentation was completed, contrary to facility policy requiring immediate and thorough investigation of abuse allegations.
A resident with recent fractures and immobility did not receive a scheduled dose of Heparin for DVT prophylaxis because an LVN failed to administer the medication while the resident was at physical therapy and then incorrectly documented that it had been given. The omission was discovered after the resident reported swelling and missing the dose, leading to hospital transfer and diagnosis of extensive acute DVTs.
A nurse documented the administration of a Heparin injection to a resident when the medication had not actually been given, and later made further inaccurate edits to the medical record. The error was discovered after the resident reported not receiving the dose, and another nurse confirmed the omission. Facility policy required that the MAR be signed only after medication administration, but this was not followed, resulting in inaccurate medication records.
A resident with severe cognitive impairment was physically assaulted by another resident after a dispute over personal belongings, resulting in facial injury. Staff failed to intervene during the altercation and did not adequately assess the injured resident during rounds, as confirmed by CNA, LVN, and DON interviews. Facility policy requires protection from abuse by anyone, including other residents.
A resident with schizoaffective disorder and psychosis was denied readmission after a hospital transfer for a behavioral incident, without the facility conducting required assessments or reviewing updated care needs. The DON and interdisciplinary team made the decision without documentation or consultation of hospital records, contrary to facility policy.
A resident with severe cognitive impairment and mental health diagnoses was physically assaulted by another resident, but the facility failed to update the care plan to address physical abuse or resident-to-resident altercations. The care plan only included interventions for the physical injury, not for the abuse event itself, despite facility policy requiring comprehensive care planning.
The facility did not transmit required MDS assessments for all residents in Medicare/Medicaid-certified beds to CMS for over a year, resulting in outdated assessments and care plans. The issue was discovered after notification from the state health department, and both the MDS coordinator and DON confirmed the lapse in timely submission and validation of resident data.
A resident with polyneuropathy and anxiety disorder, requiring significant assistance and exhibiting moderate cognitive impairment, did not receive a timely neurology consult as ordered by the physician. The Social Services staff responsible for coordinating appointments was unaware of the order until informed by the resident, and there was no documentation of appointment scheduling or follow-up, resulting in a delay of care.
A resident was physically assaulted by another resident following a verbal argument in the patio area, which was witnessed by a CNA and an LVN who failed to intervene. The victim, with a history of aggressive behavior and cognitive impairment, sustained significant injuries requiring hospital treatment. The assailant, also with mental health issues, was not adequately supervised, leading to the incident.
A resident with Alzheimer's and dementia became agitated and physically aggressive when CNAs continued personal care despite her refusal. The resident, requiring substantial assistance, kicked a CNA during an attempt to change her adult brief. Staff interviews revealed that the CNAs did not honor the resident's refusal, escalating the situation and potentially violating her rights.
A resident with hemiplegia and hemiparesis required two-person assistance for transfers, as per their care plan. However, a CNA attempted to transfer the resident alone, resulting in the resident's leg getting caught in the wheelchair wheels and sustaining a laceration requiring sutures. The facility's policy on safe transfers was not followed, leading to the injury.
The facility failed to maintain the privacy and dignity of two residents during ADLs by not closing the privacy curtain, leaving them exposed to others. Both residents had severe cognitive impairments and required assistance. Interviews with CNAs and an LVN confirmed the need for privacy, aligning with the facility's policy on resident privacy.
A resident assessed as high-risk for wandering eloped from the facility due to inadequate supervision and monitoring. The resident's care plan, which required constant observation and monitoring for wandering, was not effectively implemented. Staff failed to respond to the entrance/exit door alarm, and the resident's wander guard was found broken. The resident, with a history of schizophrenia and hypertension, was found days later in a neighborhood, having missed their medication.
The facility failed to label and date food items in storage, risking foodborne illness due to potential spoilage. Additionally, the dishwasher's sanitizing chemical levels were insufficient, risking contamination of dishes and utensils. These deficiencies were confirmed through observations and staff interviews, highlighting non-compliance with facility policies.
A facility failed to maintain Refrigerator #1, leading to a pool of water at the bottom, observed during the defrosting of meats. Staff reported the issue had persisted for two weeks, with maintenance notified but not yet resolved. The Regional Dietary Manager had informed the Administrator, who was responsible for follow-up, but a technician was delayed in addressing the problem.
A facility failed to treat three residents with dignity and respect. Two residents experienced delays in call light responses, despite staff being aware of the signals. Another resident was fed by a CNA who did not maintain eye level, contrary to facility policy. These actions violated the residents' rights and facility policies on timely call light response and promoting dignity.
The facility failed to complete PASRR Level II evaluations for three residents, despite indications from PASRR Level I assessments. These evaluations are essential for determining appropriate placement and specialized services for residents with mental illnesses or intellectual disabilities. The deficiency was confirmed by MDS nurses, who acknowledged the absence of necessary evaluations, which are crucial for providing specialized services.
A visually impaired resident's care plan was not properly implemented, as the call light was left out of reach, leading to potential risks. The resident, who preferred the call light on the wheelchair handrail, was not accommodated due to staff's lack of awareness of the visual impairment. The DON highlighted the necessity of adhering to care plans to ensure timely care.
The facility did not post daily nurse staffing information, as required, at the entrance or nurse's station. A RN and the Director of Staff Development confirmed the absence of this information, which should be posted at the start of each shift according to facility policy.
A facility failed to document the administration of controlled substances in real-time for four residents, leading to discrepancies in medication counts. The residents, with diagnoses such as anxiety disorder and schizophrenia, were prescribed Lorazepam and Alprazolam. An LVN admitted to not documenting the administration immediately, contrary to facility policy, which requires immediate recording in the MAR and Controlled Drug Record log. This oversight risked medication errors and potential harm.
The facility's dietary staff lacked competency in preparing fortified meals, as observed when a staff member incorrectly added tomato sauce for fortification. Interviews revealed misunderstandings about the purpose of fortified meals, with staff believing it was to make food easier to swallow. The Dietary Regional Manager confirmed no record of training for the staff on fortified meal preparation, despite job descriptions requiring knowledge of nutritional practices.
A facility failed to investigate a resident-to-resident altercation where one resident with severe cognitive impairment attempted to hit another resident with moderate cognitive impairment using a wheelchair. The incident was not reported to the Administrator as required by facility policy, leading to a lack of investigation and potential risk for further altercations.
A resident with vision loss was inaccurately assessed as having adequate vision due to insufficient evaluation by the MDS Nurse. The resident's admission assessment documented legal blindness, but the MDS assessment failed to reflect this, potentially delaying necessary care and services.
A resident with severe cognitive impairment and high fall risk was left unsupervised in a wheelchair, as the care plan lacked specific interventions for direct line of sight monitoring. Staff interviews confirmed the need for constant supervision, which was not reflected in the care plan, leading to a deficiency in care.
A resident receiving enteral feedings was not properly positioned, with the head of the bed lower than the required 35-45 degrees, leading to a potential risk of aspiration. Despite physician orders and care plan instructions, the nursing staff failed to frequently assess and ensure the resident's safe positioning during feedings. The CNA identified the issue but needed assistance from an LVN, who did not provide the necessary support, highlighting a deficiency in care.
The facility failed to obtain informed consent for psychotropic medications for several residents, including one with major depressive disorder and schizophrenia, another with severe cognitive impairment, and a third with schizoaffective disorder. In each case, the necessary signatures from physicians and responsible parties were missing, violating residents' rights and potentially leading to inappropriate medication use.
A resident was prescribed antibiotics without meeting the McGeer Criteria, as required by the facility's antibiotic stewardship program. The resident was readmitted with a urinary tract infection and prescribed Bactrim, despite the Antibiotic Use Tracking Sheet indicating the criteria were not met. The Infection Prevention Nurse and DON acknowledged the oversight, and the facility's policy mandates a review of antibiotic orders upon admission, which was not conducted.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, resulting in injury. One resident with moderately impaired cognition and medical conditions including metabolic encephalopathy, COPD, and type 2 DM was punched in the face by another resident. According to nursing progress notes, the incident occurred in the early evening when the injured resident reported that the other resident had come to his room, knocked on his door, and then punched him when he came out. The injured resident was observed with a moderate amount of bleeding and sustained a laceration to the right lower lip, an open area on the right inner lip, and an abrasion to the right upper lip. CNA 1 reported that she was in the dining room assisting residents with meals and observed the injured resident waving his hands toward the other resident, who was about six feet away, as the second resident entered the dining room. While scanning the room, CNA 1 briefly looked away, and when she looked back, she saw the second resident punch the first resident in the face, immediately causing visible bleeding from the lip. Staff then separated and supervised the residents. Subsequent observation showed the injured resident with a scab on the right side of his lower lip, and the resident confirmed that another resident had punched him, causing the cut and leading to his transfer to the hospital for evaluation. The resident who delivered the punch had intact cognition and diagnoses including metabolic encephalopathy, COPD, and type 2 DM. Nursing progress notes for this resident documented that he admitted to hitting the other resident, stating he had been startled and did not know why he hit him and did not intend to do so. The DON acknowledged that residents have the right to be free from physical abuse and that the facility’s investigation substantiated that one resident hit another. The facility’s abuse, neglect, and exploitation policy stated that each resident has the right to be free from abuse and that residents must not be subject to abuse by anyone, including other residents.
Failure to Involve Cognitively Intact Resident in IDT Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to involve a cognitively intact resident in Interdisciplinary Team (IDT) care conferences and the development and implementation of her person-centered plan of care. The resident, originally admitted in 2022 and readmitted in early 2023, had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder. Her MDS assessment indicated she understood others, was understood by others, had intact daily decision-making abilities, and that it was very important to her to participate in discussions about her care. A History and Physical documented that she was alert, oriented to person, place, time, and situation, and had the capacity to understand and make medical decisions. During an interview, the resident reported she was not always made aware when her IDT care conferences were being held and became tearful, stating she wanted to participate in these meetings about her care. Review of IDT conference records with the Infection Prevention Nurse showed that one scheduled IDT meeting was not rescheduled after the resident requested a postponement due to not feeling well, and the next meeting occurred three months later. Documentation for that later meeting contained no evidence of the resident’s participation. The Infection Prevention Nurse acknowledged that if residents request rescheduling, the meeting should be rescheduled and that residents need to be part of their IDT meetings. The DON stated residents or their representatives should always be part of IDT care conferences, and facility policies and resident rights documents confirmed that residents have the right to participate in the development and revision of their care plans and to be informed in advance of changes to the care plan.
Missing Consultant Reports in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records when consultation reports for one resident were missing from the resident’s chart. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, was originally admitted in 2022 and readmitted in early 2023. An MDS assessment indicated the resident had intact cognition and was able to understand and be understood by others. The resident reported that she had several consultation appointments in 2025 and that her physician informed her that the consultation notes were not present in her medical record. During a concurrent interview and record review with the Medical Records Director, it was confirmed that not all of the resident’s 2025 consultation reports were in the medical record and that they should have been placed in the chart or uploaded. The missing documents included orthopedic and neurology consultation notes, which the Medical Records Director stated should be available so physicians and staff could refer to them and have a clearer picture of the resident’s health. The DON also stated that consultant notes should be in the resident’s medical record. The facility’s undated policy titled “Accuracy of Medical Records” indicated that all medical records are to be complete, accurate, and updated to reflect care and services provided to each resident.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with encephalopathy, schizoaffective disorder, anxiety disorder, and severe cognitive impairment was originally admitted on 3/1/2025 and required set-up assistance with eating, oral hygiene, and personal hygiene. Another resident, admitted on 9/24/2025 with encephalopathy, heart failure, dementia, schizoaffective disorder, mood disorder, anxiety disorder, and severe cognitive impairment, required supervision with eating, partial assistance with oral hygiene, and substantial assistance with personal hygiene, showering, and toileting hygiene. Both residents had significant cognitive and functional impairments at the time of the incident. According to CNA 1’s written statement and interview, the aggressor resident was standing on the left side of the other resident’s bed while the victim was lying in bed. The aggressor kicked the resident on the left side of the body, then kicked again, causing the resident to roll off the bed and fall onto the floor mat on the right side. CNA 1 attempted to intervene but was pushed away by the aggressor and then called for help. During this time, the aggressor reached for and threw a water pitcher, with the pitcher and water landing on the resident’s face, and then grabbed and threw a urinal filled with urine, which landed on the resident’s chest. Nursing documentation on 1/26/2026 at 2:15 p.m. indicated the resident had been hit by another resident and presented with slight swelling of the left temporal area, redness on the left shin, right knee, and chest, and responded to name by saying yes or moaning. Emergency Department records later that evening documented a left maxillofacial contusion after being hit in the face. LVN 2 reported hearing calls for help, finding the victim resident on all fours on the fall mattress, the aggressor pacing and stating, “I beat him up,” and observing fluids (water and urine) on the floor and on the resident. The DON stated that residents have the right to be free from abuse, acknowledged that the aggressor physically abused the other resident, and stated that staff should have physically separated the residents after the first kick to prevent the subsequent kicks and the throwing of the water pitcher and urinal.
Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Shoulder Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment and prevent accidents when a resident’s bathroom floor was wet, leading to a slip and fall. The resident, who had morbid obesity and osteoarthritis, was cognitively intact and required supervision with toileting hygiene, with a documented fall risk and a care plan intervention to maintain a hazard‑free and safe environment. On the morning of 10/19/2025, the resident went to the bathroom, used the toilet, stood up, pulled up her pants, took a step forward, slipped on the wet bathroom floor, and fell, landing on her right arm and shoulder. Following the fall, nursing documentation recorded that the resident reported the floor was wet and that she lost her balance because of it, with right shoulder pain rated 8/10. An LVN who responded to the incident confirmed that the bathroom floor was wet, though not flooded, and acknowledged that floors should not be wet because they are hazardous and can cause residents to slip and fall. The resident reported calling for help without response, then scooting on her back to the bathroom door to open it and call out, after which assistance arrived. The facility’s fall team notes identified the fall as related to an environmental factor, specifically wet floor surfaces, particularly risky for residents with balance limitations. Subsequent clinical records documented ongoing and frequent right shoulder pain over the next several months, with repeated complaints of severe pain and limited ability to raise the arm. An orthopedic consultation noted the resident’s report that she slipped on a slippery bathroom floor while getting off the toilet and had significant right shoulder pain since the fall. An MRI later showed a full thickness tear of the supraspinatus tendon with retraction and fluid in the subacromial and subdeltoid bursa. Facility policies on hazardous areas and falls stated that hazards are anything with potential to cause injury and that staff will try to prevent resident falls with identified interventions, but housekeeping coverage for resident rooms did not extend to early morning hours, and janitorial staff only checked rooms when specifically alerted, contributing to the unaddressed wet bathroom floor.
Failure to Assign One-to-One Monitoring Results in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with a history of aggressive behaviors and a care plan requiring one-to-one monitoring was not assigned dedicated staff for supervision. The resident in question had diagnoses including schizophrenia, moderate cognitive impairment, and exhibited physical aggression such as kicking, hitting, and pushing. Despite care plan interventions specifying one-to-one monitoring and nursing notes indicating the need for constant supervision, the facility did not assign a staff member to provide this level of monitoring. As a result, the resident was left unsupervised on the smoking patio, where he punched another resident on the left side of the chest. The incident was witnessed by an activities assistant, who was present to provide smoking supplies and general supervision but was not assigned as the one-to-one monitor for the aggressive resident. Interviews with staff confirmed that the assignment for one-to-one monitoring was missed, and the Director of Nursing acknowledged that a dedicated one-to-one staff member could have potentially prevented the incident. Both residents involved had schizophrenia, but the victim had intact cognition and required only supervision or touch assistance for activities of daily living. The facility's policy stated that residents should not be subject to abuse by anyone, including other residents.
Failure to Implement One-to-One Monitoring Results in Resident-to-Resident Aggression
Penalty
Summary
The facility failed to implement a care plan intervention of one-to-one monitoring for a resident with a diagnosis of schizophrenia, who exhibited aggressive behaviors such as yelling, verbal aggression, and attempts to strike out at staff. The resident's care plan, developed after previous episodes of aggression and exit-seeking behavior, specifically included one-to-one monitoring as an intervention to minimize these behaviors. However, on the day of the incident, the assigned one-to-one monitoring was not provided, and the only staff present on the smoking patio was an Activities Assistant who was not designated as the resident's one-to-one monitor. As a result of this lapse, the resident was able to approach and punch another resident on the left side of the chest while unsupervised. Interviews with staff confirmed that the one-to-one monitoring assignment was missed, and the intervention outlined in the care plan was not followed. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the failure to implement the specified intervention led to an incident of resident-to-resident aggression.
Failure to Notify Physician of Missed Medication Dose and Delayed Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's physician when a scheduled dose of Heparin, prescribed for DVT prophylaxis, was missed. The resident, who had a history of a displaced intertrochanteric fracture and was dependent on staff for activities of daily living, reported to an LVN that her afternoon dose of Heparin was not administered after returning from physical therapy. The LVN confirmed with the nurse responsible for the dose that it had been forgotten, but did not report the missed dose to the registered nurse or the physician, citing fear of being labeled a snitch. The physician was not informed of the missed dose until several days later by the Director of Nursing. Additionally, the facility staff did not notify the physician when the resident was not transferred to a general acute care hospital as ordered. Although the physician had ordered a stat venous doppler and authorized transfer to the hospital for further evaluation, the resident expressed a preference to remain at the facility until the doppler could be completed. The LVN on duty did not inform the physician of the resident's decision to delay transfer, instead planning to endorse the situation to the next shift. The physician only learned of the resident's decision and subsequent transfer the following day. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition and medication errors to the physician and appropriate supervisory staff. However, these procedures were not followed, resulting in the physician being unaware of both the missed medication dose and the delay in hospital transfer, as documented in interviews and record reviews.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. One resident, who had a diagnosis of metabolic encephalopathy and intact cognition but was dependent on staff for bed mobility, was attacked in his room by another resident diagnosed with metabolic encephalopathy and schizophrenia, with moderately impaired cognition and requiring substantial assistance with activities of daily living. The attacking resident entered the victim's room, yelled accusations, threw a banana, and struck the resident multiple times with a plastic water pitcher and her fists. The incident resulted in the victim sustaining a 1 cm x 0.5 cm abrasion on the right side of his forehead, multiple areas of redness on his forehead and right forearm, and required immediate first aid for seven days. The event was witnessed by staff and another resident. Staff responded to yelling and screaming, finding the aggressor in the victim's room, and intervened to separate the two. The aggressor was described as very combative and continued to yell and scream even after being removed from the room. The victim reported feeling shocked and scared, using his arms and a blanket to protect himself during the attack, and called for help until staff arrived. The aggressor accused the victim of giving her a shot and raping her, according to both staff and another resident who witnessed the incident. Documentation reviewed included admission records, Minimum Data Sets, change of condition forms, skin integrity sheets, and treatment administration records, all confirming the injuries and the sequence of events. The facility's policy on abuse, neglect, and exploitation states that residents should not be subject to abuse by anyone, including other residents. However, in this instance, the facility failed to prevent one resident from physically abusing another, resulting in physical injury and emotional distress.
Failure to Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with metabolic encephalopathy and schizophrenia, who had moderately impaired cognition and required substantial assistance with activities of daily living. The resident accused another resident of rape in the presence of staff and other residents. A CNA witnessed the incident and provided a written report to an RN but omitted the rape allegation, assuming the RN would report it. The RN overheard the allegation and reported it to the DON. Despite being informed, the DON did not include the sexual abuse allegation when reporting the incident to the California Department of Public Health (CDPH). The Administrator was unaware of the allegation and stated that, had he known, he would have reported it as required by mandated reporter regulations. The facility's policy indicated that suspected abuse should be reported to the State Agency, but this was not followed, resulting in the failure to timely notify CDPH of the allegation.
Failure to Investigate Resident's Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse made by a resident with metabolic encephalopathy and schizophrenia, who was assessed as having moderately impaired cognition and requiring substantial assistance with activities of daily living. On the morning in question, staff responded to yelling and found the resident in another resident's room, where she struck him with a water pitcher and accused him of rape. Multiple witnesses, including a roommate and a CNA, confirmed hearing the resident make the allegation, and staff documented her aggressive behavior and need for one-to-one monitoring following the incident. Despite being aware of the allegation, the Director of Nursing did not document or conduct a thorough investigation into the claim, relying instead on his own assessment that the accused resident could not have committed the act due to his physical limitations. The facility's policy required immediate investigation and documentation of all abuse allegations, including interviews and chronological records, but no such documentation was provided for this incident. This failure resulted in the inability to determine whether the alleged abuse occurred.
Failure to Administer and Accurately Document Anticoagulant Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to administer Heparin as ordered by the physician for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The physician's order specified that the resident was to receive Heparin 5000 units/mL, 1.0 mL subcutaneously every eight hours for deep vein thrombosis (DVT) prophylaxis. On the day of the incident, the resident attended physical therapy and was not present in her room at the scheduled medication time. The LVN did not administer the scheduled dose and mistakenly documented in the Medication Administration Record (MAR) that the dose had been given. Later that day, the resident reported to another LVN that she had not received her afternoon dose of Heparin and was experiencing swelling in her legs. Upon review, the second LVN confirmed with the first LVN that the dose had indeed been missed. The resident continued to complain of swelling, and her left lower extremity was observed to be swollen. The physician was notified, and a venous doppler was ordered but could not be performed due to the presence of a soft leg cast and brace. The resident was subsequently transferred to a general acute care hospital for further evaluation. At the hospital, the resident was assessed and diagnosed with extensive acute DVTs of the left lower extremity. Interviews with facility staff confirmed that the missed dose of Heparin was due to the resident being away at physical therapy and the proximity to shift change. The LVN acknowledged both the failure to administer the medication and the erroneous documentation. The facility's policy required medications to be administered as ordered and documented accurately, which was not followed in this instance.
Falsification of Medication Administration Record for Anticoagulant Therapy
Penalty
Summary
Facility staff failed to ensure accurate documentation of medication administration for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The resident was cognitively intact but dependent on staff for activities of daily living. Physician orders required the resident to receive Heparin injections subcutaneously every eight hours for DVT prophylaxis. On a specified date, the Medication Administration Record (MAR) indicated that the resident was not available for her scheduled Heparin dose at 2 p.m. due to participation in therapy, and a subsequent audit report showed documentation of administration at 2:18 p.m., with later changes to the record. The resident reported to another nurse that she did not receive her afternoon Heparin dose after returning from therapy. The second nurse reviewed the MAR, which showed the dose as given, and upon contacting the original nurse, confirmed that the dose had not been administered. The resident experienced swelling in her left leg later that shift, which was assessed and reported to the registered nurse and physician. Interviews with the involved nurse revealed that he had not administered the medication because the resident was not present and that he had erroneously documented the administration in the MAR. He also admitted to making further inaccurate edits to the medical record at a later date. The Director of Nursing confirmed that the nurse admitted to both failing to administer the medication and documenting it as given. Facility policy required that the MAR be signed only after medication administration, which was not followed in this instance. The inaccurate documentation resulted in an incorrect depiction of the resident's medication management and had the potential to disrupt continuity of care.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident punched another in the face, resulting in swelling and discoloration near the left eye. The incident occurred after one resident became upset that another was wearing his shoes and, after asking for them to be removed without staff intervention, resorted to physical violence. The injured resident, who had a history of schizophrenia and anxiety disorder and was assessed as having severely impaired cognitive skills, was unable to recall or explain the incident during interviews. The aggressor had diagnoses of schizoaffective disorder and unspecified psychosis, with intact cognitive skills according to assessments. Staff interviews revealed that the assigned CNA did not visually assess the injured resident during night rounds, as the resident was asleep with his head covered, and the CNA preferred not to disturb sleeping residents. The LVN on duty was not informed of the incident and did not observe any abnormalities during her rounds, admitting she did not see the resident's face during shift changes. The DON confirmed that staff are expected to check on all residents face-to-face during rounds to ensure their safety. The facility's policy states that residents must not be subject to abuse by anyone, including other residents.
Resident Denied Readmission Without Proper Assessment After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident who was transferred to a general acute care hospital was properly evaluated for readmission and was denied return to the facility without adequate assessment. The resident, who had a history of schizoaffective disorder and unspecified psychosis, was initially admitted with intact cognitive skills and required supervision or assistance with daily activities. The resident was transferred to the hospital after an incident where he hit his roommate, which was the first occurrence of such behavior. Despite this, the facility did not document any efforts to determine if the resident's needs could still be met or if he continued to pose a danger to others upon potential return. Interviews revealed that the DON instructed hospital case workers not to return the resident, citing danger to others, but admitted there was no documentation or assessment to support this decision. The DON also acknowledged that the facility's interdisciplinary team made the decision without reviewing hospital reports, treatment plans, or consulting the resident's physician. The facility's policy required a review of the discharge plan, current condition, care needs, diagnosis, treatment plan, and behavioral or psychosocial support needs, but this process was not followed in this case.
Failure to Develop Comprehensive Care Plan After Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing physical abuse for a resident who was punched by another resident. The resident involved had a history of schizophrenia and anxiety disorder, with severely impaired cognitive skills for daily decision-making, and required assistance with several activities of daily living. Despite the incident of physical abuse, the care plan was only updated to address the resulting hematoma and redness on the resident's left eye, but did not include interventions or goals related to the abuse event itself. During a review of the care plan, the Director of Nursing confirmed that there was no updated care plan for physical abuse or resident-to-resident altercation, even though such an incident was documented in the electronic health record. The facility's policy requires the interdisciplinary team to develop individualized, comprehensive care plans for each resident, but this was not followed in this case, resulting in a lack of documented strategies to address and prevent further abuse.
Failure to Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for all residents in Medicare/Medicaid-certified beds were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) from August 2024 onward. Review of the facility's MDS 3.0 NH Final Validation Report confirmed that the last successful transmission and validation occurred on 7/31/2024, with no subsequent submissions verified up to 8/11/2025. Interviews with the MDS coordinator revealed that she became aware of the transmission failure only after being notified by the California Department of Public Health, and that the facility's IT staff were working to resolve the issue and transmit the backlog of assessments. The MDS coordinator acknowledged that her responsibilities included ensuring timely and accurate MDS submissions and that the lack of transmission resulted in outdated assessments and care plans for residents. The Director of Nursing (DON) confirmed that the last MDS transmission occurred in 7/2024 and recognized that failure to submit MDS assessments in a timely manner leads to outdated care plans, which are essential for reflecting the current care provided to residents. Review of the facility's policy and procedure indicated that the MDS coordinator is responsible for transmitting assessments, correcting errors, and ensuring validation reports are received. The deficiency was identified through interviews and record review, with the absence of federally mandated resident assessment data affecting all residents in certified beds during the specified period.
Failure to Schedule and Follow Up on Ordered Neurology Consultation
Penalty
Summary
The facility failed to schedule and follow up on a physician-ordered neurology consultation for a resident with diagnoses including polyneuropathy and anxiety disorder. The resident, who had moderate cognitive impairment and required significant assistance with daily activities, had an order for a neurology consult documented in the Physician Order Summary. Despite this, there was no evidence in the resident's chart that the appointment had been scheduled or confirmed, and the Social Services staff responsible for coordinating such appointments was unaware of the order until the resident personally informed her. Interviews revealed that the resident had expressed concerns about his symptoms and the need for a neurology evaluation, and staff acknowledged that the process for scheduling specialty consultations was not initiated as required. The facility's policy indicated that ancillary services should be scheduled promptly based on physician orders, with nursing staff responsible for notifying the appropriate department. The lack of timely coordination resulted in a delay in care and services for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him on the left upper cheek. This incident occurred after a verbal argument between the two residents was witnessed by a CNA and an LVN, who did not intervene in time to prevent the escalation. The argument took place in the patio area, where the residents were unsupervised, leading to the physical altercation. Resident 1, who was the victim of the assault, had a history of aggressive behavior and impaired cognitive ability due to conditions such as dementia and schizophrenia. His care plan included interventions to manage his aggressive episodes, such as removing other residents from the area if he became aggressive. However, these interventions were not followed, resulting in Resident 1 sustaining significant injuries, including a black eye, laceration, and fractures, which required hospital evaluation and treatment. Resident 2, who committed the assault, also had a history of mental health issues, including schizophrenia and delusions. His care plan included strategies to manage his potential for aggressive behavior, such as refocusing his attention and altering his environment. Despite these measures, the lack of supervision and timely intervention by staff allowed the situation to escalate, leading to the physical abuse of Resident 1.
Failure to Honor Resident's Refusal of Care
Penalty
Summary
The facility failed to honor a resident's right to refuse care, leading to increased agitation and physical aggression. Resident 1, who was admitted with Alzheimer's disease, dementia, depression, and unspecified psychosis, exhibited fluctuating capacity to understand and make decisions. The resident required substantial assistance with personal care tasks. During an incident, the resident became physically aggressive, kicking a CNA when informed that her adult brief would be changed. Despite the resident's agitation and refusal to return to bed, the CNAs continued with the personal care, which escalated the resident's aggression. Interviews with staff revealed that the CNAs did not honor the resident's refusal and continued to provide care despite the resident's physical aggression. The CNAs acknowledged that they should have stopped the care and returned later to prevent further agitation and potential injury. The facility's policy on resident rights emphasizes treating residents with respect and dignity, which was not adhered to in this instance, as the staff continued care against the resident's wishes, potentially violating her rights.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from a wheelchair to a bed, resulting in an injury. The resident, who had impairments on both sides of the upper and lower extremities due to hemiplegia and hemiparesis following a stroke, required total assistance from two to three persons for transfers as per their care plan. However, Certified Nursing Assistant (CNA) 4 attempted to transfer the resident alone, contrary to the care plan and facility policy, leading to the resident's left leg getting caught in the wheelchair wheels and sustaining a laceration that required ten sutures. The incident occurred when CNA 4 lifted the resident by placing one arm under the armpit and holding the pants with the other hand. During the transfer, the resident's left leg was caught in the wheelchair's wheel, causing a deep cut. The resident was then transferred to a General Acute Care Hospital for evaluation and treatment of the laceration. Interviews with the resident and staff confirmed that the resident should have been transferred with two-person assistance due to their condition, which included left-sided paralysis and the inability to fully support their body during transfers. The facility's policy on Safe Resident Handling/Transfers was not followed, as it mandates that residents be handled and transferred safely to prevent injury. The care plan for the resident clearly indicated the need for two to three staff members for transfers, which was not adhered to by CNA 4. This oversight in following the care plan and facility policy directly led to the resident's injury during the transfer process.
Failure to Ensure Resident Privacy During ADLs
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during the performance of Activities of Daily Living (ADLs) by not closing the privacy curtain. This deficiency was observed in the cases of two residents, both of whom had severe cognitive impairments and were dependent on assistance for daily tasks. The failure to close the privacy curtain left these residents visually exposed to other staff and residents, which could lead to feelings of embarrassment and a violation of their right to personal privacy. Interviews with multiple Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) confirmed that the privacy curtain should have been closed completely during ADLs to maintain resident privacy and dignity. The facility's policy on privacy and confidentiality also indicated that residents have a right to personal privacy. Despite this, the CNAs involved did not adhere to these guidelines, resulting in the exposure of the residents during personal care activities.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident assessed as high-risk for wandering, resulting in the resident eloping from the facility. The resident, who had a history of wandering and required frequent monitoring, was not observed or tracked as indicated in their care plan. The care plan specified constant observation and monitoring for episodes of wandering or attempted elopement every shift, but these measures were not effectively implemented. The facility's staff did not respond to the entrance/exit door alarm when the resident left the facility. The alarm system was not clearly audible due to a second set of glass doors that muffled the sound, and there was no designated staff to monitor the entrance and exits continuously. Additionally, the resident's wander guard was found broken on their bedside table, indicating a failure in the system meant to alert staff of potential elopement. The resident, who had fluctuating capacity to understand and make decisions, was found in the neighborhood where their family lives after being missing for several days. The resident had a history of schizophrenia, psychosis, paraplegia, and hypertension, and was at risk for medical complications due to missing their high blood pressure medication. The facility's reliance on the wander guard system without additional interventions such as hourly monitoring and designated staff for monitoring contributed to the resident's unnoticed departure.
Removal Plan
- The facility has implemented measures to locate the resident, including notifying the local police, contacting local hospitals, notifying Resident 1's responsible party, and staff searching the vicinity.
- Assigned a Certified Nurse Assistant (CNA) as a Rounder to document at least every hour to identify the whereabouts of residents at risk for wandering and elopement.
- Each facility exit door is equipped with a security camera for monitoring. The Administrator, the DON, and/or RN Supervisor will be responsible for monitoring video footage.
- The front entrance/exit door alarm was made more audible by outfitting the glass doors with an audible door alarm.
- A facility staff (Door Monitor) was assigned to provide continuous supervision of the exit door located between stations B and C.
- The RN Supervisor will be responsible for activating/deactivating door alarms and will conduct rounds to ensure exit doors are properly secured and alarmed.
- The DON initiated in-services to licensed nurses, CNAs, and registry staff regarding the facility's systems on resident supervision and elopement prevention.
- Staff in-serviced on the need to follow up, develop, and implement a care plan for residents assessed as a risk for wandering.
- A Resident Location Tracking log was implemented to document visual checks at least hourly of each resident at risk for wandering and elopement.
- Each exit door is outfitted with an audible door alarm that will set off a piercing horn sound when a door is opened after the alarm has been activated.
- The DON initiated reassessment of residents in the facility and identified those at high risk for wandering and elopement. Care plan revisions were done for all residents identified as high risk.
- Developed a list of residents at high risk for wandering and elopement, made available at each station for all incoming staff. A huddle will be conducted at the beginning of each shift to communicate which residents are at risk.
Deficiencies in Food Labeling and Dishwasher Sanitization
Penalty
Summary
The facility failed to properly label and date food items stored in their refrigerators and freezers, as observed during a survey. Specifically, several food items, including turkey breasts, broccoli, cookie dough, ham, bacon, chicken, ice cream, and various other items, were found without labels indicating the date received or expiration date. This lack of labeling was confirmed through interviews with dietary aides and the cook, who acknowledged that labeling is essential to ensure food is discarded when expired, preventing potential foodborne illnesses. The facility's policy requires all food to be labeled and dated, but this was not adhered to, placing residents at risk. Additionally, the facility did not maintain proper chemical levels in the dishwasher used for sanitizing dishes. During an observation, the test strip used to check chlorine levels in the dishwasher did not change color, indicating a 0 ppm level of chlorine, which is insufficient for sanitization. Interviews with dietary aides and the regional dietary manager confirmed that the dishwasher's chemical levels should be adequate to kill germs on dishes, as per the facility's policy. This deficiency could lead to the use of contaminated dishes and utensils, posing a risk of foodborne illness to the residents.
Refrigerator Malfunction Leads to Potential Contamination Risk
Penalty
Summary
The facility failed to maintain Refrigerator #1 in proper working condition, as observed on 7/16/2024, when a pool of water was found at the bottom of the refrigerator. This issue was noted during the defrosting of ham, chicken, and bacon, with standing water observed under the container of defrosting chicken. An interview with a staff member revealed that water had been dripping from the top of the refrigerator and collecting at the bottom for the past two weeks. The staff member confirmed that maintenance had been notified and had checked the refrigerator, acknowledging that the situation was not normal and could lead to bacterial growth. Further interviews revealed that the Regional Dietary Manager (RDM) had sent a weekly report to the Administrator (ADM), who was responsible for following up with maintenance. The report, dated 7/11/2024, indicated significant water condensation in Refrigerator #1. The ADM confirmed receiving the report and stated that maintenance assessed the refrigerator on 7/17/2024. The Maintenance Supervisor (MS) reported being notified about the issue on 7/11/2024 or 7/12/2024, assessed the refrigerator, and cleaned the coils, noting the bottom was dry at that time. However, a technician was unable to visit until 7/18/2024, leaving the issue unresolved at the time of the survey.
Failure to Respond to Call Lights and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as observed during a survey. Resident 10 and Resident 33 experienced delays in response to their call lights, which were not promptly acknowledged by staff. Resident 10, who was cognitively intact and required substantial assistance for personal care, expressed frustration over the repeated delays in answering her call light. During the survey, it was observed that a Licensed Vocational Nurse (LVN) ignored the call light signals for both residents, despite being in close proximity and aware of the activated signals. The facility's policy required all staff to respond to call lights, but this was not adhered to, leading to potential safety risks and unmet needs for the residents. Resident 61, who had moderate cognitive impairment and required assistance with eating, was not treated with dignity during mealtime. A Certified Nurse Assistant (CNA) was observed feeding Resident 61 while standing, rather than sitting at eye level, which is necessary to promote dignity and respect. The facility's policy emphasized the importance of maintaining eye contact and treating residents with respect during feeding, but this was not followed in Resident 61's case. The CNA acknowledged the oversight and the importance of being at eye level to ensure the resident's comfort and dignity. The facility's policies on call light response and promoting resident dignity were not followed, as evidenced by the staff's actions and inactions. Interviews with staff, including the Director of Staff Development and a Registered Nurse, confirmed that all staff members were responsible for responding to call lights and that feeding residents at eye level was crucial for maintaining dignity. The failure to adhere to these policies resulted in the residents feeling neglected and disrespected, highlighting a deficiency in the facility's care practices.
Failure to Complete PASRR Level II Evaluations for Residents
Penalty
Summary
The facility failed to follow through with the Preadmission Screening and Resident Review (PASRR) recommendations for three residents, resulting in the absence of PASRR Level II evaluations. These evaluations are crucial for determining appropriate placement and identifying specialized services for individuals with mental illnesses or intellectual disabilities. The deficiency was identified during a review of the residents' records, which showed that despite the PASRR Level I indicating the need for a Level II evaluation, none was completed for the residents in question. Resident 4 was admitted with severe cognitive impairment and multiple diagnoses, including basal cell carcinoma and major depressive episode. Resident 60 had chronic kidney disease, hypertensive heart disease, and depression, with fluctuating decision-making capacity. Resident 61 was diagnosed with gastro-esophageal reflux disease, hypertension, and bipolar disorder, also with fluctuating decision-making capacity. The Minimum Data Set Nurses confirmed the lack of PASRR Level II evaluations, acknowledging the importance of these evaluations in providing specialized services. The facility's policy required coordination with the PASRR program, but this was not adhered to, leading to the deficiency.
Failure to Implement Person-Centered Care Plan for Visually Impaired Resident
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for Resident 152, who was visually impaired. The care plan did not include specific interventions to ensure the resident's call light was within reach, which is crucial for a resident with vision loss. During observations, it was noted that the call light was placed on the bed, out of reach for Resident 152, who was sitting in a wheelchair. The resident expressed a preference for having the call light on the handrail of the wheelchair, indicating a lack of communication and understanding of the resident's needs by the staff. CNA 6, who was assigned to Resident 152, was unaware of the resident's visual impairment and did not ensure the call light was accessible before leaving the room. This oversight was acknowledged by the CNA, who admitted that not knowing the resident could not see the call light put the resident at risk for injury and delayed assistance. The Director of Nursing emphasized the importance of implementing care plans to ensure timely and appropriate care, particularly for residents with visual impairments. The facility's policy mandates the development of comprehensive person-centered care plans, but this was not effectively executed for Resident 152.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted and readily available to residents and visitors. During an observation at the facility entrance, it was noted that there was no daily staffing information posted. A Registered Nurse confirmed that the staffing information was not posted at the nurse's station or the front entry doors, where it should have been. The Director of Staff Development, who is responsible for posting this information, admitted that the daily staffing information was not posted for the day. According to the facility's policy and procedure, the daily staffing sheet should be posted at the beginning of each shift to inform visitors and residents of the staffing details for the day.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to properly track and document the administration of controlled substances for four residents, leading to discrepancies in medication counts. The residents involved had various diagnoses, including anxiety disorder, schizophrenia, major depressive disorder, and suicidal ideations. The medications in question were Lorazepam and Alprazolam, which are used to manage anxiety symptoms. The failure to document the administration of these medications in real-time was observed during a medication storage check, where discrepancies were found between the actual count of tablets and the recorded count in the Controlled Drug Record log. The licensed vocational nurse (LVN 2) admitted to administering the medications to the residents but had not documented the administration immediately as required by the facility's policy. Instead, LVN 2 was recording the times on a separate vital signs sheet with the intention of updating the records later. This practice was against the facility's policy, which mandates immediate documentation in the Medication Administration Record (MAR) and the Controlled Drug Record log to ensure accurate tracking of controlled substances. The registered nurse (RN 1) emphasized the importance of reconciling and documenting controlled substances immediately to prevent potential medication errors, such as overdoses or early administration by another nurse. The facility's policy and procedure documents also supported this requirement, highlighting the need for timely documentation to maintain an accurate inventory of medications. The failure to adhere to these procedures posed a risk of misinformation and potential harm to the residents.
Deficiency in Dietary Staff Competency for Fortified Meals
Penalty
Summary
The facility failed to ensure that dietary staff members were competent in the safe and effective preparation of fortified meals. During an observation, a staff member was seen adding extra tomato sauce to a meal, believing this constituted fortification. In interviews, the staff members revealed a misunderstanding of the purpose of fortified meals, with one stating that extra sauce or gravy was added to make food easier to swallow, and another indicating that cheese was sprinkled on top for fortification. This indicates a lack of proper training and understanding of fortified meal preparation among the dietary staff. The facility's job description for cooks requires them to ensure foods meet the individualized needs of residents and maintain knowledge of current nutritional practices. However, the Dietary Regional Manager confirmed there was no record of the staff receiving education on preparing fortified meals. The posted kitchen sign for fortified diets also did not align with the staff's actions, as it specified adding margarine or gravy, not tomato sauce or cheese. This discrepancy highlights the deficiency in training and competency among the dietary staff, impacting their ability to provide appropriate nutritional care.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct an investigation following a resident-to-resident altercation between Residents 18 and 61. Resident 18, who has severe cognitive impairment and is sometimes understood, was observed attempting to hit Resident 61 with a wheelchair after Resident 61, who has moderate cognitive impairment and functional impairment in one upper extremity, was seen crawling on the floor towards Resident 18's bed. The altercation was stopped by a Certified Nurse Assistant (CNA), who reported the incident to a Licensed Vocational Nurse (LVN). The Administrator was not informed of the altercation until later and stated that the LVN did not consider the incident an altercation due to Resident 18's method of communication being yelling. The facility's policy requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. The failure to report and investigate the incident resulted in the facility not identifying other potential resident-to-resident altercations, posing a risk for further incidents.
Inaccurate Vision Assessment of Visually Impaired Resident
Penalty
Summary
The facility failed to appropriately assess a resident who was visually impaired, leading to an inaccurate assessment of the resident's vision. The resident, who was admitted with diagnoses including vision loss, schizoaffective disorder, and muscle weakness, was documented as legally blind in the admission assessment. However, the Minimum Data Set (MDS) assessment inaccurately indicated that the resident had adequate vision, which was not consistent with the resident's documented condition. The MDS Nurse (MDSN) did not conduct a thorough assessment, as she relied on the resident's ability to make eye contact and a verbal confirmation that the resident could see her, without further probing into the resident's ability to read or see objects. The Director of Nursing (DON) acknowledged the importance of a proper assessment to ensure the resident received appropriate care and services for her visual impairment. The failure to accurately assess the resident's vision could result in a delay of care and necessary services.
Failure to Revise Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to revise the comprehensive resident-centered care plan for a resident, identified as Resident 88, who was at high risk for falls. The care plan did not include specific interventions for direct line of sight monitoring, which was necessary due to the resident's severe cognitive impairment, poor safety awareness, and high fall risk. Observations revealed that Resident 88 was left unsupervised in a wheelchair in her room, contrary to the need for constant supervision. Interviews with staff, including a Registered Nurse (RN) and a Certified Nurse Assistant (CNA), confirmed that the resident required supervision and should not have been left alone in her room. The resident's medical history included schizophrenia, muscle weakness, and polyarthritis, and assessments indicated severe cognitive impairment and a high fall risk score. Despite these factors, the care plan lacked specific interventions for line of sight supervision, which was acknowledged by the RN and the Director of Nursing (DON) as a necessary measure to prevent falls. The facility's policy required care plans to be comprehensive and reflect the specific needs of residents, but this was not adhered to in the case of Resident 88, leading to a deficiency in care.
Failure to Ensure Proper Positioning for Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feedings, leading to a potential risk of aspiration. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed with the head of the bed (HOB) positioned lower than the required 35-45 degrees during feeding times. Despite physician orders and care plan instructions to maintain the HOB at the specified angle to prevent complications such as aspiration, the resident was found in an unsafe position with the feeding pump infusing enteral feedings. The deficiency was further highlighted by the actions and inactions of the nursing staff. A Certified Nurse Assistant (CNA) identified the unsafe positioning but required assistance from a Licensed Vocational Nurse (LVN) to turn off the feeding pump and reposition the resident. The LVN entered the room twice but failed to assess or assist the resident, leaving without ensuring proper positioning. The LVN admitted to not reassessing the resident's position frequently, as required, which placed the resident at risk for aspiration. The Director of Nursing confirmed the necessity of frequent assessments to ensure proper positioning and feeding tolerance, as outlined in the facility's policy and procedure for enteral nutrition.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to residents, resulting in a violation of residents' rights and the potential for inappropriate use of such medications. For Resident 14, who was admitted with diagnoses including major depressive disorder, schizophrenia, and suicidal ideations, the facility did not secure the necessary signatures from the physician or the conservator on the informed consent forms for medications such as Ativan, Lexapro, Risperdal, and Valproic Acid. This oversight was confirmed during an interview with a Registered Nurse Supervisor, who acknowledged that the medications should not have been administered without proper consent. Similarly, for Resident 4, who had severe cognitive impairment and was dependent on assistance for daily activities, the facility failed to complete the informed consent form for the administration of Lorazepam. The Director of Nursing noted that the consent form lacked the signature and date from the resident's responsible party, as well as verification from the licensed nurse that informed consent had been obtained by the physician. This incomplete documentation was identified during a review of the resident's records. Additionally, Resident 152, who was admitted with conditions including vision loss and schizoaffective disorder, did not have a completed informed consent form for the administration of Ativan and Invega Sustenna. The Director of Nursing confirmed that the absence of the resident's signature on the consent form constituted a violation of resident rights. The facility's policies and procedures require that informed consent be documented and signed by both the physician and the resident or their legal representative prior to the administration of psychotropic medications.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for a resident when an antibiotic was prescribed without meeting the McGeer Criteria, which are used to determine the appropriate use of antibiotics. The resident, who had been readmitted to the facility with a diagnosis of a urinary tract infection, was prescribed Bactrim, an antibiotic, despite not meeting the criteria for its use. This was documented in the facility's Antibiotic Use Tracking Sheet, which indicated that the McGeer criteria were not met. During interviews, the Infection Prevention Nurse acknowledged that the resident was readmitted with antibiotics ordered but did not meet the criteria, and the physician was not contacted to address this issue. The Director of Nursing confirmed that the purpose of the antibiotic stewardship program is to ensure antibiotics are used appropriately and that the Infection Preventionist is responsible for following up when antibiotics do not meet the criteria. The facility's policy on the Antibiotic Stewardship Program states that antibiotic orders obtained upon admission should be reviewed for appropriateness, but this was not done in this case.
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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