Mid-wilshire Health Care Cntr
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 676 S. Bonnie Brae Street, Los Angeles, California 90057
- CMS Provider Number
- 056174
- Inspections on file
- 37
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 36 (1 serious)
Citation history
Health deficiencies cited at Mid-wilshire Health Care Cntr during CMS and state inspections, most recent first.
A resident who was cognitively intact and required assistance with daily activities was not provided the opportunity for their next of kin to participate in a care plan conference, despite facility policy and the resident's care plan indicating a preference for family involvement. Documentation did not show that the next of kin was invited or notified, resulting in the resident and their next of kin not being given their right to participate in care planning.
A resident with dementia and anxiety disorder was moved to different rooms multiple times without advance written notice or proper documentation, and the responsible party was not notified as required. Staff interviews revealed that notifications were made informally and not documented in the medical record, contrary to facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Two residents were involved in an incident where an allegation of employee-to-resident abuse was not reported to authorities or investigated in a timely manner, despite facility policy requiring immediate action. One resident, with intact cognition, filed a grievance on behalf of another with severe cognitive impairment, describing forceful care by a CNA that led to distress. The DON and Administrator did not report the incident as required, citing lack of physical harm and incomplete communication of the incident details.
The facility did not complete annual performance evaluations for two LVNs and three CNAs, including a Restorative Nursing Assistant, as required by policy. The DSD was unaware of the requirement and had not reviewed the policy, and the DON confirmed that evaluations were not performed or documented in the employee files.
The facility did not follow standardized recipes or portion sizes for pureed diets, resulting in multiple residents receiving alternative foods of incorrect texture and consistency instead of the planned menu items. The menu lacked inclusion of therapeutic and texture-modified diets, and staff did not have guidance on appropriate portions or recipes, as confirmed by dietary staff and the registered dietitian.
Surveyors found that kitchen staff failed to follow safe food storage and preparation practices, including thawing meat on the counter, not maintaining the ice machine in a sanitary condition, and storing multiple food items without proper labeling or dating. These actions were contrary to facility policy and staff knowledge, and were confirmed by interviews and record reviews.
A resident with severe cognitive impairment and multiple chronic conditions was found in bed with the call light out of reach, despite care plan and facility policy requiring it to be accessible. Staff confirmed the call light was not within reach and acknowledged the importance of proper placement for timely assistance.
A resident with a history of DKA and uncontrolled diabetes experienced repeated episodes of extremely high blood glucose, with readings exceeding the glucometer's measurable range. Nursing staff did not notify the physician or document these events as required by facility policy and professional standards, and inaccurately recorded 'HI' readings. The lack of communication and documentation resulted in a failure to provide care according to orders and standards of practice.
A resident with severe cognitive impairment and a g-tube for nutrition did not have their enteral feeding bag changed every 24 hours as required by facility policy. Staff confirmed the bag had been in use for two days, acknowledging the risk of infection and GI complications due to this lapse.
A resident with dementia and a high risk for falls was admitted without a comprehensive fall prevention care plan, contrary to facility policy. Despite a high Morse Fall Score, the resident was not adequately monitored, leading to a fall and a left femur fracture. Facility staff acknowledged the absence of a necessary care plan, which contributed to the incident.
A facility failed to prevent falls for a high-risk resident with dementia and a history of falls. Despite having a care plan, the resident experienced multiple falls due to ineffective interventions and lack of proper monitoring. The facility did not revise the care plan after each fall, leading to repeated incidents and injuries.
A resident reported that a CNA touched her private parts and forced her to touch his private area, causing significant psychological distress. The incident was confirmed by surveillance video, and the CNA was asked to leave the facility. The resident's account remained consistent when reported to staff and police.
The facility failed to ensure that a CNA had the appropriate abuse training, leading to an alleged sexual abuse incident involving a resident. The CNA did not attend any abuse training sessions, and there was no employee file to verify competencies. The resident reported inappropriate touching by the CNA, and surveillance footage corroborated the timeline. Facility staff confirmed that registry staff were not provided with formal abuse training, violating the facility's policy.
Failure to Involve Next of Kin in Care Planning
Penalty
Summary
The facility failed to include a resident's next of kin (NOK) in the care plan conference, despite the resident's care plan indicating a preference for family or significant other involvement. The resident, who was cognitively intact and required varying levels of assistance with daily activities due to diagnoses including heart failure and lack of coordination, attended the care conference. However, there was no documentation that the NOK was invited to participate, as required by the facility's policy and the resident's care plan preferences. Interviews and record reviews confirmed that while the NOK was reportedly invited and unable to attend due to work obligations, this was not documented in the resident's records. The facility's policies require prompt and accurate documentation of such events and emphasize the importance of involving residents' families or representatives in care planning. The lack of documentation and failure to ensure the NOK's participation resulted in the resident and their NOK not being given their right to participate in the care planning process.
Failure to Provide Advance Written Notice and Documentation for Room Changes
Penalty
Summary
The facility failed to honor a resident's right to receive advance written notice and proper documentation before room changes occurred. Specifically, a resident with dementia and anxiety disorder, who required varying levels of assistance with daily activities, was moved to different rooms on four separate occasions. On each occasion, the responsible party (RP) was not notified in advance, and no written notice was provided explaining the reason for the room change. Additionally, there was no documentation in the resident's medical record regarding the room changes or the notification of the RP. Interviews with facility staff revealed inconsistencies in the notification process. The director of staff development confirmed that the RP should have been notified and consent obtained prior to any room change, but could not find documentation to support this. The social worker stated that notifications were made via text messages and that she kept a binder for room changes, but admitted that written notices were not provided and that documentation in the medical record was lacking. The facility's own policy required advance notice and documentation of room changes, which was not followed in these instances.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures for two residents when an allegation of employee-to-resident abuse was not reported to the state licensing/certification office, police, or ombudsman, and the incident was not investigated in a timely manner. Resident 2, who had intact cognition and the capacity to make decisions, filed a grievance on behalf of Resident 3, who had severe cognitive impairment and was dependent on staff for most activities of daily living. The grievance described an incident in which a CNA allegedly proceeded forcefully with care despite the resident's refusal, resulting in the resident yelling and screaming in resistance. Interviews and record reviews revealed that the Director of Nursing acknowledged the grievance contained an allegation of abuse and should have been reported, but it was not, as there was no physical problem observed. The Administrator stated he was aware of the incident but was not informed of the specific details indicating forceful behavior, which would have prompted reporting. The facility's policy required immediate reporting of all alleged violations of abuse to appropriate authorities, but this procedure was not followed in this case.
Failure to Complete Annual Performance Evaluations for Staff
Penalty
Summary
The facility failed to ensure that five employees received annual performance evaluations as required by facility policy. During a review of employee files with the Director of Staff Development (DSD), it was found that performance evaluations for two LVNs and three CNAs, including one Restorative Nursing Assistant, had not been completed. The DSD stated she was unaware of the requirement for annual performance evaluations and had not reviewed the relevant facility policy. The Director of Nursing (DON) confirmed that annual performance evaluations were required and acknowledged that the current DSD had not been instructed to perform them. The facility's policy indicated that each employee should receive an annual performance evaluation, with documentation maintained in the human resources file.
Failure to Follow Standardized Recipes and Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes for the lunch menu were followed for residents on pureed diets. During observations, it was noted that twenty-three residents on pureed diets did not receive the pureed versions of the menu items listed for the regular diet, such as pureed soybean paste stew and fern salad. Instead, they were served alternative pureed foods like meat, rice, and beans. The pureed foods provided were of a thin, soupy consistency rather than the required homogenous, cohesive, pudding-like texture. Staff interviews revealed that the menu did not include therapeutic or texture-modified diets, nor did it specify standard portions or serving guides for these diets. The dietary supervisor acknowledged difficulties in preparing the Korean menu for pureed diets and admitted to using portion sizes from an old menu as a reference. Further interviews and observations confirmed that the registered dietitian had not reviewed the menu or provided in-service training to staff regarding texture-modified diets. The dietitian stated that residents on pureed diets should receive the same foods as those on regular diets, and that the menu should include all therapeutic and texture-modified diets with appropriate recipes and portion sizes. Facility policy reviews indicated that menus should include standardized recipes, nutrient analysis, and portion control, but these were not being followed for the pureed diet. As a result, residents on pureed diets were not receiving meals consistent with the planned menu or in the correct texture and portion, as required by facility policy.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Surveyors observed frozen sliced pork thawing on the kitchen counter instead of in the refrigerator, contrary to both facility policy and staff knowledge, which require thawing in a refrigerator or by other approved methods. The staff member responsible for this acknowledged the error, stating the meat should not have been left on the counter. Additionally, the kitchen was understaffed at the time, with the Dietary Supervisor and another staff member performing multiple duties, including dishwashing and cooking. Further deficiencies were identified with the facility's ice machine, which was found to have pink residue inside the storage bin and on the baffle, indicating it was not maintained in a sanitary manner. The ice scoop was also overdue for cleaning. The Maintenance Supervisor admitted to not cleaning the ice machine on schedule and failing to use sanitizer as required by facility policy. Review of cleaning logs and policies confirmed that the ice machine should be cleaned regularly with a sanitizer solution, but this was not done as specified. Additional issues were found with the labeling and dating of food items in the refrigerators. Open milk gallons and individual cups of beverages were stored without open or use-by dates, and other items such as sliced cheese, kimchi, and previously cooked rice were also found without proper labeling or dating. Facility policies require all refrigerated, ready-to-eat foods to be labeled and dated, and leftovers to be discarded if not used within specified timeframes. The Dietary Supervisor confirmed that staff failed to follow these procedures, resulting in improper food storage and potential for foodborne illness.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, Parkinson's disease, lack of coordination, and polyosteoarthritis, was found in bed with the call light not within reach. The resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene, bathing, and transfers, as documented in the Annual Minimum Data Set. The resident's care plan specifically included an intervention to keep the call light within reach due to the risk of bedside rail entrapment. During an observation, the call light was seen hanging at the end of the bed, out of the resident's reach. A CNA present in the room confirmed the call light was not accessible and acknowledged the importance of its placement. Interviews with an LVN and the Director of Staff Development further confirmed that facility policy requires call lights to be within easy reach of residents to ensure timely assistance. A review of the facility's policy also supported this requirement.
Failure to Notify Physician and Document High Blood Glucose Readings in Diabetic Resident
Penalty
Summary
A resident with a history of diabetic ketoacidosis (DKA) and uncontrolled diabetes was admitted to the facility with diagnoses including unspecified acidosis and Type II diabetes with ketoacidosis. The resident's care plan included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, administering diabetes medications as ordered, and reporting abnormal findings to the physician. Despite these interventions, the resident experienced multiple episodes of extremely high blood sugar, with readings over 500 mg/dL documented on at least 27 occasions over a two-month period. The blood glucose machine used by the facility could only register readings up to 599 mg/dL, displaying 'HI' for higher values, which occurred several times for this resident. Facility staff failed to notify the resident's physician about these consistently high blood sugar readings, and there was no documentation of physician contact or a change in the resident's condition related to these events. Interviews with nursing staff and supervisors confirmed that the physician was not informed of the high readings, and that documentation of communication and interventions was lacking. The facility's policy required staff to contact the provider for glucose values above certain thresholds or when the glucometer reading was too high, but this was not followed in practice. Additionally, staff inaccurately documented 'HI' readings from the glucometer as 599 mg/dL, rather than recording the actual result and following the manufacturer's instructions to contact a healthcare professional immediately. The resident's family was not made aware that the physician had not been contacted regarding the high blood sugar levels. The medical director and other staff acknowledged that the standard of practice was not followed, and that the lack of communication and documentation represented a failure to provide care in accordance with professional standards.
Failure to Change Enteral Feeding Bag Every 24 Hours
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dysphagia, aphasia, dementia, and Parkinson's disease, who was dependent on a gastrostomy tube (g-tube) for nutrition, did not receive proper care in accordance with facility policy. The resident's enteral feeding bag, which was supposed to be changed every 24 hours per the facility's Enteral Feeding Via Pump Administration policy, was observed to have been in use for two days without being changed. The feeding bag was dated two days prior to the observation, and the feeding pump was turned off at the time of inspection. Interviews with facility staff confirmed that the feeding bag and tubing had not been changed as required, and staff acknowledged the risk of infection and gastrointestinal complications associated with this lapse. The facility's policy, as well as statements from the Director of Staff Development and a Licensed Vocational Nurse, indicated that the failure to change the feeding bag and tubing daily placed the resident at risk for adverse outcomes.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of falls and dementia, who was assessed as high risk for falls. Despite the facility's policy requiring a person-centered care plan to manage risk factors, no such plan was created for the resident upon admission. The resident's Morse Fall Score was 75, indicating a high risk for falls, yet there was no documentation of a fall prevention care plan or monitoring for the resident on the day following admission. On the second day after admission, the resident was found on the floor, complaining of pain, and was subsequently diagnosed with a left femur fracture at a General Acute Care Hospital. The facility's failure to frequently monitor the resident and anticipate their needs, as well as the absence of a fall prevention care plan, contributed to the incident. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan should have been developed and implemented to prevent such an occurrence. The facility's policies, including the Person Centered Plan of Care and Post Fall Management Program, emphasize the importance of developing and updating care plans to prevent falls and accommodate resident needs. However, these policies were not followed in the case of the resident, leading to a preventable fall and subsequent injury. The lack of a fall prevention care plan and inadequate monitoring were identified as deficiencies in the facility's care for the resident.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident with dementia, a history of multiple falls, and a high risk for falls received the necessary care and services to prevent accidents and falls. The facility did not implement its Fall Prevention Program policy and procedure to identify interventions related to the resident's specific risks and causes. Additionally, the facility did not evaluate the effectiveness of interventions and implement new ones to prevent repeated fall incidents after the resident fell on multiple occasions. The resident was not monitored for the behavior of trying to get out of bed without assistance as per the physician's order, leading to repeated falls and a laceration requiring hospital transfer. The resident was admitted with diagnoses including a history of falling, dementia, lack of coordination, and Alzheimer's disease. The resident's care plan included interventions such as monitoring whereabouts, helping with transfers and ambulation, providing proper fitting shoes, maintaining a safe environment, and keeping the call light within reach. Despite these interventions, the resident experienced multiple falls, including incidents where the resident was found on the floor after attempting to go to the bathroom without assistance. The facility's staff did not revise the care plan effectively after each fall, and the same interventions were repeatedly implemented without success. Interviews with facility staff revealed that the resident was forgetful, confused, and unable to walk independently. Staff acknowledged that the resident did not use the call light and often tried to get out of bed without assistance. The facility did not use a bed alarm, which could have alerted staff when the resident attempted to get out of bed. The Director of Nursing and other staff members admitted that the care plan interventions were not person-centered and were ineffective in preventing the resident's falls. The facility's policies and procedures required reassessment and revision of care plan interventions after each fall, but this was not done, leading to recurrent falls and injuries for the resident.
Failure to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nurse Assistant (CNA). The resident, who was cognitively intact and had medical decision-making capacity, reported that the CNA touched her private parts and forced her to touch his private area. This incident caused the resident significant psychological distress, including feelings of fear, shame, anxiety, and guilt. The resident initially reported the incident to a caregiver from home, who then informed the facility staff. The incident occurred during the 7 AM to 3 PM shift when the CNA was assigned to care for the resident. Surveillance video confirmed the CNA's presence in the resident's room during the reported time frame. The resident described the incident in detail, stating that the CNA touched her inappropriately and made her touch him, despite her saying 'no' multiple times. The resident was observed crying and tearful during interviews, expressing fear of seeing the CNA again and concern about potential repercussions for reporting the incident. The facility's staff, including the Social Services Director and Administrator, were informed of the incident and took immediate steps to ensure the resident's safety. The CNA was asked to leave the facility and was not allowed to return. The resident's account of the incident remained consistent when reported to various staff members and the police. The facility's policy on abuse and neglect prohibits such actions, and the incident was thoroughly documented and investigated by the facility staff.
Failure to Provide Abuse Training to CNA Leads to Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) 1 had the appropriate abuse training, which led to an incident of alleged sexual abuse involving a resident. CNA 1, who had been working at the facility for several months, did not attend any of the abuse training sessions provided by the facility. The facility's records confirmed that CNA 1 did not participate in multiple in-service training sessions on abuse prevention and reporting, and there was no employee file for CNA 1 to verify competencies or skill sets. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that registry staff, including CNA 1, were not provided with formal abuse training during their orientation at the facility, relying instead on the registry agency to provide such training. This lack of training was in direct violation of the facility's Abuse and Neglect Prohibition Policy, which mandates that all staff, including those from registry agencies, receive abuse prevention training during orientation and ongoing sessions at least annually. The incident in question involved Resident 1, who was cognitively intact and had medical decision-making capacity. Resident 1 reported that CNA 1 had touched her inappropriately and forced her to touch his private area during a routine change of her incontinent brief. Surveillance video footage corroborated the timeline of CNA 1's presence in Resident 1's room, although it did not capture the alleged abuse directly. Resident 1 was visibly distressed during the interview, describing the incident in detail and expressing fear and confusion about whom to report the incident to. The facility's records indicated that Resident 1's family and physician were notified of the incident. Interviews with facility staff, including the DSD, DON, and the Administrator, revealed a systemic failure to ensure that registry staff received the necessary abuse training. The facility's Master Staffing Agreement with the registry agency placed the responsibility for compliance with health regulations, including abuse prevention training, on the facility. Despite this, the facility did not provide formal abuse training to registry staff, creating a potential risk for abuse. The Administrator, who was also the abuse coordinator, acknowledged that all staff should be trained on abuse prevention and that the lack of training could lead to potential abuse incidents.
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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