Mar Vista Country Villa Healthcare & Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3966 Marcasel Ave, Los Angeles, California 90066
- CMS Provider Number
- 555726
- Inspections on file
- 60
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mar Vista Country Villa Healthcare & Wellness during CMS and state inspections, most recent first.
A resident was re-admitted with multiple medical conditions, including sepsis, osteoarthritis, hypothyroidism, GERD, hypertension, and electrolyte and lipid disorders, and required supervision with eating and moderate assistance with toileting and transfers. Despite a physician order for RD evaluation, no admission weight was documented, and the RD instead used the most recent GACH weight as the baseline. Subsequent weights were entered later, and the MDS triggered a significant weight change based on comparison to the hospital weight, which was documented as a clinically significant loss. In interview, the RD confirmed that the absence of an admission weight led to reliance on the hospital weight and acknowledged that an admission weight should have been obtained by staff.
A resident with ESRD and type 2 DM, who had intact decision-making capacity, was subject to a proposed discharge for improved health without receiving a properly executed 30-day written notice. The notice in the record lacked the resident or representative’s signature, and it was not sent to the ombudsman as required by facility policy. The facility representative signed the notice shortly before the planned discharge, and the physician ordered discharge with HH and DME the next day. The resident reported feeling rushed and harassed to sign discharge paperwork on the same day as discharge, while an LVN stated he received last-minute notification of the discharge. The ombudsman confirmed the notice was not faxed until much later and that prior reminders about 30-day notice and documentation had been given, while the social services director and administrator described practices that did not align with the written policy for notifying the ombudsman.
A resident with dementia and multiple comorbidities, identified as a high fall and elopement risk, was left unsupervised due to insufficient staffing and staff reassignments during the night shift. The resident wandered outside and sustained an unwitnessed fall, resulting in a laceration that required hospital treatment. Staff interviews and record reviews indicated that the assigned CNA was diverted to provide 1:1 supervision for another high-risk resident, leaving the original assignment inadequately monitored.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with cognitive impairments and multiple diagnoses, including hypokalemia and COPD, experienced a significant change in condition when they confabulated stories of being raped by a CNA. The LVN documented the incident but failed to notify the physician or use the SBAR tool as required by the facility's policy, potentially delaying necessary care.
A resident with cognitive impairments reported being raped by a CNA, but the LVN who documented the allegation failed to report it to the DON or FA, as required by the facility's policies. Interviews revealed that key staff were unaware of the allegations, delaying an investigation and notification to authorities. The facility's policies mandate immediate reporting of abuse allegations, which was not followed in this case.
A facility failed to investigate a resident's allegations of abuse, as required by its policies and procedures. The resident, with cognitive impairments and requiring assistance for daily activities, reported being raped and touched by a CNA. Despite documentation by an LVN, the issue was not reported to the DON or FA, nor was an investigation initiated. The RNS, DON, and SSD were unaware of the allegations, highlighting a breakdown in communication and reporting. This failure delayed a State Agency inspection and risked unidentified abuse in the facility.
A resident with cognitive impairments and multiple health conditions reported being raped and touched by a CNA, but the facility failed to document and implement a comprehensive care plan addressing the incident. The LVN acknowledged the oversight, which violated the facility's policies on care planning and change of condition notification.
A resident with a history of verbal aggression and refusal of medication repeatedly provoked another resident, leading to a physical altercation. Despite having a care plan, the facility failed to effectively monitor and document the aggressive behavior or offer prescribed medications, resulting in a deficiency in care.
A resident with multiple health conditions reported missing incontinent briefs, which were not stocked by the facility. Despite informing the social worker and DSS, the issue was not promptly addressed, and the facility failed to investigate the grievance or offer alternative solutions. The facility did not adhere to its grievance policy, resulting in unresolved complaints.
A facility failed to maintain hospice visit records for a resident receiving hospice care. The resident had multiple health conditions and required assistance with daily activities. The facility's hospice binder lacked necessary hospice nursing and doctor visit notes, contrary to the facility's policy. Interviews revealed that the facility did not follow up to obtain these notes, potentially leaving nursing staff uninformed of changes recommended by hospice staff.
A resident with cognitive impairments eloped from the facility due to inadequate supervision and lack of alarm systems on exit doors. The resident, who required supervision for daily activities, was found missing during a CNA's rounds. Despite a search by staff, the resident was only located later at a bus stop. The facility lacked proper documentation of staff rounds and did not have a wander guard on the resident, contributing to the incident.
A deficiency in medication management was identified in an LTC facility when an LVN failed to replace missing medications for residents, leading to borrowing a Lidocaine patch from another resident and missing a Florastor dose. The LVN did not follow proper procedures for reordering medications, risking residents' pain management and supplement needs.
The facility failed to manage Glucose Quality Control Solution properly, leading to potential confusion and inaccurate blood sugar readings. An LVN found mismatched lot numbers and expired solutions in Medication Cart A, with no formal policy in place. The DON admitted uncertainty about expiration dates and acknowledged the risk of false readings causing harm to residents.
The facility failed to store food in a sanitary manner, risking foodborne illnesses. A resident had apple juice on the floor, posing an infection risk. Dented and unlabeled canned food was improperly stored with ready-to-use food. The unit refrigerator for residents' food was unlocked and contained expired items due to staff miscommunication about responsibilities.
The facility failed to ensure catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. One resident with cognitive impairment had their catheter bag uncovered until the DON intervened, while another resident with dementia was observed with an exposed catheter bag in a wheelchair. This deficiency contravenes the facility's policy on maintaining residents' dignity.
A resident with dementia and other medical conditions was observed in a wheelchair with a urinary catheter drainage bag in open view, lacking a dignity cover. Staff interviews confirmed the absence of a dignity bag, which is required by the facility's policy to maintain resident dignity. The Director of Nursing acknowledged the necessity of a dignity bag for privacy and decency.
A resident with multiple health conditions, including legal blindness, was found with medications at their bedside without a physician's order or assessment for self-administration capability. Facility staff confirmed that residents should only have medications at bedside if cleared by a physician and evaluated for competence, which was not done in this case.
The facility failed to provide a quiet and homelike environment, affecting two residents' ability to sleep due to another resident's continuous screaming. Despite staff interventions, the noise persisted, and the facility lacked policies to address this issue.
A facility failed to complete a PASRR Level II assessment for a resident with multiple mental health diagnoses, as required by the PASRR Level I screening. The resident's care plans lacked individualized treatments, and staff interviews revealed no tracking system for required assessments. Facility policies outlined the need for such assessments, but the absence of a tracking log contributed to the oversight.
A resident with an indwelling catheter was found with yellow cloudy fluid and sediments in the tubing, indicating a possible infection. The facility failed to change the catheter bag as per the physician's order and did not notify the physician about the sediment, contrary to the facility's policy. This oversight placed the resident at increased risk for a urinary tract infection.
Two residents in an LTC facility did not receive the correct oxygen therapy as prescribed by their physicians. One resident, with multiple health issues, was found with a nasal cannula not placed correctly, while another resident with COPD received a higher oxygen flow rate than ordered. These errors were confirmed by nursing staff and acknowledged by the DON, highlighting a failure to follow the facility's oxygen therapy policy.
The facility did not complete annual performance evaluations for a CNA hired in 2001, as revealed during a record review with the DSD. The absence of evaluations for 2023 and 2024 was noted, with the DSD and DON emphasizing the importance of competencies for safe practices and proper resident care. The facility's policy requires competency assessments upon hiring, annually, and as needed.
The facility failed to follow infection control protocols for two residents. A resident's nasal cannula tubing was on the floor, and their oxygen humidifier was not changed weekly as required. Another resident's supra pubic catheter drainage bag was touching the floor. These lapses occurred despite facility policies mandating sanitary conditions and regular equipment changes.
The facility failed to ensure that the ADON, who is currently an LVN awaiting RN licensure in California, had the appropriate skills to train RN staff on resident care and assessment. The ADON conducted in-service training for CNAs, LVNs, and RNs, which was outside the LVN's scope of practice. Interviews with the DON and ADM confirmed that the ADON should not train RNs until obtaining an RN license, and future training will be conducted by the DON and an RN.
The facility's DSD transitioned from IPN to DSD without completing the required continuing education course, following the resignation of the previous DSD. This left the DSD without the necessary competencies to effectively manage the facility's educational programs.
The facility's governing body failed to report a change in the Administrator (ADM) as required by regulations. The ADM, who started in 10/2023, was also an ADM at another facility and could not provide documentation of the Change of Ownership (CHOW) application. The facility's policy requires reporting such changes within ten days, but this was not done, potentially affecting the safety and well-being of all 56 residents.
A resident with diabetes, chronic kidney disease, and depression experienced discomfort due to delayed lunch service at a facility. The delay was caused by logistical issues, as staff had to manually transport meal carts from the basement due to a non-functional elevator. This resulted in meals being served later than the scheduled time, affecting the resident's dignity and comfort.
A resident with severe cognitive impairment and identified as a fall risk fell and sustained injuries due to inadequate supervision and failure to follow care plan directives. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to physician orders. The CNA left the resident unattended, leading to a fall and subsequent hospitalization for a head injury and laceration.
Failure to Obtain Admission Weight Led to Inaccurate Baseline and Triggered Weight Loss Variance
Penalty
Summary
The deficiency involves the facility’s failure to obtain an admission weight in accordance with professional standards of practice for one resident. The resident was re-admitted with multiple diagnoses including sepsis, osteoarthritis of the hip and knee, cognitive communication deficit, hypokalemia, hypothyroidism, hyperlipidemia, thrombocytopenia, vitamin D deficiency, GERD, hypertension, and a disorder of phosphorus metabolism. The resident’s MDS showed intact cognition, supervision or touch assistance needed with eating, and moderate assistance needed with toileting and transfers. A physician order dated 1/27/2026 requested an RD consultation to evaluate and treat as needed. However, the dietary profile dated 2/3/2026 showed no weights recorded, and there was no documented weight at the time of admission. Because an admission weight was not obtained, the RD used the most recent GACH weight of 110 lbs from 1/24/2026 as the baseline. A subsequent physician order dated 2/13/2026 called for weekly weights for four weeks. An IDT note dated 2/20/2026 documented that the MDS triggered a significant weight change, comparing the 110 lb hospital weight to later weights and identifying an approximate 19–19.2 lb loss, or 17.3%–17.5% change, which was described as clinically significant and placing the resident at risk for malnutrition, functional decline, dehydration, and increased morbidity. The RD’s care plan revision on 2/11/2026 listed weights of 110 lbs on 1/24/2026, 89.4 lbs on 2/4/2026, and 90.5 lbs on 2/9/2026, and documented a 20.6 lb/18.7% one-month loss. In interview, the RD stated there was no weight documented at admission, so the last hospital weight was used as the baseline, and acknowledged that ideally the RNA would obtain an admission weight and that the use of the hospital weight had triggered a weight loss variance.
Failure to Provide Timely 30-Day Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice of a proposed transfer and discharge to a resident, the resident’s responsible party, and the state long-term care ombudsman at least 30 days prior to the proposed discharge date. The resident, who had type 2 diabetes mellitus and end-stage renal disease and was documented as having decision-making capacity with no cognitive impairment, was initially given a Notice of Proposed Transfer and Discharge dated early in the month stating that discharge was appropriate because the resident’s health had improved sufficiently. The notice in the record lacked the resident or representative’s signature and was not faxed to the ombudsman. The facility’s policy required that a copy of the notice be placed in the medical record and faxed to the ombudsman, and that when a transfer or discharge is initiated by the facility, notice be provided to the resident, responsible party, and ombudsman 30 days prior to discharge unless specific exceptions applied. Despite this, the facility representative did not sign the notice until late in the month, and the physician’s order to discharge the resident with home health and DME was entered the following day. The resident reported not recalling receiving the proposed discharge documents within the prior four weeks and stated feeling rushed and harassed to sign a document and be discharged the same day. The ombudsman confirmed the facility did not fax the notice of proposed discharge until the day after the resident interview and had previously reminded social services about the 30-day notice and record-keeping requirements. An LVN involved in discharge planning stated he usually received at least a week’s notice for discharges but was only given the resident’s discharge plan and notification the day before the planned discharge and was told the discharge had been moved up without further details. The social services director acknowledged that when the resident declined to sign the notice earlier in the month, it was not faxed to the ombudsman, and the administrator stated the notice did not need to be faxed because it was not considered a facility-initiated or involuntary discharge, contrary to the facility’s written policies.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Unwitnessed Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to maintain adequate supervision for a resident identified as a wanderer and at high risk for falls. The resident, an elderly female with multiple diagnoses including dementia, atrial fibrillation, and osteoarthritis, required hourly visual checks and wore a wander bracelet due to her high risk of elopement. Despite these interventions, the resident was able to leave her bed and room multiple times during the night, ultimately wandering outside onto the patio unsupervised, where she sustained an unwitnessed fall resulting in a laceration above her left eye that required hospital treatment and sutures. Review of records and staff interviews revealed that on the night of the incident, the certified nursing assistant (CNA) assigned to the resident was also tasked with being a 1:1 sitter for another high fall risk resident in a different room for several hours, leaving the original assignment unattended. The remaining CNA attempted to monitor both assignments but was also responsible for a large number of residents. Staff reported that during the night shift, there were fewer personnel available compared to the day shift, making it more difficult to provide adequate supervision for residents with high acuity and wandering behaviors. The resident's care plan included interventions such as a low bed, visual checks, and proximity to the nursing station, but no 1:1 sitter was assigned. Interviews with staff, including the charge nurse, director of staff development, and assistant director of nursing, confirmed that the resident was not identified as needing a sitter and that staffing assignments were adjusted due to a last-minute call-off. The facility's policy required adequate staffing to meet resident needs, but on the night in question, the combination of high resident acuity, staff reassignments, and reduced night shift staffing contributed to the failure to provide the necessary supervision, resulting in the resident's unsupervised exit and subsequent fall.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility staff failed to notify the physician of a change in condition for one of the residents, identified as Resident 1. This resident was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set indicated that Resident 1 had moderately impaired cognitive skills and required moderate to maximal assistance for activities of daily living. On a specific date, a Licensed Vocational Nurse (LVN) documented in the progress notes that Resident 1 confabulated stories about being raped and touched by a Certified Nursing Assistant. Despite this significant change in condition, the LVN did not report the incident to the physician or document the change using the SBAR communication tool as required by the facility's policy. The facility's policy on Change of Condition Notification mandates that residents, family, legal representatives, and physicians be informed of changes in a resident's condition in a timely manner. The policy specifies that the attending physician must be notified of any sudden and marked adverse change in a resident's condition that denotes a new problem or complication. The LVN acknowledged the failure to report and document the change in condition but was unsure why it was not completed. This oversight had the potential to delay necessary care, treatment, and services for Resident 1.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of abuse in accordance with state and federal law. This deficiency was identified during a review of a resident's records and interviews with facility staff. The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had cognitive impairments and required significant assistance with activities of daily living. The resident reportedly confabulated stories of being raped and touched by a CNA, which was documented by an LVN in the resident's progress notes. Despite the documentation, the LVN did not report the allegations to the Director of Nursing (DON) or the Facility Administrator (FA), as required by the facility's policies. Interviews with the Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) revealed that none of them were informed of the allegations. The RNS stated that if the LVN had reported the issue, an investigation could have been initiated, and the necessary authorities, including the local police, ombudsman, and Department of Public Health, could have been notified. The facility's policies and procedures, reviewed in June 2024, clearly state that all staff are mandatory reporters and must report any allegations of abuse immediately to the administrator or designated representative. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leaving residents unprotected from possible abuse.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures by not ensuring an investigation was completed for a reasonable suspicion of abuse in accordance with state and federal law. This involved a resident who was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The resident's cognitive skills for daily decision-making were moderately impaired, requiring moderate to maximal assistance from staff for activities of daily living. The deficiency arose when a Licensed Vocational Nurse (LVN) documented in the resident's progress notes that the resident confabulated stories about being raped and touched by a Certified Nursing Assistant (CNA). Despite this documentation, the LVN did not report the issue to the Director of Nursing (DON) or the Facility Administrator (FA), nor did they initiate an investigation as required by the facility's policies. The Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) were all unaware of the resident's allegations, indicating a breakdown in communication and reporting procedures. The facility's policy on abuse and neglect mandates that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source, and suspicion of crimes be promptly reported and thoroughly investigated. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leading to unidentified abuse within the facility and a failure to protect residents from possible abuse.
Failure to Implement Comprehensive Care Plan After Resident's Report
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being raped and touched by a Certified Nursing Assistant (CNA). The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had moderately impaired cognitive skills and required significant assistance with activities of daily living. Despite the resident's report to a Licensed Vocational Nurse (LVN), there was no documentation in the care plan addressing the incident. The LVN acknowledged the omission and confirmed that an individualized care plan should have been completed. The facility's policy on comprehensive person-centered care planning requires care plans to be reviewed and revised upon the onset of new problems or changes in condition. Additionally, the policy on change of condition notification mandates that a licensed nurse document and update the care plan to reflect the resident's current status. The failure to adhere to these policies resulted in a deficiency that could negatively impact the resident's health and safety.
Failure to Manage Resident Aggression Leads to Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, leading to a deficiency in care. Resident 3, who had a history of verbal aggression and refused medication, repeatedly provoked Resident 4 with unwanted verbal interactions. Despite having a care plan in place to manage Resident 3's behavior, the facility did not effectively monitor or document the resident's aggressive actions, nor did they offer or document the refusal of prescribed medications like Xanax to manage anxiety and aggression. Resident 3 was admitted with diagnoses including bipolar disorder and unspecified psychosis, and was known to exhibit provocative behavior towards staff and other residents. The care plan for Resident 3 included interventions to reduce verbal aggression and promote positive interactions, but these measures were not adequately implemented. Interviews with staff revealed that Resident 3 was often verbally abusive and did not adhere to facility policies or medical orders, contributing to ongoing conflicts with Resident 4. Resident 4, who was also admitted with a history of mood disorders, was subjected to repeated verbal taunts by Resident 3, leading to a physical altercation where Resident 4 threw ice at Resident 3. The facility's failure to manage Resident 3's behavior and document interventions or notify medical staff of behavioral instability resulted in an environment where verbal abuse occurred, placing Resident 4 and others at risk for further incidents.
Failure to Investigate and Resolve Resident's Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance regarding a resident's missing incontinent briefs. The resident, who was admitted with multiple diagnoses including COPD, morbid obesity, and chronic respiratory failure, reported that their diapers were being stolen. The facility did not stock the resident's size, so the hospice company ordered them. Despite the resident's complaint to the social worker and the Director of Social Services (DSS), the issue was not promptly addressed. The DSS was informed of the missing briefs and noted the resident's grievance in a report. However, the DSS did not ensure immediate action was taken, such as installing a lock on the resident's closet as promised. The Director of Nursing (DON) acknowledged the facility's lack of investigation into the allegation and failure to offer alternative solutions, such as ordering more briefs for the resident. The facility's grievance policy requires staff to take immediate action to prevent further violations of resident rights while investigating complaints. However, the facility did not adhere to this policy, as evidenced by the lack of investigation and resolution of the resident's grievance. The resident's complaint was not adequately addressed, and the facility did not follow through with the necessary steps to resolve the issue.
Failure to Maintain Hospice Visit Records
Penalty
Summary
The facility failed to maintain hospice visit records for a resident who was receiving hospice care. The resident, admitted in July 2024, had multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, morbid obesity, heart failure, gout, major depressive disorder, gastro-esophageal reflux disease, glaucoma, and dependence on supplemental oxygen. The resident's Minimum Data Set indicated intact cognition but dependence on assistance for toileting, personal hygiene, and transfers. During an observation in December 2024, it was found that the facility's hospice binder lacked the resident's hospice nursing and doctor visit notes. Interviews with the Director of Nursing and the Director of Medical Records revealed that the facility did not have the hospice notes for the resident, and there was no follow-up to obtain them. The facility's policy required hospice notes to be included in the facility's progress notes and for nursing staff to be informed of any changes recommended by hospice staff. However, this documentation was missing, which was not in line with the facility's policy and had the potential to leave nursing staff uninformed of any changes recommended by hospice staff for the resident.
Resident Elopement Due to Inadequate Supervision and Lack of Alarms
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including metabolic encephalopathy, unspecified altered mental status, and diabetes, was cognitively intact but required supervision for daily activities. Despite this, the resident was able to leave the facility without staff knowledge, as the facility lacked proper alarm systems on exit doors and did not have a staff member monitoring the front desk during nighttime hours. On the night of the incident, a CNA discovered the resident missing during rounds and reported it to an LVN. The staff searched the facility and surrounding area but could not locate the resident. The resident was eventually found by an LVN at a bus stop later that morning. Interviews with staff revealed that the resident did not have a wander guard at the time of the incident, and there was no documentation of regular rounding on residents, which was supposed to occur every two hours according to facility policy. The facility's policies on resident safety and elopement were not followed, as there were no alarms on exit doors, and the resident did not have a wander guard. The lack of documentation for staff rounds further contributed to the failure to prevent the resident's elopement. The facility's Director of Nursing acknowledged these deficiencies and the potential risks associated with unsupervised resident elopement.
Medication Management Deficiency in LTC Facility
Penalty
Summary
The report identifies a deficiency in pharmaceutical services at the facility, specifically involving the failure of a Licensed Vocational Nurse (LVN) to replace missing medications for residents. The LVN did not replace a missing Lidocaine patch for one resident, leading to the borrowing of a patch from another resident, which risked depleting the second resident's supply. Additionally, the LVN failed to replace a missing Florastor supplement for another resident, resulting in a missed dose. The deficiency was observed during a medication pass when the LVN discovered the absence of the Florastor bubble pack in the resident's drawer and noted the missing Lidocaine patches in another resident's bag. The LVN attempted to address the issue by writing a note to the Registered Nurse Supervisor (RNS) to reorder the Florastor and borrowed a Lidocaine patch from another resident's supply. The RNS confirmed that borrowing medication from another resident is not permitted and outlined the procedure for reordering medications when supplies are low. The residents involved had various medical conditions requiring specific medications. One resident, who required Lidocaine patches for pain management during dialysis, reported experiencing pain when the patches were unavailable. The facility's policy clearly states that medications should not be used for any patient other than the one for whom they were prescribed, highlighting the importance of maintaining adequate medication supplies and following proper procedures for reordering and administering medications.
Improper Management of Glucose Quality Control Solution
Penalty
Summary
The facility failed to properly manage and label Glucose Quality Control Solution, leading to potential confusion and inaccurate blood sugar readings. During an observation, it was found that Medication Cart A contained a Glucose Quality Control Solution with an open date and a mismatched lot number between the solution bottle and its storage box. The Licensed Vocational Nurse (LVN) acknowledged that the Director of Nursing (DON) instructed staff that the solution expires 28 days after opening, but there was no policy reviewed by the LVN regarding this. The Glucose Meter Quality Control Results Log confirmed the 28-day expiration rule, but the facility lacked a formal policy and procedure for handling the Glucose Quality Control Solution. The DON admitted uncertainty about the expiration of the Glucose Quality Control Solution and confirmed that the facility did not have a policy for the glucometer or the solution. The absence of a clear policy and the use of expired solutions could lead to false glucose readings, potentially resulting in inappropriate insulin administration and harm to residents. The DON acknowledged the risk of false readings causing severe health issues, such as hypoglycemia, which could lead to coma. However, no specific corrective actions or follow-up measures were mentioned in the report.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to ensure food was stored in a sanitary manner, which could lead to foodborne illnesses. During a facility tour, a resident was observed with a bottle of apple juice on the floor by her bed, which was brought by a friend a few days prior. The resident, who has multiple medical conditions including diabetes and dysphagia, was assessed to have intact cognition and the capacity to make medical decisions. The Licensed Vocational Nurse noted that placing the juice on the floor posed an infection control issue, and the Director of Nursing stated that food brought by visitors should be stored in a communal refrigerator to prevent potential food poisoning. In the kitchen's walk-in food storage area, dented and unlabeled canned food was found stored alongside ready-to-use canned food. The Dietary Supervisor confirmed that dented or expired canned food should be separated and returned to the manufacturer or discarded to prevent accidental use. The facility's policy requires food items to be correctly labeled and dated, with dented or bulging cans placed in a separate storage area. The unit refrigerator used to store food brought by residents' families was found unlocked, with food dated beyond the allowed storage period. The Infection Preventionist and Director of Nursing stated that food should be discarded after 72 hours, but due to a miscommunication about staff responsibilities, expired food was not removed. The Administrator acknowledged the miscommunication, which led to the failure in maintaining the residents' refrigerator, resulting in expired food being accessible to residents.
Failure to Maintain Dignity with Catheter Bag Coverage
Penalty
Summary
The facility failed to ensure that catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. Resident 50, who was readmitted with acute kidney failure, cognitive impairment, and other health issues, was observed with their catheter drainage bag not initially placed in a dignity bag. During an observation, the Director of Nursing was seen placing the catheter bag in a dignity bag, acknowledging the importance of maintaining the resident's dignity. Resident 46, diagnosed with dementia, mild cognitive impairment, and other health conditions, was observed in a wheelchair with their urinary catheter drainage bag visibly exposed and not covered by a dignity bag. The facility's policy emphasizes the importance of maintaining residents' dignity and quality of life, which includes keeping urinary catheter bags covered. The failure to adhere to this policy resulted in a deficiency concerning the residents' dignity.
Failure to Provide Dignity Bag for Catheter Compromises Resident's Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing a dignity bag cover for a urinary catheter drainage bag. The resident, who was admitted with diagnoses including dementia, mild cognitive impairment, muscle wasting, benign prostate hypertrophy, and obstructive and reflux uropathy, was observed in a wheelchair with the catheter drainage bag in open view, without a privacy cover. This observation was made during a tour, where the resident was seen using his legs to wheel himself around the facility, with the drainage bag hoisted and tucked in the back pocket of the wheelchair. Interviews with staff revealed that the Restorative Nurse Assistant (RNA) acknowledged the absence of a dignity bag and was unaware of who assisted the resident to the wheelchair. The Director of Nursing confirmed that a dignity bag should be provided for decency and privacy. The facility's policy on resident rights and quality of life prohibits demeaning practices and emphasizes the importance of covering urinary catheter bags to promote dignity. The failure to provide a dignity bag compromised the resident's right to be treated with dignity.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering oral medications. Resident 29, who had multiple diagnoses including diabetes mellitus, dysphagia, congestive heart failure, atrial fibrillation, breast cancer, hearing loss, and acute angle-closure glaucoma, was observed with several medications on top of their bedside drawer. These medications included a nasal decongestant, pain relief ointment, antibiotic ointment, and a laxative. Despite Resident 29's statement that they were cleared by an ER doctor to have these medications at bedside, there was no evidence of a physician's order or an assessment by the interdisciplinary team to confirm the resident's capability to self-administer these medications safely. Interviews with facility staff, including an LVN and the DON, revealed that residents are only allowed to have medications at bedside if they have a physician's order and have been evaluated for competence in self-administration. The LVN expressed concerns about Resident 29's legal blindness and the potential for inaccurate self-administration, which could lead to health complications. The facility's policy requires an assessment of the resident's cognitive, physical, and visual ability to self-administer medications, which was not documented in this case.
Failure to Maintain a Quiet and Homelike Environment
Penalty
Summary
The facility failed to ensure a quiet, comfortable, and homelike environment for two residents, resulting in their inability to sleep or rest peacefully. Resident 210, who was admitted with hypertension and muscle weakness, reported being unable to sleep due to noise at night and during the day, caused by another resident's continuous screaming. This resident expressed concern for the screaming resident's well-being and feared that she might not receive help if needed. Similarly, Resident 48, who also had hypertension, muscle weakness, and hyperlipidemia, reported being unable to sleep at night due to the same issue. Both residents indicated that the screaming persisted until the day shift staff intervened. Observations confirmed that a resident was continuously screaming and yelling, with staff entering the room to calm the resident temporarily. However, the screaming resumed once staff left the room. Interviews with staff, including a CNA and a Registered Nurse Supervisor, revealed that the screaming resident frequently called for help, stopping only when checked on by staff. The facility lacked a policy and procedures to maintain a quiet, comfortable, and homelike environment, contributing to the deficiency.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to ensure that a PASRR Level II assessment was completed for Resident 27, as required by the PASRR Level I screening. This oversight placed Resident 27 at risk of not receiving the necessary care and specialized services tailored to their mental health needs. The resident's care plans did not indicate any individualized rehabilitative treatments and services as required by the PASRR Level II for their mental health condition. Resident 27 was admitted and readmitted to the facility with multiple diagnoses, including metabolic encephalopathy, multiple sclerosis, major depressive disorder, bipolar disorder, paranoid personality disorder, and schizophrenia. Despite these conditions, the facility did not complete the necessary PASRR Level II assessment, which was indicated by the PASRR Level I screenings conducted on two separate occasions. The resident's medical records, including progress notes and psychosocial notes, highlighted ongoing mental health challenges and the need for specialized therapeutic interventions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of a tracking system to monitor which residents required PASRR Level II assessments. The facility's policies and procedures outlined the need for such assessments and the role of the Interdisciplinary Team in reviewing and implementing recommendations. However, the absence of a tracking log and reliance on identifying residents with psychosis or on psychotropic medications as triggers for Level II assessments contributed to the oversight in Resident 27's case.
Failure to Change Catheter Bag and Monitor for Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who had a history of hypertensive chronic kidney disease, obstructive and reflux uropathy, and other conditions, was observed with yellow cloudy fluid and sediments in the catheter tubing. The facility's policy required the catheter bag to be changed per the physician's order, which was not adhered to, as the catheter bag had not been changed since the date written on it, 10/21/2024, despite the physician's order to change it per schedule and as needed. Observations and interviews with the Director of Nursing (DON) and other staff revealed that the catheter bag was overdue for a change, and the presence of sediment indicated a possible infection. The DON and other staff acknowledged that the sediment could be a sign of infection and that a physician should be notified immediately. However, the facility's records did not indicate that the catheter had been changed as required, and the staff failed to notify the physician about the sediment in the catheter tubing. The facility's policy and procedures for catheter care, revised on 6/10/2021, required nursing staff to assess the indwelling catheter for signs of infection, including cloudiness and sediment, and to notify the physician for clinical interventions. The failure to follow these procedures placed the resident at increased risk for a urinary tract infection, as the catheter bag was not changed according to the physician's order and facility policy, and the presence of sediment was not promptly addressed.
Oxygen Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents received the correct amount of prescribed oxygen as ordered by their physicians. Resident 7, who was admitted with multiple diagnoses including encephalopathy, diabetes mellitus, and dementia, was observed with an oxygen concentrator set at 3 liters per minute, but the nasal cannula was not placed on the resident's nostrils as required. Instead, it was found on the resident's chest, covered by linens. This oversight was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged the error and corrected it by placing the nasal cannula on the resident's nostrils. The Director of Nursing (DON) later confirmed that this failure could have led to desaturation and other serious health issues. Resident 2, who was admitted with chronic obstructive respiratory disease (COPD) and other respiratory conditions, was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. A Registered Nurse (RN) confirmed the discrepancy and acknowledged that administering oxygen at a higher rate than prescribed constitutes a medication error. The DON emphasized that oxygen is considered a medication, and incorrect administration could lead to complications such as hypercapnia. The facility's policy on oxygen therapy, dated 2017, mandates that oxygen be administered per physician orders to meet resident needs safely. Both incidents highlight a failure to adhere to these policies, resulting in potential risks to the residents' health. The facility's job description for Licensed Vocational Nurses also requires them to prepare and administer medication as ordered by the physician, which was not followed in these cases.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to complete annual performance evaluations for one out of five sampled staff members, specifically a Certified Nursing Assistant (CNA 2) who was hired on 10/29/2001. During a record review with the Director of Staff Development (DSD), it was found that there was no performance evaluation for CNA 2 for the years 2023 or 2024 in the employee file. The DSD acknowledged the importance of competencies to ensure staff are performing safe practices and are competent, noting the potential harm to residents if evaluations are not conducted. The Director of Nursing (DON) confirmed that performance evaluations are conducted annually and as needed to ensure staff have the proper skills to care for residents. The facility's policy on Staff Competency Assessment, revised on 3/17/2022, states that competency assessments should be performed upon hiring, during the employee's 90-day employment, annually, or any time new equipment or procedures are introduced and as needed.
Infection Control Lapses in Oxygen and Catheter Management
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, leading to potential infection risks. Resident 2's nasal cannula tubing was observed touching the floor, and the oxygen humidifier had not been changed since 10/13/2024, despite facility policy requiring weekly changes. Resident 2 was admitted with chronic obstructive respiratory disease, chronic respiratory failure with hypoxia, and heart failure, and was dependent on staff for various activities. During an observation, the Registered Nurse confirmed the humidifier's outdated status and acknowledged the risk of infection from tubing contact with the floor. Resident 50's supra pubic catheter drainage bag was found touching the floor, which could lead to infection. Resident 50 had been readmitted with acute kidney failure and a history of transient ischemic attack, and was also dependent on staff for daily activities. The Director of Nursing raised the bed to prevent the catheter bag from touching the floor, acknowledging the infection risk. The facility's policies on infection control and oxygen therapy emphasize maintaining a sanitary environment and changing equipment per guidelines, which were not followed in these instances.
Inadequate Training by LVN for RN Staff
Penalty
Summary
The facility failed to ensure that the Assistant Director of Nursing (ADON) and a licensed vocational nurse (LVN) possessed the necessary skills to train registered nursing staff on resident care and assessment. The ADON, who has been in the position since March 2024, does not hold a California registered nursing (RN) license and is currently licensed as an LVN while awaiting her RN credentials in California. Despite this, the ADON was responsible for conducting in-service education and training for Certified Nursing Assistants (CNAs), LVNs, and RNs, including topics such as abuse and falls. The facility's in-service records confirmed that the ADON provided training to the nursing staff, either independently or with the Director of Staff Development (DSD). Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the ADON was training RNs, which was acknowledged as being outside the scope of practice for an LVN. The DON stated that moving forward, only the DON and an RN would conduct in-service training for RNs, as LVNs are not authorized to train RNs. The ADM also recognized that the ADON should not be training RNs until she obtains her RN license in California. The facility's job descriptions and policies further highlighted the discrepancy, as the LVN's role is to provide nursing care under the supervision of an RN, and the ADON's responsibilities include assisting the DON and supervising nursing personnel.
DSD Lacks Required Competencies Due to Incomplete Training
Penalty
Summary
The facility failed to ensure that the Director of Staff and Development (DSD) possessed the necessary competencies and skill sets required to effectively plan, implement, direct, and evaluate the educational programs for all employees. This deficiency arose because the DSD transitioned from the role of Infection Preventionist Nurse (IPN) to DSD without completing the mandatory continuing education course required for the position. The transition occurred in March 2023 following the resignation of the previous DSD, leaving the current DSD to manage the responsibilities without the requisite training. The DSD acknowledged during an interview that she had not completed the necessary continuing education due to the abrupt transition and was in the process of handling the paperwork herself to obtain the required certificates.
Failure to Report Change in Administrator
Penalty
Summary
The facility's governing body failed to ensure that the Administrator (ADM), responsible for managing and overseeing the implementation of policies and procedures, reported a change in the Administrator as required by State and Federal regulations. This deficiency was identified through interviews and record reviews, revealing that the Electronic Licensing Management System (ELMS) listed a different name for the ADM of Skilled Nursing Facility 1 (SNF 1) as of 7/29/2024. The ADM, who started in 10/2023, was also serving as an ADM at another facility. During an interview, the ADM admitted to applying for the Change of Ownership (CHOW) with the State Department in 10/2023 but was unable to provide documentation of the application to the surveyor, claiming it was not a regulation to keep a copy. The facility's policy and procedure, titled Governing Body and revised on 5/23/2019, states that the Governing Body appoints a qualified Administrator licensed by the State of California, responsible for the facility's management and accountable to the Governing Body. The policy also requires the facility to submit a new application package to the California Department of Public Health whenever a change in ownership occurs, and all other changes must be reported to the Licensing and Certification District Office in writing within ten days of the change. The failure to report the change in Administrator had the potential to affect the safety and overall well-being of all 56 residents in the facility.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to provide timely meal service to a resident, which compromised the resident's dignity and comfort. The resident, who has type two diabetes mellitus, chronic kidney disease, and major depressive disorder, was observed waiting for a lunch tray past the scheduled meal time. The resident expressed irritation and discomfort due to hunger, as the lunch trays were consistently delivered late, often close to 1 p.m., despite the meal schedule indicating that lunch should be served at 12 p.m. The delay in meal service was attributed to logistical challenges faced by the staff. The facility's elevator was out of service, requiring certified nursing assistants to manually transport meal carts from the basement kitchen to the first floor via a steep ramp. This process was time-consuming and interfered with their ability to assist residents promptly. The facility's policy mandates that meals be served at regularly scheduled hours, and the failure to adhere to this schedule resulted in the resident's dissatisfaction and discomfort.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of a resident, leading to a fall and subsequent injuries. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was identified as a fall risk. Despite having a care plan and physician orders that required the bed to be in a low position and floor mats to be in place, these measures were not followed. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to the care plan and physician orders. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident unattended after providing care, with the bed in a high position and side rails up. The CNA stepped away to call for assistance in repositioning the resident, during which time the resident fell from the bed, sustaining a head injury and a laceration to the left eyebrow. The resident was subsequently transferred to a hospital for evaluation and treatment, where a CT scan revealed frontal scalp soft tissue swelling, and the resident received sutures for the laceration. Interviews with staff and other residents confirmed that the bed was not in the prescribed low position, and floor mats were absent at the time of the fall. The facility's policies on fall management and resident safety were not adhered to, as the necessary precautions to prevent falls were not implemented. The incident highlights a failure to follow established care plans and physician orders, resulting in harm to the resident.
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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