Meadowbrook Behavioral Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3951 East Blvd., Los Angeles, California 90066
- CMS Provider Number
- 05A269
- Inspections on file
- 30
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Meadowbrook Behavioral Health Center during CMS and state inspections, most recent first.
A resident with a documented history of poor boundaries and inappropriate touching, including public masturbation and intrusiveness, was not adequately monitored or managed, resulting in the resident entering a shared bathroom and attempting to touch another resident's private area without consent. The victim, also with a psychiatric diagnosis, reported feeling scared and violated, and staff interviews confirmed ongoing issues with the perpetrator's behavior. The psychologist was not fully informed of the extent of the behaviors, and facility policy requiring identification and intervention for at-risk residents was not effectively implemented.
A resident with paranoid schizophrenia repeatedly engaged in inappropriate behaviors, including touching other residents and staff without consent, as well as public masturbation. Despite extensive documentation and staff awareness of these incidents, the psychologist was not informed of the frequency or severity of the behaviors, nor of specific boundary violations. This lack of communication resulted in another resident experiencing psychological distress and a physical altercation, highlighting a failure to provide appropriate mental health services and interventions.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with significant mental health conditions and lacking decision-making capacity engaged in sexual activity without adequate staff awareness or oversight. Staff interviews revealed inconsistent knowledge of the relationship, and after the encounter, one resident experienced emotional distress, reported feeling unsafe, and was transferred to a hospital following allegations of aggression. The facility failed to ensure a safe environment and proper supervision for these residents.
A resident with a history of exchanging money for sex engaged in non-consensual sexual contact with another resident who lacked capacity to consent, despite prior documentation of sexually inappropriate behavior. Facility staff failed to investigate or act on known risks, and did not implement necessary supervision or interventions, resulting in sexual abuse and emotional harm.
The facility failed to implement its abuse prohibition policy, resulting in a resident who lacked capacity being sexually abused by another resident with a known history of exchanging money for sex. Staff were aware of the perpetrator's sexually inappropriate behaviors but did not properly report or investigate these actions, and the facility did not take adequate steps to prevent or address the abuse as required by policy.
A facility failed to prevent the spread of sexually transmitted infections by not ensuring that residents, who lacked decision-making capacity and were under conservatorship, practiced safe sex. Despite knowing that a resident with a confirmed STI engaged in unprotected sex with others, staff did not implement or monitor infection control measures such as condom use, and interviews revealed a lack of procedures to ensure safe sexual practices.
Two residents were subjected to physical abuse in separate incidents: one involving a physical altercation with a staff member, and another involving a fight between two residents after a verbal dispute escalated. In both cases, staff failed to prevent or promptly intervene in the altercations, resulting in injuries that required medical evaluation.
A resident was not allowed to return to the facility after hospitalization despite being medically cleared for discharge on oral antibiotics. The facility cited the need for isolation due to MSSA, although no isolation order was present. The resident remained in the hospital longer than necessary, and their bed was given to a new resident.
Residents in the facility were unable to access the results of the most recent survey due to the survey binder being placed in a quarantined area, inaccessible to them. Despite having intact cognition and the ability to perform ADLs independently, residents expressed interest in reviewing the survey results but were unaware of their location. Staff confirmed the binder's placement in a restricted area, violating the facility's policy on resident rights to access information about their care.
The facility failed to ensure safe food storage and preparation, with unlabeled and undated cooked chicken and meats in the freezer, and raw chicken improperly stored above vegetables. Interviews revealed non-compliance with facility policies, risking contamination.
The facility failed to use an effective cleaning agent for infection control and did not maintain an adequate supply of N95 masks, as all available masks were expired. The Housekeeping Supervisor was not trained on infection control, and the Director of Nursing confirmed the need for non-expired masks to ensure resident safety. The facility's policy required available PPE at all times, which was not met.
The facility failed to maintain essential kitchen equipment and infrastructure, resulting in a leaking pipe under the kitchen sink and a separated wall panel, creating gaps for pests. The Dietary Supervisor and Maintenance Director were unaware of these issues, and improper food storage practices were also observed. The facility's maintenance policy was not effectively implemented, leading to these deficiencies.
The facility failed to accurately code the MDS for a resident's antipsychotic medication use and did not transmit assessments for two residents within the required timeframe. A resident was incorrectly marked as not taking antipsychotic medication despite being prescribed Zyprexa. Additionally, two residents had completed MDS assessments that were not transmitted on time. The DON acknowledged these issues, which are against facility policy requiring timely and accurate MDS submissions.
The facility failed to develop and implement comprehensive care plans for two residents, one with herpes and another on psychotropic medication. Resident 16's care plan lacked interventions for herpes, while Resident 14's plan did not address the use of Buspirone. Interviews with staff confirmed non-compliance with facility policies requiring timely and person-centered care plans.
The facility failed to ensure housekeeping staff were competent in infection control practices, risking infection spread among residents. The Housekeeping Supervisor admitted the disinfectant used did not specify its effectiveness against bacteria or viruses, and had not received any infection control training. The Director of Staff Development did not maintain files for contracted housekeepers, and a review of the HS's file showed no infection control training records, despite facility policy requiring such training.
The facility did not post nurse staffing information in a location accessible to residents, as required by policy. The staffing form was placed in a restricted area, confirmed by the DSD and DON, making it inaccessible to residents. A resident expressed interest in knowing staff numbers, but the information was not available to them.
The facility was found to have exceeded the maximum resident capacity in three rooms, with two rooms housing seven residents each and one room housing five residents. Despite the overcrowding, a resident reported adequate space. The facility had requested a waiver, citing that their residents, diagnosed with chronic mental illness, were ambulatory and capable of egress without staff assistance, and that the room arrangements did not adversely affect their health and safety.
The facility did not meet the required 80 square feet per resident in six rooms, with sizes ranging from 67.2 to 78.1 square feet per bed. Despite this, a resident reported feeling that the space was adequate.
A resident reported non-consensual sexual abuse by an LVN, who allegedly kissed and touched her inappropriately. The facility failed to promptly investigate or report the incident, and the LVN admitted to being alone with the resident in a non-resident area, violating facility policies. The resident felt unsafe and did not want to remain in the facility.
The facility failed to maintain updated competency evaluations and necessary documentation for its nursing staff, including LVNs and CNAs. Employee files lacked current licenses, CPR cards, and evidence of annual competencies or abuse training. Interviews with staff revealed that some had not completed required training since hiring, highlighting a potential deficit in skills and knowledge necessary for resident care.
The facility failed to supervise two residents in the staircase, leading to one resident pushing another, placing them at risk for serious injury. Both residents had diagnoses of paranoid schizophrenia and exhibited behavioral issues leading up to the incident. Staff interviews revealed that the stairwell was often left unsupervised, contributing to the altercation.
Failure to Protect Resident from Inappropriate Touching by Peer with Known Behavioral Issues
Penalty
Summary
The facility failed to protect a resident from inappropriate touching by another resident, despite being aware of the perpetrator's ongoing behavioral issues. One resident, diagnosed with paranoid schizophrenia and under conservatorship, had a documented history of poor personal boundaries, including repeated incidents of standing too close, touching others, and masturbating in public. Over the course of a year, staff documented hundreds of episodes of intrusive and inappropriate behaviors, including touching both residents and staff without consent. The care plan for this resident included interventions such as behavioral health consultations, participation in a special treatment program, and one-to-one counseling, but these measures did not prevent further incidents. The incident in question involved the resident with a history of boundary violations entering a shared bathroom while another resident was using it and attempting to touch the resident's private area without permission. The victim, also diagnosed with paranoid schizophrenia and under conservatorship, reported feeling scared, uncomfortable, and violated, and responded by physically defending himself. Staff interviews confirmed that the perpetrating resident was known for intrusive behaviors and that redirection and supervision were routinely used, but these interventions were insufficient to prevent the incident. Staff and other residents corroborated the pattern of inappropriate touching and lack of respect for personal boundaries. Documentation and interviews revealed that the psychologist responsible for the resident was not informed of the full extent of the inappropriate behaviors, including public masturbation and attempts to kiss staff. The facility's policy required identification of residents at risk for abusive behaviors and consideration of alternative placement if warranted, but these steps were not fully implemented. The failure to adequately monitor and intervene allowed the incident to occur, resulting in psychological and emotional distress for the victim and increased risk for peer conflict and safety concerns among other residents.
Failure to Notify Psychologist of Repeated Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to notify the psychologist regarding a resident who exhibited repeated inappropriate behaviors, including touching other residents and staff without consent. Despite extensive documentation of these behaviors in the resident's care plan and behavior summaries, which included hundreds of episodes of intense staring, standing too close, intrusiveness, masturbating in public, and inappropriate touching throughout the year, the psychologist was not informed of the severity or frequency of these incidents. The psychologist was also unaware of specific boundary violations, such as the resident attempting to kiss a staff member and entering shared bathrooms while occupied by other residents. The resident in question had a diagnosis of paranoid schizophrenia and was under conservatorship, with a documented history of poor boundaries and inappropriate social behaviors. The care plan included interventions such as encouraging behavioral health consultation and 1:1 counseling, but there was no evidence that the psychologist was kept informed of ongoing or escalating behaviors. Staff interviews confirmed that the resident's inappropriate touching and boundary issues were longstanding and required frequent redirection, but these actions were not effectively communicated to the psychologist for further intervention or adjustment of the treatment plan. Another resident, who was also diagnosed with paranoid schizophrenia and under conservatorship, reported psychological stress and emotional distress after being inappropriately touched by the first resident. This incident led to a physical altercation between the two residents. Staff and other residents corroborated the ongoing issues with the resident's intrusive behaviors. Facility policy required identification and intervention for residents with disruptive behaviors, but the lack of communication with the psychologist represented a failure to provide appropriate treatment and services for residents with mental disorders or psychosocial adjustment difficulties.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Safe Environment and Oversight for Residents Unable to Consent to Sexual Activity
Penalty
Summary
The facility failed to ensure a safe environment and adequate oversight for two residents who were unable to make their own decisions, resulting in one resident experiencing emotional distress and feeling unsafe. Both residents had significant mental health diagnoses, including schizoaffective disorder, anxiety disorder, paranoid schizophrenia, and bipolar disorder, and were under conservatorship, indicating they could not make their own medical decisions but could express their needs. Despite these limitations, the facility did not ensure that staff were aware of or monitored the sexual activities between the two residents. Staff interviews revealed inconsistent awareness and understanding of the residents' relationship and sexual activities. A Certified Nursing Assistant acknowledged the relationship and stated that residents had the privilege to have sex, but also indicated that staff should be alerted if residents were seen together in certain ways. However, a Registered Nurse was unaware of the sexual relationship and had not been informed by the residents or other staff. The Director of Nursing and the Administrator described general monitoring practices but did not demonstrate that specific oversight or interventions were in place for these two residents, who were known to lack decision-making capacity. Following the sexual encounter, one resident exhibited significant emotional and psychological distress, including panic, anxiety, increased pacing, new or worsened delusions or hallucinations, and expressed feeling unsafe and wanting to harm others. The resident was subsequently evaluated by a psychiatric crisis team and transferred to a hospital. The facility was notified by the hospital that the resident alleged her boyfriend was sexually and physically aggressive with her. The facility's investigation confirmed that staff were not fully aware of the sexual activities or the need for closer monitoring of these residents, as required by their conditions and care needs.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a known history of exchanging money for sex while residing at the facility. On the evening of the incident, the resident with a history of sexually inappropriate behavior entered the victim's room without consent, exposed himself, and engaged in non-consensual sexual contact, including touching and sucking on the victim's breasts, despite the victim repeatedly telling him to stop. The victim was unable to consent to sexual activities due to her mental health condition, which included paranoid schizophrenia and a legal conservatorship indicating incapacity to make her own decisions. Prior to the incident, there were documented indications that the perpetrator had been sexually active with multiple residents and had exchanged money for sexual favors. This information was recorded in progress notes and reported to a director who was no longer employed at the facility, but the DON and other key staff were not made aware of these behaviors. The facility did not investigate the allegations of money exchange for sex or the ongoing sexually inappropriate behavior, and staff were unaware of the extent of the perpetrator's actions until after the incident occurred. Interviews and record reviews revealed that staff, including CNAs and RNs, had observed or were aware of a prior relationship between the two residents, but there was no evidence that the facility assessed either resident's capacity to consent to sexual activity or implemented appropriate supervision or interventions to prevent abuse. The facility's policies prohibited abuse, mistreatment, and exploitation, and required immediate reporting and investigation of any allegations or suspicions of sexual abuse, but these procedures were not followed, resulting in the resident experiencing sexual abuse and emotional distress.
Failure to Implement Abuse Prohibition Policy Resulting in Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy and Procedure to prevent, prohibit, and investigate allegations of sexual abuse, specifically in the case involving two residents. One resident, who lacked the capacity to consent to sexual activities and was under a conservatorship, was subjected to non-consensual sexual contact by another resident with a known history of exchanging money for sex within the facility. Despite documentation and staff awareness of the perpetrator's sexually inappropriate behaviors and history, the facility did not take adequate steps to prevent further incidents or investigate prior allegations of exploitation and abuse. The incident occurred when the resident with a history of sexually inappropriate behavior entered the room of the resident lacking capacity, exposed himself, and engaged in sexual acts despite being told to stop multiple times. The victim reported feeling objectified and devalued as a result of the assault. Staff interviews and record reviews revealed that the perpetrator had previously been sexually active with multiple residents and had exchanged money for sexual favors, but these behaviors were not properly reported or investigated by facility leadership, including the DON and administrators. Documentation showed that staff, including a program counselor, were aware of the perpetrator's actions and had reported them to a former director, but the information was not escalated to the DON or administrator as required by policy. The facility's policies clearly defined non-consensual sexual contact and mandated immediate reporting and investigation of any allegations or suspicions of abuse. However, the facility failed to follow these procedures, resulting in the occurrence of sexual abuse and the lack of protection for vulnerable residents.
Failure to Prevent Transmission of Sexually Transmitted Infections Among Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in preventing the transmission of sexually transmitted infections (STIs) among residents. Three residents, all under conservatorship and lacking capacity to make their own decisions, engaged in unprotected sexual activity with each other. One resident with a confirmed diagnosis of a sexually transmitted virus had unprotected sex with another resident, who subsequently had unprotected sex with a third resident. Documentation showed that these interactions occurred on multiple occasions, and staff were aware of the sexual activities but did not implement adequate precautions to prevent STI transmission. Medical records indicated that the residents involved had significant mental health diagnoses, including schizophrenia and schizoaffective disorder, and were considered gravely disabled, requiring conservatorship for placement and decision-making. Despite these vulnerabilities, the facility's staff allowed residents to engage in sexual activity during designated free time without ensuring the use of condoms or verifying consent capacity. Staff interviews revealed a lack of knowledge and procedures regarding monitoring or promoting safe sex practices among residents, and there was no evidence of consistent implementation of infection control measures specific to sexual activity. The facility's own infection prevention and control policy referenced adherence to CDC guidelines, which recommend condom use to prevent the spread of HIV and other STIs. However, interviews with staff, including the infection preventionist, DON, and counselors, demonstrated that the facility did not have effective systems in place to ensure these guidelines were followed. The failure to implement appropriate precautions and monitor sexual activity among residents with known or suspected STIs resulted in a deficiency in the facility's infection prevention and control program.
Failure to Protect Residents from Physical Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect residents from physical abuse in two separate incidents involving both staff-to-resident and resident-to-resident altercations. In the first incident, a resident with schizoaffective and bipolar disorder, who was cognitively intact and independent in activities of daily living, was involved in a physical fight with a primary counselor inside the resident's assigned room. The resident initially reported a fall but later disclosed the altercation, which was corroborated by the roommate and another staff member. The resident sustained a swollen right palm and an abdominal bruise as a result of the incident. The facility's investigation confirmed that the physical altercation occurred in the presence of another staff member who did not intervene. In the second incident, two residents with intact cognition and independence in daily activities engaged in a physical altercation after a verbal dispute escalated. One resident approached the other in the hallway, and after an exchange of words, initiated physical contact by hitting the other resident, who then retaliated. Staff interviews revealed that although staff were present and heard the argument, they did not intervene until the altercation became physical. Both residents required x-rays following the incident, and one resident reported nasal pain as a result of being struck in the nose. The facility's policies defined physical abuse to include hitting and other forms of corporal punishment, and required protection of residents from such harm. In both cases, staff failed to prevent or promptly intervene in the altercations, resulting in residents being subjected to physical abuse and requiring medical evaluation. The incidents were substantiated by resident and staff interviews, as well as medical records documenting the injuries sustained.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its policy and procedures by not allowing a resident to return after hospitalization, despite the resident being medically cleared for discharge. The resident, who had been admitted to the facility with diagnoses including paranoid schizophrenia and diabetes mellitus, was transferred to a General Acute Care Hospital (GACH) for abdominal pain and shortness of breath. During the hospital stay, the resident was diagnosed with pneumonia, fecal impaction, and developmental delay. The resident's physician orders indicated a plan to discharge the resident back to the facility on oral antibiotics, but the facility did not permit the return, citing the need for isolation due to MSSA, despite no isolation order being present. The Assistant Admissions Coordinator (AAC) and the Director of Nursing (DON) were involved in the decision-making process. The AAC was informed by the Social Worker (SW) that the resident might be discharged on the seventh day of the bed-hold period. However, the DON decided against readmission due to the resident's need for isolation and ongoing IV antibiotics, which were later changed to oral antibiotics. Despite the change, the resident was not readmitted, and the bed was given to a new resident. This resulted in the resident remaining in the hospital longer than necessary, potentially affecting their psychosocial wellbeing.
Residents Denied Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents could easily access the results of the most recent survey and any plan of correction. This deficiency was observed for four residents, all of whom had intact cognition and were capable of performing activities of daily living independently. These residents expressed interest in reviewing the survey results but were unaware of where the information was located. Interviews with the residents revealed their desire to understand the facility's performance and any issues identified in the survey. The survey results were found to be located in a binder placed in a quarantined area, which was inaccessible to residents. The area was marked with yellow and black tape to prevent residents from wandering near the exit door, and the binder was not visible from behind the quarantine tape. Staff members, including the Program Manager, Assistant Administrator, and Administrator, confirmed that the survey binder was in this restricted area, and residents were not permitted to enter. The facility's policy on resident rights indicated that residents should have access to information regarding their care, including survey results. However, the placement of the survey binder in a quarantined area effectively denied residents this right. The facility's failure to provide residents with access to the survey results was a violation of their rights to information about their care while in the facility.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a kitchen tour and interviews with dietary staff. A container of cooked leftover chicken was found in the refrigerator without a date, and opened, unboxed bags of meatballs, egg rolls, and other meats in the kitchen's freezer were not labeled or dated. Additionally, a pan of uncooked chicken was improperly stored on top of raw vegetables in the refrigerator. These practices were contrary to the facility's policy, which requires all foods to be dated, labeled, and stored in a manner that prevents contamination. Interviews with the Dietary Supervisor and a dietary staff member revealed a lack of adherence to the facility's food handling policies. The Dietary Supervisor was unaware of which staff member stored the cooked chicken, and both he and the dietary staff member acknowledged that storing raw chicken on top of vegetables could lead to contamination and illness. The facility's policy mandates that uncooked and raw animal products be stored separately and below ready-to-eat foods to prevent contamination, a guideline that was not followed in this instance.
Inadequate Infection Control Measures and Expired PPE
Penalty
Summary
The facility failed to use an appropriate cleaning agent to prevent the spread of infection. During an observation, a bottle of rapid multi-surface disinfectant cleaner was found on the housekeeping cart, but it did not indicate its effectiveness against bacteria or viruses. The Housekeeping Supervisor admitted to not being trained or having completed an infection control competency with the contracted cleaning service or the facility. The Administrator confirmed that the Housekeeping Supervisor should be knowledgeable about the cleaning supplies to ensure the facility uses the right disinfectant to prevent infections. Additionally, the facility did not maintain an adequate supply of N95 masks, as all available masks were expired. The Maintenance Supervisor acknowledged the expired status of the masks and stated that a new supply would be ordered. The Director of Nursing also confirmed the expiration of the masks and emphasized the need for non-expired masks to ensure resident safety and prevent disease spread during a respiratory outbreak. The facility's policy indicated that personal protective equipment should be available at all times, but this was not adhered to in the case of the N95 masks.
Facility Fails to Maintain Kitchen Equipment and Infrastructure
Penalty
Summary
The facility failed to maintain essential kitchen equipment and infrastructure, leading to several deficiencies. During an inspection, it was observed that there was a leaking pipe under the kitchen sink, with a red bucket placed underneath to catch the water. The Dietary Supervisor was unaware of the leak, which posed a risk of staff slipping and potential mold growth. Additionally, the entire wall panel from the sink was completely separated from the wall, creating gaps that could allow pests and rodents to enter the kitchen. The Maintenance Director, who had been employed for five months, was also unaware of these issues and did not maintain a log of kitchen inspections. The inspection further revealed improper food storage practices, including unlabelled and undated opened bags of meat and a pan of uncooked chicken placed on top of raw vegetables. There was also a container of cooked chicken without a date and no documentation on the cooling down log for the cooked chicken stored in the refrigerator. The facility's pest control invoice from the previous month had already highlighted the structural concerns, yet no action had been taken to address them. The facility's maintenance policy requires regular inspections and maintenance of the building and equipment, but these were not effectively implemented, leading to the observed deficiencies.
MDS Coding and Submission Deficiencies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding antipsychotic medication use. Resident 48, who was admitted with diagnoses including paranoid schizophrenia, was prescribed Zyprexa, an antipsychotic medication, since 2021. However, the MDS incorrectly indicated that the resident was not taking any antipsychotic medication, despite the Medication Administration Record showing daily administration of Zyprexa. The Director of Nursing acknowledged the error, stating that the MDS should accurately reflect the care the resident was receiving. Additionally, the facility did not transmit the quarterly and annual assessments for two residents within the required 14-day period after completion. Resident 45, admitted with schizophrenia and anemia, and Resident 52, admitted with schizophrenia, both had completed MDS assessments that were not transmitted. The Director of Nursing noted that the MDS nurse is responsible for timely submission, but the assessments were not marked as accepted in the system, indicating they were not transmitted. The facility's policy and procedures require that resident assessments be submitted in accordance with federal and state guidelines. The Assessment Coordinator or designee is responsible for ensuring timely submission to the CMS' QIES Assessment Submission and Processing system. The failure to accurately code and timely transmit MDS assessments could lead to incorrect reflection of residents' care plans and services received.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for two residents, leading to potential risks of suboptimal care. Resident 16 was admitted with diagnoses including herpes viral infection and immunodeficiency virus. Despite being cognitively intact and not requiring assistance with activities of daily living, the baseline care plan for Resident 16 did not include interventions or goals for managing genital herpes. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that the facility did not comply with its policy of developing and implementing a baseline care plan within 48 hours of admission. Resident 14, admitted with schizophrenia, anxiety disorder, and pain, was prescribed Buspirone for anxiety. However, the care plan for Resident 14 lacked individualized, person-centered objectives, monitoring, and a timetable to address the use of Buspirone. The Registered Nurse Supervisor confirmed the absence of a care plan for the psychotropic medication, which is necessary to monitor potential side effects. The Director of Nursing acknowledged the importance of care planning for psychotropic medications to ensure resident safety. The facility's policies and procedures require the interdisciplinary team to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes. The failure to adhere to these policies for Residents 14 and 16 indicates a deficiency in providing effective and person-centered care, potentially compromising their physical, mental, and psychosocial well-being.
Inadequate Infection Control Training for Housekeeping Staff
Penalty
Summary
The facility failed to ensure that staff, particularly those in housekeeping, were competent in infection control practices, which could potentially lead to the spread of infections among residents. During an interview, the Housekeeping Supervisor (HS) admitted that the disinfectant used in the facility did not specify which bacteria, infections, or viruses it was effective against. Furthermore, the HS had not received any in-service training or completed an infection control competency since being employed, either with the contracted cleaning service or the facility itself. Additionally, the Director of Staff Development (DSD) stated that she did not maintain files for the housekeepers, as they were contracted employees, and that the Administrator kept the HS's employee file. The contracted company was responsible for the other housekeepers' files. The DSD also mentioned that all housekeepers' annual competencies were completed online with the contracted company. A review of the HS's employee file revealed no records of infection control in-service, competency, or training. The facility's policy required all staff, including contracted personnel, to participate in regular in-service education, including training on infection prevention and control program standards.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a visible and prominent place daily, as required by their policy. During an observation, the Daily Nurse Staffing form, which indicated the number of CNAs, LVNs, and RNs scheduled for each shift, was found in an area secured by quarantine tape, inaccessible to residents. This area was near the staff restroom and exit, which residents were not permitted to enter. The Director of Staff Development confirmed that the staffing information was posted by the time clock, in a location not accessible to residents, and acknowledged that residents could not read the posting from its position. Interviews with residents and staff further highlighted the deficiency. A resident expressed interest in knowing the number of staff on duty, stating that such information was not available to them. The Director of Nursing also confirmed that residents were not allowed in the area where the staffing hours were posted, making it impossible for them to see the information. The facility's policy, revised in August 2022, required that staffing numbers be posted in a prominent location accessible to residents and visitors, which was not adhered to, leading to the deficiency.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three of the 27 resident rooms exceeded the maximum capacity. Specifically, two rooms housed seven residents each, and one room housed five residents. This was observed during a facility tour, where it was noted that some beds had curtains closed around them, and some residents were not present in the room. Despite the overcrowding, a resident interviewed stated that the room provided adequate space. The facility had submitted a room waiver request, indicating that their resident population, diagnosed with chronic and persistent mental illness, were healthy, ambulatory, and capable of egress without staff assistance. The waiver claimed that the room arrangements did not adversely affect residents' health and safety or impede their ability to achieve their highest practicable well-being.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to meet the requirement of providing at least 80 square feet per resident in six out of 27 resident rooms. Specifically, Rooms 1, 3, 5, 7, 8, and 9 did not meet the required space per resident, with room sizes ranging from 67.2 to 78.1 square feet per bed. This deficiency was identified through observation, interview, and record review, including a room waiver letter and client accommodations analysis form completed by the facility. During an interview, a resident stated that the room provided adequate space, despite the documented deficiency.
Failure to Investigate Alleged Sexual Abuse by LVN
Penalty
Summary
The facility failed to thoroughly investigate an allegation of non-consensual sexual abuse involving a Licensed Vocational Nurse (LVN) and a resident. The incident was first reported to the Director of Nursing (DON) on November 28, 2024, although the alleged abuse occurred around October 2024. The resident reported that the LVN entered her room, kissed her, and touched her inappropriately, later instructing her to meet him in the chart room where further inappropriate contact occurred. Despite the resident's intact cognition, the facility did not take immediate action to ensure her safety or conduct a comprehensive investigation. Interviews with various staff members, including the Program Director, Social Services, and the Primary Counselor, revealed inconsistencies in the handling of the report. The resident initially confided in the Primary Counselor, who then informed the Program Manager, DON, and Administrator. However, the facility did not promptly report the incident to the Department of Public Health, nor did they take the resident to a hospital for further examination. The LVN involved admitted to being alone with the resident in the chart room and providing her with food, which is against facility policy. The facility's policies prohibit staff from being alone with residents in non-resident areas like the chart room and from providing outside food or clothing without proper authorization. Despite these policies, the LVN admitted to purchasing clothes and food for residents, further violating facility guidelines. The failure to adhere to these policies and the lack of a timely and thorough investigation into the allegations left the resident feeling unsafe and unwilling to remain in the facility.
Deficiency in Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that the nursing staff met the required skills and competency evaluations, as evidenced by the lack of updated documentation in the employee files for four staff members, including two Licensed Vocational Nurses (LVNs) and two Certified Nursing Assistants (CNAs). During a review of these files, it was found that there were no current LVN licenses, updated CPR cards, annual competencies, or updated background checks. Additionally, there was no evidence of CNA licenses, CPR care, annual competencies, or abuse training. The Director of Nursing (DON) acknowledged that these documents should be current and present in the employee files, and that annual competencies, including abuse training, are mandatory at the facility. Interviews with the nursing staff further highlighted the deficiency. One LVN admitted to not having completed abuse training since being hired and could not recall the last time he underwent annual competency training. Another LVN also could not remember when he last received training for abuse, annual competencies, sexual harassment, or a background check, indicating that these were only completed upon hiring. Both staff members emphasized the importance of annual competencies to ensure they do not forget how to properly care for residents or complete essential tasks. The facility's policy and procedures require competency evaluations upon hire, annually, and as necessary, but these were not adhered to, leading to a potential deficit in knowledge, training, and certification among the nursing staff.
Failure to Supervise Residents Leading to Physical Altercation
Penalty
Summary
The facility failed to follow its Abuse Prohibition Policy and Procedure by not supervising two residents, Resident 1 and Resident 2, while they were in the facility's staircase. This lack of supervision led to an incident where Resident 2 pushed Resident 1, placing Resident 1 at risk for serious injury, harm, or death. The incident occurred on 5/10/2024 at 10:40 AM when both residents were exiting the staircase after being excused from a group session due to a verbal argument. Resident 1, who has a diagnosis of paranoid schizophrenia and exhibits symptoms of psychosis, was admitted to the facility with a care plan that included monitoring for medical conditions contributing to psychosis and encouraging participation in special treatment programs. Despite these interventions, Resident 1 had episodes of labile moods and suspicious behavior leading up to the incident. On the day of the incident, Resident 1 reported being pushed multiple times by Resident 2 in the staircase. Resident 2, also diagnosed with paranoid schizophrenia and exhibiting risk for distressed mood symptoms, had a care plan that included encouraging participation in special treatment programs and providing support for distressed moods. Resident 2 had episodes of intrusiveness and disorganized thought processes leading up to the incident. During the incident, Resident 2 reported pushing Resident 1 out of the way because she felt threatened. Staff interviews revealed that the stairwell was often left unsupervised, and there was no specific person designated to supervise the stairs, leading to the altercation between the two residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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