Mayflower Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 5043 Peck Rd, El Monte, California 91732
- CMS Provider Number
- 555374
- Inspections on file
- 33
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Mayflower Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiplegia, muscle weakness, and dry eye syndrome, who was care planned as dependent for ADLs and expected to be kept clean and well-groomed, was observed with dried eye discharge around and beneath both eyes and reported feeling uncomfortable and needing help to clean the eyes. The resident was later seen in the activities room still with eye discharge present. An activities assistant and a CNA stated that nursing staff were responsible for ensuring residents were clean and well-groomed to maintain dignity. The DON and facility policies on ADL support and resident rights emphasized maintaining grooming, hygiene, and dignity, but these were not followed in this case.
A resident with severe cognitive impairment, hemiplegia/hemiparesis after stroke, and on anticoagulant therapy developed skin discoloration on the left upper arm, left side of the body, and right forearm, which was reported to an LVN and documented on a Change of Condition form. Despite this identified change, no person-centered care plan was developed or implemented to address or monitor the skin discoloration. During interviews and record review, an LVN and the DON confirmed the absence of a related care plan, which was not consistent with the facility’s policy requiring comprehensive, measurable care plans to be updated when a resident’s condition changes.
Surveyors found expired food items in the refrigerator, unlabeled trays of prepared food, and incomplete documentation of dish machine, sanitizer, and temperature logs. The Dietary Supervisor confirmed these lapses, which were not in accordance with facility policy.
Surveyors found that two residents did not receive safe and appropriate respiratory care: one had oxygen tubing touching the floor while in use, and another had unlabeled oxygen tubing and was receiving oxygen at a rate different from the physician's order. Both issues were confirmed by staff as not following facility policy for oxygen administration and infection control.
The facility did not obtain informed consent before installing bed rails for a resident with severe cognitive impairment, failed to document or attempt alternative interventions before using side rails for a cognitively intact resident, and did not provide required padded side rails for two residents with seizure disorders as ordered by physicians. Damaged or missing padding and lack of documentation were confirmed by staff and the DON, in violation of facility policies.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. Staff and DON interviews confirmed the expectation for call light accessibility, but observations showed the devices were either tucked under a pillow or hanging on the wall, leaving the residents unable to call for assistance.
The facility did not ensure that information about advance directives was properly documented and accessible in the medical records for three residents, including one with dementia and severe cognitive impairment, one with muscle weakness and intact cognition, and one with dementia and anemia. In each case, required forms were incomplete or missing, and there was a lack of documentation that residents or their representatives were provided with information about advance directives or that follow-up was conducted as required by facility policy.
A resident with severe cognitive impairment and total dependence on staff for ADLs was left exposed during a clothing change when a CNA failed to close the privacy curtain, allowing the resident's upper chest to be visible to others. Facility leadership and policy confirmed that privacy should have been maintained during care.
A resident with dementia and anemia, who consistently received oxygen therapy as ordered, was inaccurately coded on the MDS assessment as not using oxygen. Despite daily documentation and staff confirmation of oxygen use, the MDS Coordinator failed to review relevant data, leading to incorrect reporting of the resident's respiratory treatments.
A resident with severe cognitive impairment and a primary language of Cantonese was not provided with a communication board or device in their preferred language, despite documentation of this need in their care plan and assessment. Staff confirmed that such devices were not present and that Cantonese-speaking staff were not always available, contrary to facility policy requiring accommodations for limited English proficiency.
A resident with muscle weakness, osteoarthritis, and Alzheimer's disease, who required a plate guard and two-handled cup for eating, was not properly supervised during a meal. The plate guard was incorrectly positioned, resulting in food spillage on the tray and the resident's clothes. Staff confirmed the device should have been set up to allow effective use by the resident's dominant hand, in accordance with the care plan and facility policy.
Certified Nurse Assistants failed to wear gowns, as required, while providing care to a resident on Enhanced Barrier Precautions due to a gastrostomy tube and high infection risk. The CNAs were observed only wearing gloves during high-contact care, despite facility policy and orders specifying the need for both gloves and gowns. Staff interviews confirmed awareness of the PPE requirements for residents on EBP.
A resident with severe cognitive impairment and high fall risk was found with a disconnected wheelchair pad alarm due to a broken cable. The care plan and facility policy required a functional alarm to alert staff if the resident attempted to get up, but this was not maintained, as confirmed by the DSD and DON.
The facility failed to engage 12 residents in the dining room in activities of their choice or the activity program. While the AD and AA conducted exercises with 15 residents, 12 others were left unengaged, with some sleeping in their wheelchairs. Interviews with staff revealed awareness of the need to stimulate and encourage residents, but this was not effectively implemented, contrary to the facility's policy on providing meaningful activities.
The facility failed to ensure call lights were accessible and functional for residents, increasing the risk of accidents and delays in care. Observations showed call lights were often wrapped around bed frames or siderails, making them unreachable, and bathroom pull cords were too short. Staff acknowledged these issues but did not promptly address them, compromising resident safety.
A long-term care facility failed to provide a functioning and accessible call light system for residents, as required by their policy. Observations revealed that call lights were not within reach for two residents in their rooms, and call light pull cords were not accessible for ten residents when using the bathroom. Additionally, call lights were not functioning for three residents in the bathroom. These deficiencies were identified during a survey, which included observations, interviews, and record reviews.
The facility failed to maintain cleanliness in the walk-in freezer and control pests in the kitchen area, leading to potential cross-contamination risks. Observations revealed a dirty mat in the freezer and insects in the kitchen, with the Dietary Services Supervisor acknowledging inadequate cleaning and pest control measures. Facility policies for cleaning and pest control were not effectively implemented.
The facility failed to implement its Advance Directives policy for five residents, resulting in missing or incomplete AD Acknowledgement Forms in their clinical records. This deficiency involved residents with severe cognitive impairments and various medical conditions, such as dementia and psychosis, who required assistance with daily activities. The facility's policy required AD information to be prominently displayed in medical records, but this was not followed.
The facility failed to create individualized care plans for two residents, one with psychosis and major depressive disorder, and another on oxygen therapy. Both residents lacked care plans addressing their specific needs, despite severe cognitive impairments and dependencies. Interviews confirmed the absence of necessary care plans, which should have been developed per facility policy.
The facility failed to update the care plans for two residents, leading to potential risks of not receiving appropriate interventions. One resident's care plan was not revised to remove a discontinued pad alarm order, while another's was not updated to reflect a new enteral nutrition formula. This deficiency highlights a lapse in adhering to the facility's policy for maintaining current care plans.
The facility failed to provide necessary communication tools for two non-English speaking residents with severe cognitive impairments, as required by their care plans. Observations revealed the absence of communication boards at the residents' bedsides, which was confirmed by an LVN and the DON, indicating non-compliance with the facility's communication policy.
A resident with type 2 diabetes and severely impaired cognition repeatedly refused fasting blood sugar (FBS) tests, and the facility failed to notify the physician as required. Despite the resident's need for assistance and the facility's policy to document refusals and notify the physician, there was no documentation of such notifications. Interviews with staff confirmed the oversight, highlighting a lapse in following the facility's procedures.
A resident with dementia and seizures experienced falls due to the facility's failure to implement a care plan intervention for a night light. Despite a history of falls and a care plan revision, the night light was not provided, as confirmed by staff interviews and room inspection.
A resident with heart failure and hypertension did not receive oxygen therapy as ordered, with no oxygen setup at the bedside. The facility's staff failed to clarify or discontinue the order with the physician, contrary to the facility's policy requiring physician communication for treatment changes.
A facility failed to notify the Long-term Care Ombudsman of a resident's transfer to an acute care hospital, as required by policy. The resident, who had severe cognitive impairment and was highly dependent on assistance, was transferred due to chest pain. The Social Service Assistant confirmed that no notification was sent, which is a breach of the facility's procedures.
The facility failed to ensure proper waste disposal, as one of two trash bins was left open due to being overfilled, potentially attracting pests and risking infection. The Dietary Services Supervisor noted the need to avoid overfilling bins, while the Administrator acknowledged the necessity of a third bin to prevent such issues. The facility's Pest Control policy requires daily removal of trash to prevent accumulation.
A facility failed to follow its infection control policies when an LVN did not wear gloves or perform hand hygiene before handling a resident's Foley catheter and Gastrostomy Tube feeding. The resident, who was severely cognitively impaired and dependent on staff for care, was at high risk for infection. The facility's P&P required handwashing and the use of gloves and gowns for high-contact activities, which were not adhered to, as confirmed by supervisory staff.
A resident with dementia and Alzheimer's disease was unable to access their call light because it was caught between the bed and bedrails, contrary to the care plan and facility policy. Staff interviews confirmed the call light should have been within reach, as per the facility's procedures.
A facility failed to provide bedside tables to 19 residents, violating its 'Homelike Environment' policy. A resident with dementia and anxiety disorder was found without a bedside table, leading to confusion. Staff interviews revealed inconsistent views on the necessity of bedside tables, with some unaware of the deficiency. The facility's policy required bedside tables, yet they were missing, affecting residents' well-being.
A resident with severe cognitive impairment and visual loss was unable to reach or use their bedside tray due to its placement and broken condition. Staff confirmed the tray was slanted and not within reach, posing challenges for the resident's daily activities. The Maintenance Director noted the tray's bent arm, highlighting the facility's failure to maintain a homelike environment.
Failure to Maintain Resident Dignity Through Adequate Eye Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to assist a dependent resident with basic grooming and hygiene related to eye care, resulting in the resident remaining with visible eye discharge on and beneath both eyes. The resident had a history of hemiplegia and hemiparesis following cerebral infarction, heart failure, muscle weakness, and dry eye syndrome, and was documented as lacking capacity to understand and make decisions. The MDS showed the resident was severely cognitively impaired and dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The care plan indicated a self-care deficit, extensive assistance needs with ADLs and physical function, and a goal that the resident would be clean, dry, and well-groomed daily. On observation, the resident was seen with discharge around both eyes and on the face beneath the eyes, and the resident reported feeling uncomfortable and needing help to clean the eyes. A subsequent observation in the activities room again noted discharge around and under the eyes. The Activities Assistant stated that nursing staff should have cleaned the eye discharge and ensured the resident was well-groomed before being transferred to activities, emphasizing the importance of grooming for dignity. A CNA stated that it was the nurses’ responsibility and that helping residents maintain good personal hygiene was important for dignity. The DON stated that nurses must treat residents with respect, kindness, and dignity and keep them clean and well-groomed. Facility policies on ADL support and resident rights required providing necessary services to maintain grooming and hygiene and guaranteeing residents’ rights to a dignified existence and to be treated with respect, kindness, and dignity, which were not followed in this instance.
Failure to Care Plan for Resident’s New Skin Discoloration After Change of Condition
Penalty
Summary
The deficiency involved the facility’s failure to develop and implement a person-centered care plan with measurable objectives and timetables after a resident was found with new skin discoloration. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was on anticoagulant therapy. The resident’s History and Physical documented that the resident lacked capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills and total dependence on staff for ADLs, bed mobility, and transfers. On 12/1/2025, a certified nursing assistant reported to LVN 3 at 5 AM that the resident had skin discoloration on the left upper arm, left side of the body, and right forearm, and a Change of Condition form was completed that same day. During subsequent interviews and record reviews with LVN 2 and the DON, it was confirmed that there was no care plan addressing the resident’s skin discoloration despite the documented change of condition. LVN 2 stated that LVN 3 should have developed a care plan immediately after identifying the discolorations and completing the COC. The DON also confirmed that no care plan had been created to monitor the resident’s physical and psychosocial condition related to the skin discoloration. This was inconsistent with the facility’s written policy on comprehensive person-centered care plans, which requires development and implementation of care plans with measurable objectives and timetables, and revision of care plans when there is a change in a resident’s condition.
Failure to Follow Food Storage and Sanitation Standards
Penalty
Summary
Surveyors observed that the facility failed to adhere to proper food storage and sanitation standards in several ways. During a kitchen inspection, expired food items were found in the refrigerator, including a bag of tortillas, four cheese sandwiches, and seven peanut butter and jelly sandwiches, all past their best buy dates. Additionally, trays of apple sauce and fruit cocktail were stored without preparation date labels, making it unclear when they were prepared. The Dietary Supervisor confirmed that these items should have been checked and labeled according to facility policy. Further review of facility records revealed incomplete monitoring and documentation logs for critical kitchen operations. The Dish Machine Temperature Log, Quat Sanitizer Log, and Refrigerator & Freezer Temperature Logs all had missing entries for multiple days. The Dietary Supervisor acknowledged that these logs were the responsibility of dietary staff and should have been completed to ensure proper sanitation and food safety. Facility policies reviewed indicated that expired food should not be in stock, all prepared foods should be labeled and dated, and temperature and sanitizer logs should be maintained as required.
Failure to Follow Oxygen Administration Policies for Two Residents
Penalty
Summary
The facility failed to implement its policies and procedures for oxygen administration for two residents. For one resident with chronic obstructive pulmonary disease (COPD) and heart failure, surveyors observed that the nasal cannula tubing was touching the floor while in use. Both the LVN and the DON confirmed that this practice was not in accordance with facility policy and posed an infection control risk. The facility's policy required that oxygen tubing be used in a manner that prevents it from touching the floor. For another resident with dementia and anemia, surveyors found that the nasal cannula tubing was not labeled and the oxygen was set at 1.5 L/min, which did not match the physician's order of 2 L/min. The LVN acknowledged that the tubing should have been labeled for infection control and that the oxygen flow rate should have matched the physician's order. The DON confirmed that oxygen tubing should be labeled and that oxygen must be administered as ordered by the physician. The facility's policy required weekly changes of oxygen tubing with labeling and administration of oxygen as ordered.
Failure to Follow Bed Rail and Restraint Policies for Multiple Residents
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the use of bed rails and physical restraints for four residents. For one resident with severe cognitive impairment and total dependence for activities of daily living, staff installed bilateral upper half side rails without obtaining informed consent from the resident or their responsible party. Both the LVN and DON confirmed that no signed informed consent was present in the resident's chart or electronic medical record, despite facility policy requiring this before side rail use. Another resident, who was cognitively intact and independent in bed mobility, had bilateral side rails with damaged and ripped padding. The resident stated they did not use or want the side rails, and there was no documentation that alternative interventions had been attempted prior to their use. The DON acknowledged the lack of clinical documentation for attempted alternatives and agreed that the damaged padding should have been replaced to ensure safety and dignity, as required by facility policy. Two additional residents with seizure disorders and physician orders for padded side rails were observed to have bedside rails without any foam padding. Both residents had documented cognitive impairment and active orders for padded rails as a safety precaution. Staff interviews confirmed that the required padding was not present, and the DON stated that padding was necessary to prevent injury during seizures. Facility policy specified that side rails should be padded if ordered by a physician for seizure management.
Failure to Ensure Call Lights Within Reach for Cognitively and Physically Impaired Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with significant cognitive and physical impairments. One resident, admitted with dementia, COPD, and osteoarthritis, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living. Observations revealed that this resident's call light was tucked under the pillow and not accessible, and staff interviews confirmed the resident was unaware of the call light's location. The care plan for this resident specifically required the call light to be kept within easy reach due to fall risk and impaired cognition, but this intervention was not followed. Another resident, with diagnoses including muscle weakness, lack of coordination, parkinsonism, and dementia, was also found to have their call light hanging on the wall and out of reach while sitting in bed. This resident was assessed as high risk for falls and had a care plan intervention for staff to keep the call light within reach. Both staff and the DON confirmed that call lights should be accessible at all times, especially for residents at high risk for falls. The facility's policy also required call lights to be within reach, but this was not implemented for these two residents.
Failure to Ensure Advance Directive Documentation and Communication
Penalty
Summary
The facility failed to implement its policies and procedures regarding Advance Directives (AD) for three residents by not ensuring that information about the existence or execution of ADs was properly documented and accessible in the residents' medical records. For one resident with dementia, COPD, and osteoarthritis, the AD Acknowledgement form indicated an AD had been executed, but no copy was found in the chart or uploaded to the electronic medical record (EMR). The Director of Nursing (DON) confirmed that a copy should have been available to staff to address the resident's end-of-life wishes. Another resident with muscle weakness and mobility issues, who had intact cognition, did not have a completed AD Acknowledgement Form in the medical record. There was also no clinical documentation that Social Services had provided information about ADs or attempted to reach out to the resident or responsible party to offer this information upon admission, as required by facility policy. The DON confirmed that the form should have been completed and discussed with the resident or responsible party at admission. A third resident, with dementia and anemia and lacking decision-making capacity, also did not have documentation in the medical record regarding the existence of an AD or a Physician Orders for Life-Sustaining Treatment (POLST). Progress notes showed that nursing staff only recently attempted to contact the family about the AD and POLST, and the Advance Healthcare Directive Acknowledgment form was not completed. The DON acknowledged that the form should have been completed by Social Services and that there was no documentation of follow-up attempts prior to the recent week.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to provide privacy for a resident during personal care activities. Specifically, while a certified nurse assistant was changing the resident's clothes, the privacy curtain was not closed, resulting in the resident's upper chest being exposed to their roommate and potentially to the hallway. This was directly observed by surveyors, and both the CNA and facility leadership acknowledged that the privacy curtain should have been closed during such care to maintain the resident's dignity and privacy. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including dressing and personal hygiene. Facility records, including the care plan, indicated that staff were required to maintain the resident's privacy and respect their rights during care. The facility's policy on dignity also specified that bodily privacy must be protected during personal care and treatment procedures.
Inaccurate MDS Assessment of Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident accurately reflected the resident's use of oxygen therapy. The resident, who had diagnoses including dementia and anemia and lacked decision-making capacity, was admitted with orders for oxygen therapy as needed for shortness of breath, with specific parameters for administration and monitoring. Despite these orders and daily documentation of oxygen use throughout the assessment period, the MDS assessment did not indicate that the resident was receiving oxygen therapy, and was coded as if no oxygen was used. Observations and interviews confirmed that the resident was consistently on oxygen, except during showers, and this was corroborated by nursing staff and daily vital sign records. The MDS Coordinator acknowledged failing to review the oxygen saturation summary data, which would have shown daily oxygen use during the look-back period. The facility's policy required accurate completion and attestation of the MDS, but this was not followed, resulting in inaccurate reporting to CMS regarding the resident's respiratory treatments.
Failure to Provide Communication Device in Resident's Preferred Language
Penalty
Summary
A deficiency occurred when the facility failed to provide a communication device in a language understood by a resident with cognitive and communication deficits. The resident, who spoke Cantonese and had diagnoses including dementia, bipolar disorder, and anxiety, was identified in the care plan and Minimum Data Set as needing a translator or communication device to communicate with staff. Despite this documented need, observation and interviews revealed that the resident did not have a communication board in the room, and Cantonese-speaking staff were not always available. Staff interviews confirmed that all non-English speaking residents should have access to communication boards, and the facility's policy required reasonable steps to accommodate residents with limited English proficiency, including providing communication boards with written translation. The lack of a communication device for the resident had the potential to affect communication with staff and delay the provision of care, treatment, and services.
Failure to Ensure Proper Use of Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, osteoarthritis, and Alzheimer's disease, who required adaptive equipment for eating, was not properly supervised during mealtime. The resident's care plan specified the use of a plate guard and a two-handled cup to prevent spillage, and the Minimum Data Set indicated the resident had impaired cognition and required setup or clean-up assistance with eating. During observation, the resident was seen eating independently with a plate guard, but the opening of the plate guard was incorrectly positioned, resulting in a moderate amount of food spilled on the tray and the resident's clothes. Staff interviews confirmed that the plate guard should have been positioned to allow the resident's dominant hand to use it effectively and minimize spillage. The facility's policy required that residents have adaptive equipment as indicated to maintain or improve their functional level, and that staff observe the effectiveness of such equipment. However, the improper positioning of the plate guard and lack of appropriate supervision during the meal led to ineffective use of the adaptive device, as evidenced by the food spillage and the resident's inability to maintain independence during mealtime.
Failure to Use Required PPE During Care of Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nurse Assistants 1 and 2 failed to don the required personal protective equipment (PPE), specifically gowns, while providing care to a resident who was on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube and high risk for infection. During an observation, both CNAs were seen cleaning and changing the resident while only wearing gloves, despite the care plan and physician orders indicating the need for both gloves and gowns during high-contact care activities. The resident was dependent on staff for all activities of daily living and had severely impaired cognition, further increasing the risk of infection transmission. Interviews with the CNAs, Infection Prevention Nurse, and Director of Nursing confirmed that staff were aware of the requirement to wear gowns and gloves for residents on EBP, particularly those with feeding tubes. The facility's policy also specified the use of gowns and gloves during high-contact care for residents at increased risk of multidrug-resistant organism (MDRO) acquisition. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in infection prevention and control practices.
Non-Functional Wheelchair Pad Alarm for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure that a wheelchair pad alarm was functional for a resident identified as being at high risk for falls. The resident, who had diagnoses including unspecified dementia and Alzheimer's disease, was assessed as having severely impaired cognition, unsteady gait, poor safety awareness, and a history of attempting to self-transfer from bed and wheelchair. The resident's care plan and facility policy required the use of a safety device pad alarm when the resident was in a wheelchair or bed to alert staff if the resident attempted to get up unassisted. During an observation, it was found that the resident's wheelchair pad alarm was disconnected because the cable was broken. Both the Director of Staff and Development and the Director of Nursing confirmed that the alarm was not functioning and acknowledged that it was necessary for the resident's safety. The facility's policy specified that alarms should be applied and maintained according to manufacturer instructions to ensure functionality, but this was not followed, resulting in the deficiency.
Lack of Resident Engagement in Activities
Penalty
Summary
The facility failed to ensure that 12 out of 28 residents in the dining room were encouraged to engage in activities of their choice or participate in the activity program. During observations, it was noted that while the Activity Director (AD) and Activity Assistant (AA) were conducting exercises with 15 residents, 12 residents sitting behind them were not engaged, with some looking around and others sleeping in their wheelchairs. No staff members encouraged these residents to participate in the exercise program or engage in any other activities. Interviews with the activity staff, including AA 1, AA 2, and the AD, revealed that the staff were aware of their responsibilities to interact with residents, stimulate them, and encourage participation in activities. The AD acknowledged the importance of engaging residents to maintain their abilities and enhance their quality of life. The facility's policy on daily programming emphasized providing meaningful activities appropriate to residents' abilities to enhance their quality of life, but this was not effectively implemented during the observed activities.
Deficient Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and provided adequate supervision to prevent accidents, as outlined in their policies and procedures. Specifically, the facility did not ensure that call lights were within reach for two residents in their rooms and for ten residents when using the bathroom. Additionally, call lights were not functioning for three residents when using the bathroom, increasing the potential for accidents and delays in care. Observations and interviews revealed that call light cords were often wrapped around bed frames or siderails, making them inaccessible to residents. For instance, one resident's call light was wrapped around the bed frame and dangling a few inches from the floor, making it unreachable. Another resident's call light was similarly wrapped around the bed rail, and the bathroom pull cord was too short to reach from the toilet. These deficiencies were observed during multiple visits, and staff acknowledged the issues but did not rectify them promptly. The facility's policies and procedures emphasized the importance of keeping call lights within easy reach to ensure prompt assistance. However, during a random tour, it was found that bathroom call light cords were too short and not functional, as they did not flash above the room doors when tested. This failure to adhere to the facility's policies and procedures compromised the safety and well-being of the residents, who were at risk of falls and injuries due to their medical conditions, such as dementia, schizophrenia, and generalized muscle weakness.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to provide a functioning and accessible call light system for residents, as required by their policy. Observations and interviews revealed that call lights were not within reach for two residents in their rooms, and call light pull cords were not accessible for ten residents when using the bathroom. Additionally, call lights were not functioning for three residents in the bathroom. These deficiencies were identified during a survey, which included observations, interviews, and record reviews. Resident 1's call light was found wrapped around the bed frame, making it unreachable, and the bathroom lacked a pull cord for the call light. Resident 1, who had a history of falls and impaired cognition, reported being unable to call for help after a fall in the bathroom. Similarly, Resident 2's call light was wrapped around the bed rail and the bathroom pull cord was too short to reach from the toilet. Resident 2 also had severely impaired cognition and required assistance with daily activities. Further observations revealed that the call light pull cords in the bathrooms of several other residents were too short, and the call lights did not function properly when tested. The facility's policy on call lights, which aims to ensure prompt assistance for residents, was not adhered to, leading to potential delays in care for the affected residents.
Sanitation and Pest Control Deficiencies in Kitchen Area
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the walk-in freezer and kitchen area, leading to potential cross-contamination risks. During an observation, the walk-in freezer was found to have a mat on the floor with round holes filled with a brown, black, and dry substance. The Dietary Services Supervisor (DSS) acknowledged that the staff needed to clean the walk-in freezer weekly, particularly under the mat, but this was not being done adequately. Additionally, the facility did not prevent the presence of insects in the kitchen area. A fly was observed in the dry storage area, and two gnats were seen in an open closet space where mops and mop buckets were stored. The DSS explained that a fan intended to prevent insects from entering was often turned off by staff because it disrupted items on trays. Despite this, a fly was still present during a tray line observation. The facility's policies indicated that all kitchen areas and equipment should be cleaned daily or weekly, and an ongoing pest control program should be maintained, but these were not effectively implemented.
Failure to Implement Advance Directives Policy
Penalty
Summary
The facility failed to implement its policy on Advance Directives (AD) for five residents, which could lead to providing medical care against the residents' wishes. The deficiency was identified through interviews and record reviews, revealing that the AD Acknowledgement Forms were either missing or incomplete in the clinical records of the sampled residents. This failure was noted for residents with severe cognitive impairments and various medical conditions, including dementia, anemia, and psychosis. For Resident 14, the AD Acknowledgement Form was not found in the clinical record, despite the resident's severe cognitive impairment and need for assistance with daily activities. Similarly, Resident 44's AD Acknowledgement Form was missing, and the resident was dependent on staff for personal care due to severe cognitive impairment. Resident 48's form was incomplete, and the resident also had severe cognitive impairment, requiring moderate assistance with daily activities. Resident 26's clinical record lacked both the AD Acknowledgement Form and the Physician Orders for Life-Sustaining Treatment (POLST), despite the resident's total dependence on staff for personal care. Resident 36's record also did not contain an AD Acknowledgement Form, even though the resident had severe cognitive impairment and required assistance with personal hygiene. The facility's policy required that AD information be prominently displayed in the medical record, but this was not adhered to for these residents.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents, leading to deficiencies in their care. Resident 48, diagnosed with psychosis and major depressive disorder, did not have a care plan addressing the use of Quetiapine and Sertraline, medications prescribed for managing these conditions. Despite the resident's severe cognitive impairment and need for moderate assistance with daily activities, there was no documentation of a care plan to ensure necessary care and effective interventions. Interviews with the Registered Nurse Supervisor and the MDS Coordinator confirmed the absence of a comprehensive care plan for Resident 48, which should have been developed within 14 days of admission as per the facility's policy. Similarly, Resident 10, who was on oxygen therapy due to heart failure and hypertension, lacked a care plan to address the use of oxygen and monitor the resident's response to the treatment. The resident had severely impaired cognition and was totally dependent on assistance for personal hygiene and dressing. The MDS Coordinator and Registered Nurse Supervisor acknowledged the absence of a care plan for oxygen therapy, which was necessary to ensure proper intervention and monitoring. The facility's policy required care plans to be developed on admission and updated as needed, but this was not adhered to for Resident 10.
Failure to Revise Care Plans According to Residents' Needs
Penalty
Summary
The facility failed to revise the care plans of two residents according to their current needs, which posed potential risks for not receiving appropriate interventions. Resident 36 was readmitted with diagnoses including dementia and seizures. The care plan indicated the use of a pad alarm in bed due to a history of falls. However, during an observation, it was found that the pad alarm was not in place, and the Licensed Vocational Nurse confirmed the care plan intervention was not implemented. The Registered Nurse Supervisor later stated that the physician's order for the pad alarm had been discontinued, but the care plan was not updated to reflect this change. Resident 10, who was initially admitted with heart failure, hypertension, and a gastrostomy, had a care plan indicating a specific enteral nutrition formula. However, the care plan was not updated to reflect a new order for a different formula. The Minimum Data Set Coordinator and Registered Nurse Supervisor acknowledged that the care plan was not revised to include the most current nutritional interventions. The Director of Nursing emphasized the importance of revising care plans during significant changes, such as changes in diet or enteral feeding formula. The facility's policy and procedure require care plans to be developed and revised as needed to reflect the resident's current status. The care plans act as a communication tool among healthcare professionals to ensure continuity of care. The failure to update the care plans for Residents 10 and 36 according to their current needs and physician orders highlights a deficiency in the facility's adherence to its own policies and procedures.
Failure to Provide Communication Tools for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication devices for two residents, leading to a deficiency in meeting their communication needs. Resident 19, who was non-English speaking and had severe cognitive impairments, was admitted with conditions including type 2 diabetes, dementia, and hypertension. The care plan for Resident 19 required the use of a communication board in Chinese and translation in Mandarin. However, during an observation, the communication tool was not found at the resident's bedside, which was confirmed by LVN 1, indicating a failure to adhere to the care plan. Similarly, Resident 52, who also had severe cognitive impairments and was dependent on staff for daily activities, required a communication board in Cantonese as per their care plan. During an observation, it was noted that there was no communication board at the bedside, which was acknowledged by LVN 1. The facility's Director of Nursing confirmed the necessity of having communication tools at the bedside to allow residents to express their needs. The facility's policy on accommodating communication needs was not followed, resulting in the potential for unmet needs for both residents.
Failure to Notify Physician of Resident's Refusal for FBS Tests
Penalty
Summary
The facility failed to notify a resident's physician about the resident's repeated refusal to undergo fasting blood sugar (FBS) tests as ordered. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and muscle weakness, had an order for daily FBS tests before breakfast. The order also required notifying the physician if the blood sugar level was above 300 mg/dl or below 60 mg/dl. Despite the resident's severely impaired cognition and need for assistance with personal hygiene and transfers, the Medication Administration Record (MAR) showed that the resident refused the FBS test on multiple occasions throughout June 2024. Interviews with facility staff revealed that there was no documentation indicating that the resident's physician was notified of these refusals. A Licensed Vocational Nurse (LVN) confirmed the lack of documentation and stated that nurses should notify the physician if a resident refuses medication or procedures as ordered. The Director of Nursing (DON) also stated that licensed staff should notify the physician if a resident refuses a physician's order for three consecutive days. The facility's policy on administering medications required that any refusal be documented and the physician or responsible party be notified, which was not adhered to in this case.
Failure to Implement Night Light Intervention for Resident with Fall History
Penalty
Summary
The facility failed to implement a care plan intervention to provide a night light for a resident with a history of falls. The resident, who was readmitted to the facility with diagnoses including dementia and seizures, experienced a fall in their room at night, resulting in injuries such as a bump on the forehead, a skin tear on the left forearm, and discoloration on the right knee. Despite the care plan being revised to include the provision of a night light following this incident, the intervention was not implemented, as observed during a room inspection. The resident's Minimum Data Set indicated severely impaired cognition and a need for assistance with personal hygiene and mobility. Another fall occurred in the resident's room without injury, further highlighting the lack of implementation of the care plan intervention. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the night light was not functioning and that the care plan intervention had not been carried out, contrary to the facility's policies on promoting safety and implementing resident care plans.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident, placing them at risk for shortness of breath and hypoxia. The resident, who had diagnoses including heart failure and hypertension, was admitted and readmitted to the facility with a physician's order for oxygen therapy at 2 liters per minute via nasal cannula, with the possibility to titrate up to 5 liters per minute if oxygen saturation fell below 92%. However, during an observation, the resident was found not using oxygen, and there was no oxygen setup or machine at the bedside. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the order for oxygen therapy was not clarified with the physician, and the treatment was not discontinued by a physician's order. The facility's policy indicated that oxygen administration is a licensed staff procedure based on a physician's order, and any changes to the treatment should be communicated with the physician. The failure to follow these procedures led to the deficiency in care for the resident.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long-term Care Ombudsman of a facility-initiated discharge for a resident, identified as Resident 29. This deficiency was identified during a review of Resident 29's records, which showed that the resident was transferred to a General Acute Care Hospital due to chest pain. Despite the transfer, there was no evidence that the required notification was sent to the Ombudsman, as confirmed by the Social Service Assistant during an interview and record review. The facility's policy and procedure on transfer or discharge notice, revised in March 2021, mandates that a copy of the notice be sent to the Ombudsman, either via fax or email, at the time of transfer or as instructed by the Ombudsman. Resident 29 had been admitted and readmitted to the facility with diagnoses including heart failure and dysphagia. The resident's Minimum Data Set indicated severely impaired cognition and a high level of dependency for personal hygiene and transfers. The failure to notify the Ombudsman of the transfer to the acute hospital meant that the resident was at risk of being discharged without the necessary advocacy and protection from the Ombudsman, as the Ombudsman plays a crucial role in ensuring the appropriateness of such transfers.
Improper Waste Disposal in Trash Bins
Penalty
Summary
The facility failed to ensure proper waste disposal in one of two trash bins, which had the potential to harbor pests and placed the facility at risk for diseases and infection. During an observation and interview, it was noted that Trash Bin 1 was left open because it was filled to the brim, while Trash Bin 2 had enough space for additional trash. The Dietary Services Supervisor acknowledged that facility staff needed to avoid overfilling trash bins to ensure the lids could be closed, as open bins could attract pests, insects, flies, and rodents. The facility Administrator confirmed the need for a third trash bin to prevent overfilling and ensure proper waste disposal, acknowledging that open trash bins could attract pests. A review of the facility's Policy and Procedure on Pest Control, revised in May 2008, indicated that garbage and trash should not accumulate and must be removed from the facility daily.
Infection Control Deficiency Due to Non-compliance with Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Policy and Procedures (P&P) regarding Hand Washing and Enhanced Barrier Precaution (EBP) for a resident, identified as Resident 44. The deficiency was observed when a Licensed Vocational Nurse (LVN 1) did not wear gloves before touching the resident's indwelling Foley catheter and did not perform hand hygiene before handling the resident's Gastrostomy Tube feeding. These actions were contrary to the facility's P&P, which required handwashing between routine procedures and the use of gloves and gowns during high-contact resident care activities, such as device care involving urinary catheters and feeding tubes. Resident 44 was admitted with diagnoses including retention of urine and the need for gastrostomy for nutritional support. The resident's Minimum Data Set indicated severe cognitive impairment and dependence on staff for personal hygiene and other daily activities. The care plan for Resident 44, initiated on a later date, highlighted the resident's high risk for infection due to the gastrostomy feeding and Foley catheter, with interventions requiring staff to perform hand hygiene and use EBP. Despite these documented requirements, LVN 1's failure to follow the infection control protocols was confirmed through interviews with the Registered Nurse Supervisor and the Director of Nursing, who both acknowledged the necessity of these precautions to prevent cross-contamination and infection spread.
Resident's Call Light Not Accessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which could lead to the resident not receiving or receiving delayed care. The resident, who was admitted with diagnoses of dementia and Alzheimer's disease, had severely impaired cognition and required moderate assistance with daily activities. The care plan for the resident included interventions for staff to keep the call light within reach and to attend to the resident's needs promptly. However, during an observation, it was noted that the resident could not find or pull the call light because the cord was caught between the bed and the bedrails. Interviews with facility staff, including a Certified Nurse Assistant and the Director of Nursing, confirmed that the call light should have been positioned within the resident's reach. The facility's policy and procedure on call lights, revised in March 2023, indicated that all staff should know how to place the call light for a resident and ensure it is within reach. Despite these guidelines, the call light was not accessible to the resident, highlighting a failure in adhering to the care plan and facility policy.
Deficiency in Providing Bedside Tables for Residents
Penalty
Summary
The facility failed to adhere to its policy titled 'Homelike Environment' by not providing bedside tables to 19 out of 22 sampled residents. This deficiency was identified through observations, interviews, and record reviews. Resident 2, who was admitted with dementia and anxiety disorder, was found without a bedside table, which was removed by staff for unknown reasons. The resident expressed confusion over the absence of their bedside table, especially since their roommate had one. Interviews with staff, including a CNA and LVN, revealed differing opinions on the necessity of bedside tables, with the LVN affirming that all residents should have one regardless of dining status. Further investigation revealed that the Maintenance Director was unaware of the missing bedside tables, and the Director of Staffing Development acknowledged the absence of these tables for about a month. The Director of Nursing admitted to not checking for missing furniture during rounds and recognized the importance of bedside tables for residents to place items and engage in activities. The facility's policy, reviewed with the Administrator, confirmed that bedside tables were required to provide a homelike environment, yet the deficiency persisted, affecting the well-being of the residents involved.
Failure to Accommodate Resident's Needs with Functional Bedside Tray
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring that the resident's bedside tray was within reach and in functional condition. The resident, who had been readmitted to the facility with diagnoses including generalized muscle weakness, glaucoma, and unqualified visual loss, was observed to have a severely impaired cognition and required supervision and assistance with various activities of daily living. During an observation, the resident's bedside tray was found to be placed across the room, out of reach, and slanted at an angle, making it difficult for the resident to use for personal items or meals. Interviews with staff, including a CNA and an LVN, confirmed that the tray was not within reach and was not in a condition suitable for use. The CNA acknowledged the tray's slant and its impracticality for eating, while the LVN emphasized the importance of having items within reach for the resident's safety, given the resident's blindness. The Maintenance Director also confirmed that the tray was not functional due to a bent arm, which did not promote a homelike environment as per the facility's policy on accommodating residents' needs and preferences.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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