Monte Vista Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 802 Buena Vista Street, Duarte, California 91010
- CMS Provider Number
- 055817
- Inspections on file
- 35
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Monte Vista Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop comprehensive, person-centered care plans for two residents related to vaccination refusal and influenza status. One resident with sepsis and a UTI, documented as having moderately impaired cognition and needing assistance with several ADLs, formally declined COVID-19, RSV, influenza, and pneumococcal vaccines, but this refusal was not addressed in the care plan despite facility policy. Another resident with a healing femur fracture and hemiplegia, severely impaired decision-making, and high ADL dependence tested positive for influenza, yet no care plan addressed the influenza diagnosis. The IP and DON confirmed that individualized care plans for these issues were missing, contrary to the facility’s written care plan policy.
Surveyors found that an LVN reported receiving an influenza vaccine from an outside provider but never submitted proof of vaccination, and the facility did not obtain or document this information in the employee file. Review of the personnel records confirmed there was no influenza vaccination record for this LVN, despite facility policy requiring that employees be offered the vaccine within a specified timeframe and that all vaccination details or outside vaccination documentation be maintained in the employee medical record. The DSD and DON both acknowledged the importance of having this documentation on file and confirmed that the missing record did not comply with the facility’s influenza vaccine policy.
A resident with dementia, UTI, and moderately impaired cognition, who was dependent on staff for toileting and bathing, alleged that a CNA grabbed and injured the resident’s arm during incontinence care. CNAs and the IPN reported the allegation to an LVN and assessed the resident, with documentation noting both a small area of redness and later no new marks or scratches, and inconsistent statements by the resident. Despite a written policy requiring immediate reporting of abuse allegations within two hours and removal of any accused employee from resident contact, the allegation was not reported within the required timeframe, and the CNA accused of abuse was not removed from resident care and returned to the resident’s room after the allegation.
A resident with DM, hemiplegia, and hemiparesis, who was dependent for ADLs and transfers, was found via hip X-ray to have a suspected acute right femur fracture and was later confirmed at a GACH to have an acute femur fracture. Despite facility policy requiring that injuries of unknown origin be promptly reported to the Ombudsman, Police, and State Survey Agency and thoroughly investigated, the DON acknowledged that no investigation was conducted to determine how the fracture occurred and that the required external reports were not made within the mandated 2-hour timeframe.
A resident with DM, hemiplegia, and hemiparesis, who was dependent for ADLs and transfers, had a bilateral hip X-ray showing a suspected acute right femur fracture and was transferred to a GACH, where imaging confirmed an acute right femur fracture. Despite these findings, the DON reported that no investigation was conducted to determine how the fracture occurred and that the injury of unknown origin was not reported to the Ombudsman, police, or State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting and thorough investigation of all suspected abuse and injuries of unknown origin.
A resident with DM and post-stroke hemiplegia/hemiparesis, dependent for ADLs and transfers but able to make decisions, was sent to an outside pain specialist appointment accompanied by a spouse. The assigned LVN did not obtain or document assessments or VS when the resident left for or returned from the appointment, and the DON could not locate any related nurse’s notes or VS in the medical record. Both the LVN and DON acknowledged that facility policy requires licensed staff to complete and document assessments and VS around outside appointments, and the facility’s charting policy requires documentation of services provided and changes in condition to support IDT communication.
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by a clogged toilet in a resident's bathroom that went unaddressed for two days despite being reported. Additionally, multiple bathrooms and resident rooms exhibited maintenance issues such as unpainted plaster, cracked caulking, and chipped paint. The Maintenance Director acknowledged that these issues were not properly reported by staff, posing a potential risk to residents' health.
A facility failed to follow a physician's order for a resident's Losartan Potassium administration, which required holding the medication if the resident's SBP was below 140 mmHg or HR was below 85. Despite these parameters, the medication was administered on several occasions when the resident's readings were below the specified thresholds. The LVN and RNS acknowledged the oversight, which was contrary to the facility's policy for safe medication administration.
Two residents in an LTC facility received inadequate pressure ulcer care. One resident's low air loss mattress was incorrectly set, potentially delaying healing of a stage 4 ulcer. Another resident, with severe cognitive impairment, was not repositioned as per care plan, leading to open scratch marks. These deficiencies highlight failures in adhering to care protocols and professional standards.
The facility failed to provide appropriate respiratory care for three residents, including untimely changes of nebulizers and unlabeled oxygen tubing. A resident's nebulizer was not changed weekly as required, and two residents had unlabeled oxygen equipment, with one lacking a physician's order for oxygen therapy. These deficiencies were observed during a survey, highlighting lapses in infection control and equipment management.
A resident with severe cognitive impairment and multiple diagnoses, including diabetes, did not receive full doses of medications via a gastrostomy tube, resulting in a 9.68% medication error rate. The LVN failed to ensure complete administration, leaving significant medication residue in cups. The RN Supervisor confirmed the resident did not receive full therapeutic doses, violating the facility's medication administration policy.
The facility failed to label two medications, Senna and Docusate Sodium, with the date they were opened, as required by policy. This oversight was discovered during an observation of Med Cart 2, where the LVN confirmed the medications were part of the house supply and should have been dated to ensure effectiveness. The RN Supervisor reiterated the importance of labeling to maintain medication potency.
The facility failed to provide fortified diets as ordered for two residents, one with cerebral infarction and hemiplegia, and another with metabolic encephalopathy and diabetes. Despite the diet roster and menu indicating the need for fortified diets, meal trays lacked the required super soup. The Dietary Supervisor confirmed the oversight, which could impact the residents' caloric intake.
The facility failed to discard expired food items in the kitchen's dry storage, posing a risk of food-borne illnesses. An open package of corn meal and baking powder were found expired during an observation. The Dietary Supervisor acknowledged the need for immediate disposal but could not explain the oversight, and the facility lacked a specific policy for handling expired items.
The facility failed to manage a norovirus outbreak effectively, as isolation precautions were prematurely discontinued for symptomatic residents. Staff did not consistently wear appropriate PPE, and personal care items were not properly labeled or stored, increasing the risk of cross-contamination.
A facility failed to maintain a functional call light for a resident, leading to frustration and potential risk. Bathrooms and rooms were found in disrepair, posing health risks. Additionally, a resident's bed control was intermittently non-functional, causing discomfort, and the issue was not promptly reported or logged for maintenance, highlighting lapses in the facility's maintenance processes.
A facility failed to maintain a resident's dignity and privacy during care. A CNA exposed a resident's lower body while washing their face and neck, contrary to the facility's policy requiring covered care to ensure privacy. The resident had severe cognitive impairment and required maximum assistance with personal hygiene.
A resident with end-stage renal disease and diabetes was found with an unauthorized bottle of Pepto Bismol Ultra in their room, without a physician's order or consent for self-administration. The resident, with moderately impaired cognition, admitted to using the medication for indigestion. The facility failed to assess the resident's ability to self-administer safely, as required by policy.
A resident tested positive for C. diff, but the facility failed to develop a care plan from the time of the positive result until several days later. Despite receiving treatment orders, no care plan was created to address the resident's condition, and appropriate isolation measures were initially lacking.
A resident with dementia and a history of falls did not have a toileting schedule as per their care plan, leading to potential fall risks. The resident was observed getting up unassisted and feeling dizzy, and had previously fallen while attempting to pick up pants. The DON acknowledged that a toileting schedule could prevent such incidents, but it was not in place.
A resident with severe cognitive impairment and recurrent UTIs experienced a deficiency in catheter care when the facility failed to follow the physician's order for daily irrigation of the Foley catheter. Observations revealed sediments on the catheter tubing, and the last recorded irrigation was several days prior, despite the resident's care plan indicating a need for monitoring and maintenance. The facility's policy required immediate reporting of unusual findings, which was not adhered to, contributing to the resident's ongoing issues.
A resident with a G-Tube was administered medications mixed with apple sauce instead of water, contrary to facility policy and without a physician's order. The LVN involved stated this was their usual practice, but the RN Supervisor and Director of Staff Development confirmed it could lead to tube occlusions and decreased medication potency.
The facility failed to serve food at safe and appetizing temperatures, with observations showing food items like chicken and green beans below the recommended temperature range. Resident Council Minutes also documented complaints about cold food. The Dietary Supervisor noted that unappetizing food could lead to residents not eating and potential weight loss.
A resident with hemiplegia and other conditions experienced a non-functional call light, leading to potential delays in care. The resident reported the issue, and a CNA confirmed the malfunction, stating the importance of a working call light, especially in emergencies. The facility's policy requires call lights to be operational and defects reported promptly.
The facility failed to maintain a pest-free environment in Kitchen 1, where two dead cockroaches were found near the walk-in freezer. A Dietary Aide confirmed the presence of the cockroaches and used a broom with dust and green beans to sweep them away. The Dietary Supervisor noted that the cockroaches might have appeared after a recent pest control visit. The facility's policy requires kitchen areas to be clean and pest-free, which was not followed.
Failure to Care Plan Vaccine Refusal and Influenza Diagnosis for Two Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans addressing vaccination refusal and influenza status for two residents. One resident was originally admitted with sepsis and a urinary tract infection and had documented capacity to understand and make decisions, with an MDS showing moderately impaired cognitive skills and a need for supervision or assistance with several ADLs. Vaccine consent forms dated shortly after admission showed this resident declined COVID-19, RSV, influenza, and pneumococcal vaccines. However, review of the resident’s care plan with the Infection Prevention Nurse (IP) revealed there was no care plan addressing the resident’s refusal of these vaccines, despite facility policy requiring a care plan when a resident declines vaccine administration upon admission. Another resident, admitted with a right femur fracture and hemiplegia/hemiparesis following cerebral infarction, also had documented capacity to understand and make decisions, but an MDS indicated severely impaired cognitive skills for daily decision making and dependence or high assistance needs for toileting, showering, dressing, hygiene, and eating. The IP reported being informed that this resident tested positive for influenza, yet concurrent review of the resident’s care plan showed there was no care plan addressing the resident’s influenza diagnosis. Both the IP and the DON acknowledged the absence of individualized care plans for these current medical conditions, despite a written policy requiring comprehensive, person-centered care plans with measurable objectives and timetables, including for services not provided due to a resident’s exercise of the right to refuse treatment.
Failure to Document Staff Influenza Vaccination per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to implementation of its influenza vaccination policy for staff. An LVN reported in interview that they had received an influenza vaccine in August 2025 but had not provided proof of vaccination to the facility. Review of the LVN’s Personnel Action Form, dated with a hire date in early December 2025, and the employee file showed there was no documentation of influenza vaccination. The Director of Staffing Development confirmed that the facility’s practice was to obtain a copy of each employee’s influenza vaccination documentation and place it in the employee file, and acknowledged that this documentation was missing for the LVN. The DON stated it was important to have the LVN’s influenza vaccine documentation on file because it would indicate whether the LVN had received the vaccine and was important for resident safety. Review of the facility’s written P&P titled “Influenza Vaccine,” revised March 2022, showed that all employees without medical contraindications were to be offered the influenza vaccine annually, and that employees hired between October 1 and March 31 were to be offered the vaccine within five working days of job assignment. For those who received the vaccine, the policy required documentation of the vaccination details in the employee’s medical record, and stated that staff could obtain vaccines from personal physicians but must provide documentation of previous vaccination to the facility. The absence of any influenza vaccination record for the LVN in the employee file was inconsistent with these policy requirements.
Failure to Timely Report Abuse Allegation and Remove Accused CNA From Resident Contact
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, exploitation, and misappropriation reporting and investigation policy for a resident who alleged abuse by a CNA. The resident had dementia, a UTI, moderately impaired cognition, and was dependent on staff for toileting hygiene and bathing. On the date of the incident, two CNAs reported that the resident complained a CNA had grabbed the resident’s upper arm, with documentation in the progress note that there was a small area of redness, although the CNAs stated the redness was present before they assisted the resident. A change in condition evaluation documented that a CNA grabbed the resident’s upper arm, resulting in a small area of redness, and that the resident did not know the current location, situation, or date/time. A post-event review later documented that the resident alleged a CNA scratched or ripped the resident’s arm and that the resident, who had dementia and an active UTI, provided inconsistent statements. Staff interviews showed that the allegation was reported internally but not handled in accordance with the facility’s written policy. CNA 1 reported the allegation to LVN 1 and the infection prevention nurse (IPN), and both LVN 1 and the IPN assessed the resident’s skin and reported finding no new marks, scratches, or redness. The incident time was variably recalled as around early to mid-afternoon. Despite the facility policy requiring that suspicions of abuse be reported immediately to the administrator and other officials within two hours and that any employee accused of abuse be placed on leave with no resident contact, the allegation was not reported within the required two-hour timeframe, and CNA 1 was not removed from resident contact and re-entered the resident’s room after the allegation. The DON confirmed that staff should have reported the allegation immediately and that CNA 1 should have been suspended from resident contact in accordance with the policy.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report and investigate an injury of unknown origin for one of ten sampled residents, as required by its abuse, neglect, exploitation, or misappropriation reporting and investigating policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented as dependent on staff for ADLs and transfers. A bilateral hip X-ray obtained on 12/21/2025 at 9:14 a.m. showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 p.m. the same day documented the suspected right femur fracture and a physician recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing documentation indicated the resident was transported by ambulance to the hospital at 4:20 p.m. Subsequent hospital imaging on 12/22/2025 at 9:11 a.m. confirmed an acute right femur fracture. The DON stated during interview that the facility did not conduct an investigation to determine how the resident sustained the right femur fracture and did not report this injury of unknown origin to the local Ombudsman, the Police, or the State Survey Agency within two hours of obtaining the X-ray results, as required by the facility’s policy. Review of the written policy dated 9/2022 showed that all reports of resident abuse, including injuries of unknown origin, were to be reported to local, state, and federal agencies as required by regulations and thoroughly investigated, with findings documented and reported. The DON acknowledged the facility did not follow this policy regarding the resident’s injury of unknown origin.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an injury of unknown origin for one sampled resident. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented on the MDS as dependent on staff for ADLs and transfers. A History and Physical dated 4/19/2026 indicated the resident had capacity to understand and make decisions. On 12/21/2025 at 9:14 am, a bilateral hip X-ray showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 pm the same day documented the suspected right femur fracture and the primary physician’s recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing notes show the resident was picked up by ambulance and transferred out at 4:20 pm. Subsequently, an X-ray at the acute care hospital on 12/22/2025 at 9:11 am confirmed an acute right femur fracture. Despite these findings, the DON stated during interview that the facility did not conduct an investigation to determine how the resident sustained the right femur fracture and did not report this injury of unknown origin to the local Ombudsman, police, or State Survey Agency within two hours of obtaining the X-ray results. The DON acknowledged the facility did not follow its policy, dated 9/2022, which requires that all reports of resident abuse, including injuries of unknown origin, be reported to local, state, and federal agencies as required and be thoroughly investigated by facility management, with findings documented and reported.
Failure to Assess and Document Resident Status Before and After Outside Appointment
Penalty
Summary
The facility failed to ensure that a licensed nurse completed and documented required assessments and vital signs before and after an outside medical appointment for one resident. The resident had been admitted with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, and was dependent on staff for ADLs and transfers. The resident’s history and physical indicated that the resident had the capacity to understand and make decisions. On the day in question, the resident left the facility with their spouse for an appointment with a pain specialist. Record review with the DON showed there was no nurse’s note, assessment, or vital signs documented in the medical record related to the resident’s departure for, or return from, the pain management appointment. In an interview, the LVN assigned to the resident that day confirmed that no assessment or vital signs were taken when the resident left for or returned from the appointment, despite acknowledging that facility policy requires assessments and vital signs in these circumstances. The DON also stated that the assigned licensed nurse should document vital signs and an assessment when a resident leaves and returns for a doctor’s appointment. The facility’s charting and documentation policy required that all services provided and any changes in the resident’s condition be documented to facilitate communication among the interdisciplinary team.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment, as evidenced by several deficiencies observed in resident bathrooms and rooms. One significant issue involved a clogged toilet in a resident's bathroom, which had been unusable for two days. Despite the resident reporting the issue to both nurses and certified nursing assistants, the problem was not addressed promptly. The Maintenance Director (MTD) was only informed of the issue on the day of the survey, indicating a breakdown in communication and reporting procedures within the facility. In addition to the clogged toilet, multiple resident bathrooms were found to have various maintenance issues, including unpainted plaster, cracked and peeling caulking, chipped paint, and exposed wood. These conditions were observed in bathrooms used by several residents, indicating a widespread problem with the facility's maintenance and upkeep. The MTD acknowledged that these issues had not been reported through the proper channels, as staff failed to log maintenance requests in the designated binder. Resident rooms also exhibited similar deficiencies, with observations of unpainted plaster, black marks, chipped paint, and exposed wood. These conditions were noted in rooms occupied by multiple residents, further highlighting the facility's failure to provide a homelike environment. The MTD confirmed that these areas required repair and acknowledged that the lack of proper reporting by staff contributed to the ongoing maintenance issues, posing a potential risk to residents' health.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received proper care by not adhering to the physician's order regarding the administration of Losartan Potassium, a medication used to treat hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 140 mmHg or if the heart rate (HR) was less than 85. Despite these parameters, the medication was administered on multiple occasions when the resident's SBP and HR were below the specified thresholds. The resident, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia and essential hypertension, had intact cognition according to a Minimum Data Set assessment. However, a History and Physical report indicated the resident did not have the capacity to understand and make decisions. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged the failure to follow the physician's parameters, which was important to prevent potential side effects such as hypotension. The facility's policy and procedure for administering medications emphasized the importance of administering medications as prescribed, which was not adhered to in this case.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in treatment and prevention. Resident 41, who was admitted with a stage 4 pressure ulcer on the right buttock and paraplegia, had a low air loss (LAL) mattress that was not set correctly according to the resident's weight. The mattress was set at 2 light bars instead of the required 3 light bars for a resident weighing 167 pounds. This incorrect setting was observed during an interview with the resident and confirmed by the treatment nurse, who adjusted the setting to the correct level. The facility's policy and procedure, as well as the LAL mattress user manual, indicated the importance of setting the mattress correctly to provide the necessary pressure relief and benefits. Resident 22, who had severe cognitive impairment and was dependent on assistance for personal hygiene and bed mobility, was not repositioned according to the care plan. The care plan required turning and repositioning at least every 2 hours to prevent skin breakdown. However, observations revealed that the resident was left lying on his back for extended periods, and the certified nursing assistant (CNA) did not attempt to reposition the resident due to anticipated resistance. The resident had open scratch marks on the buttocks and small scabs on the back, indicating a lack of compliance with the repositioning protocol. The facility's policy emphasized the need to reposition residents at risk of pressure injuries. These deficiencies in care could potentially delay the healing of existing pressure ulcers and increase the risk of developing new ones. The facility's failure to adhere to professional standards of practice and care plans for pressure ulcer management and prevention was evident in the observations and interviews conducted during the survey.
Deficient Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. Resident 21's nebulizer was not changed in a timely manner, as it was found unlabeled and unwrapped, dated from 2/6/2025, despite the facility's policy requiring weekly changes. This oversight occurred even though Resident 21 was in contact isolation, which necessitates strict infection control measures. The Director of Staff Development acknowledged that the nebulizer should have been changed and stored according to protocol. For Resident 52, the facility did not have a physician's order for the administration of oxygen, despite the resident receiving oxygen therapy via nasal cannula. Additionally, the oxygen tubing was not labeled with a date, which is necessary to ensure timely changes and prevent infection. Resident 52 had a history of bone cancer and chemotherapy, requiring careful management of respiratory treatments. Resident 111, who was admitted with pneumonia and acute respiratory failure, also had issues with unlabeled respiratory equipment. The nasal cannula and humidifier used for oxygen therapy were not labeled with a date, contrary to the facility's policy. The Registered Nurse Supervisor confirmed that labeling is essential for tracking when equipment needs to be changed, highlighting a lapse in adherence to infection control protocols.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to ensure that the medication error rate was below 5 percent, resulting in a 9.68 percent error rate during medication administration for one of the sampled residents. This was observed during a medication administration session where three errors were noted out of 31 opportunities. The errors involved the incomplete administration of medications via a gastrostomy tube for a resident, which could potentially affect the efficacy and benefits of the medications. The resident involved, identified as Resident 28, was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy and required attention to a gastrostomy tube. The resident's cognitive abilities were severely impaired, and they were dependent on a feeding tube for medication administration. During the medication administration process, the Licensed Vocational Nurse (LVN) failed to ensure that the full dose of medications was delivered, as evidenced by leftover medication residue in the medicine cups used for administration. The LVN admitted to not being able to identify the medications by sight and acknowledged that more water should have been added to ensure complete dissolution and administration of the medications. The Registered Nurse Supervisor confirmed that the leftover medication residue was significant and that the resident did not receive the full dose, which was necessary for therapeutic effectiveness. The facility's policy on administering medications, which requires safe and timely administration as prescribed, was not adhered to in this instance.
Failure to Label Medications Properly
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with professional principles, specifically concerning two medications, Senna and Docusate Sodium, used to treat constipation. During an observation and interview, it was found that these medications, stored in Med Cart 2, did not have an opened date label. The Licensed Vocational Nurse (LVN) acknowledged that these were part of the facility's house supply and should have been dated upon opening, as they expire 28 days after being opened. The absence of labeling could lead to the administration of ineffective medications. The Registered Nurse Supervisor confirmed that staff are required to label house supply medications with the date they are opened to maintain their potency. The facility's policy and procedure, titled 'Administering Medications,' mandates that the expiration or beyond-use date on the medication label is checked before administration and that the date of opening is recorded on multi-dose containers. The failure to adhere to this policy resulted in the potential for residents to receive ineffective and possibly contaminated medications, compromising their health, safety, and well-being.
Failure to Provide Fortified Diets as Ordered
Penalty
Summary
The facility failed to provide fortified diets as ordered by the physician for two residents, Resident 29 and Resident 112. Resident 29, admitted with diagnoses including cerebral infarction and hemiplegia, required a fortified/high protein diet with aspiration precautions. Resident 112, admitted with metabolic encephalopathy and type 2 diabetes mellitus, also required a fortified/high protein diet. The facility's diet roster confirmed these dietary needs, and the facility's menu for the specified date included 6 ounces of super soup for residents on fortified diets. However, during an observation, it was noted that the meal trays for both residents did not include the super soup, indicating a failure to follow the prescribed diet orders. The Dietary Supervisor acknowledged that the fortified diet was intended to provide extra calories and confirmed that the diet orders for Residents 29 and 112 needed to be followed. This oversight had the potential to prevent the residents from receiving the necessary caloric intake as ordered by their physician.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to ensure that expired food items were not present in the kitchen's dry storage, which could potentially lead to food-borne illnesses among residents. During an observation and interview with the Dietary Aide, it was found that an open package of corn meal and an open package of baking powder were expired but still kept in the storage area. The Dietary Aide acknowledged that these items needed to be discarded immediately. In an interview with the Dietary Supervisor, it was stated that expired food items should be discarded right away to prevent their use. However, the Dietary Supervisor could not provide a reason for the presence of expired items despite the responsibility of all kitchen staff to check for them. The facility lacked a specific policy and procedure regarding expired food items, although staff were expected to follow various storage guidelines. A review of the facility's Dry Goods Storage Guidelines confirmed the storage duration for corn meal and baking powder, emphasizing the need to check expiration dates.
Infection Control Lapses During Norovirus Outbreak
Penalty
Summary
The facility failed to adhere to infection control practices, particularly in managing a norovirus outbreak. Two residents, who were still exhibiting symptoms of norovirus, had their contact isolation precautions prematurely discontinued based on a recommendation from a Public Health Nurse. The Infection Prevention Nurse removed the isolation signs without confirming the residents were symptom-free for the required 48 hours. This oversight was confirmed when both residents reported ongoing symptoms, such as diarrhea and nausea, during interviews. Additionally, staff members did not consistently wear appropriate personal protective equipment (PPE) when interacting with residents under contact precautions. Observations revealed that CNAs and other staff entered rooms with only surgical masks, despite the presence of contact precaution signage and PPE carts. This lack of adherence to PPE protocols was acknowledged by the Director of Nursing and the Infection Preventionist, who emphasized the importance of proper PPE use to prevent the spread of infection. The facility also failed to ensure personal care items were properly labeled and stored, which is crucial for infection control. Unlabeled items such as wash basins, toothbrushes, and toiletries were found in shared restrooms, increasing the risk of cross-contamination. These deficiencies were observed in multiple shared rooms, where residents were under contact precautions due to the norovirus outbreak. The facility's policies on infection control and norovirus prevention were not effectively implemented, contributing to the potential spread of infection among residents and staff.
Deficiencies in Call Light, Bathroom Maintenance, and Bed Control Functionality
Penalty
Summary
The facility failed to ensure the functionality of a call light for a resident, which was not working since the previous night. The resident expressed frustration at having to yell for assistance, and a Certified Nursing Assistant confirmed the call light was non-functional. This deficiency was observed during an interview and concurrent observation, highlighting a lapse in the facility's adherence to its policy of ensuring call lights are operational at all times. Additionally, the facility did not maintain seven bathrooms and several rooms in good repair, as observed during an inspection with the Maintenance Director. The bathrooms and rooms had issues such as chipped paint, scratches, and cracked caulking, which were acknowledged by the Maintenance Director as potential health risks. This observation pointed to a failure in maintaining a clean, safe, and homelike environment as per the facility's policy. Another deficiency involved a resident's bed control, which was intermittently non-functional, causing discomfort due to being stuck in one position. Despite the resident informing multiple CNAs, the issue was not reported to maintenance until much later. The Maintenance Director confirmed that the bed control was only fixed after it was reported, and there was no record of the repair request in the Maintenance Log, indicating a breakdown in the facility's process for tracking and addressing maintenance issues.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote dignity and privacy during patient care for Resident 22, who was admitted with diagnoses including malignant neoplasm of the left lung and retention of urine. According to the Minimum Data Set dated 10/31/2024, Resident 22 had severe cognitive impairment and required maximum assistance with personal hygiene. During an observation on 2/21/2025, Certified Nursing Assistant 4 (CNA 4) was seen removing the sheet covering Resident 22's body, leaving the resident's lower body exposed while washing the resident's face and neck. This action was contrary to the facility's policy and procedure on dignity, which requires staff to cover other areas of the body while providing care to ensure privacy. CNA 4 acknowledged during an interview that care should be provided by washing the resident's body by area, ensuring other areas remain covered to prevent exposure. The facility's policy, dated February 2021, emphasizes the importance of promoting, maintaining, and protecting resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a proper assessment for the self-administration of Pepto Bismol Ultra for a resident with multiple diagnoses, including end-stage renal disease and type 2 diabetes mellitus with diabetic polyneuropathy. The resident, whose cognition was moderately impaired, was found with an almost empty bottle of Pepto Bismol Ultra in their room, without a physician's order or consent for self-administration, as required by the facility's policy and procedures. The resident admitted to purchasing and using the medication for indigestion without staff intervention or guidance. The Registered Nurse Supervisor confirmed that there was no order or consent for the resident to self-administer the medication and acknowledged that the facility's practice required an assessment of the resident's ability to self-administer safely, followed by obtaining a physician's order. The facility's policy indicated that residents could self-administer medications only if deemed safe and appropriate by the interdisciplinary care planning team. The presence of unauthorized medication at the bedside, especially for a dialysis patient, posed a potential risk due to possible contraindications and the need for careful monitoring.
Failure to Develop Care Plan for C. diff Positive Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who tested positive for Clostridium difficile (C. diff), a highly contagious bacteria causing severe diarrhea. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease, type 2 diabetes mellitus, gastro-esophageal reflux disease, and dependence on renal dialysis, received a positive lab result for C. diff. Despite the positive result and subsequent orders for Vancomycin treatment, no care plan was created to address the resident's condition from the time of the positive result on February 2nd until February 10th. The absence of a care plan was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that a care plan for active C. diff was only initiated on February 19th after the resident reported having diarrhea on February 16th. Observations noted that the resident's room initially lacked appropriate contact isolation signage, which was later corrected. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, which were not adhered to in this case.
Failure to Implement Toileting Schedule for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that a toileting schedule was implemented for a resident, identified as Resident 14, who was at risk for falls. Resident 14 was admitted with diagnoses including dementia and a history of repeated falls. The care plan for Resident 14, initiated on July 14, 2024, included an intervention to meet the resident's toileting needs every two hours. However, during observations and interviews, it was noted that Resident 14 did not have a toileting schedule in place, and items were stored on top of the bedside commode, obstructing its use. This lack of adherence to the care plan had the potential to result in falls and injury to the resident. On February 18, 2025, Resident 14 was observed getting up from bed unassisted and reported feeling dizzy. A change of condition report from February 15, 2025, documented an incident where Resident 14 fell while attempting to pick up pants after entering the wrong room. The Director of Nursing acknowledged that a toileting schedule could help prevent falls by ensuring the resident's needs were met, reducing the likelihood of the resident attempting to toilet independently. The facility's policy on falls indicated that staff should try various interventions to reduce or stop falls, but this was not effectively implemented for Resident 14.
Failure to Follow Catheter Care Protocol
Penalty
Summary
The facility failed to ensure that the licensed nurse followed the physician's order for indwelling catheter care for a resident with severe cognitive impairment and a history of urinary retention and lung cancer. The resident was admitted with bladder incontinence and recurrent urinary tract infections (UTIs). During an observation, brown sediments were noted on the resident's Foley catheter tubing, and the RN Supervisor confirmed the presence of light-colored sediments. Treatment Nurse 1 acknowledged that there was an order to flush the Foley catheter with acetic acid once a day for maintenance, but the last recorded irrigation was several days prior, on 2/16/2025. The resident's care plan indicated a need to monitor for signs and symptoms of UTIs, including urine cloudiness. Despite this, the resident continued to experience chronic sediments and recurrent UTIs. The facility's policy required immediate reporting of unusual findings to the physician or supervisor, but the report does not indicate that this was done in a timely manner. The resident was on a course of Ciprofloxacin for a UTI, but the persistent sediments and lack of adherence to the catheter care protocol suggest a failure in following the prescribed care plan and facility policies.
Improper Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure appropriate care and services during medication administration via a gastrostomy tube (G-Tube) for a resident. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy and dysphagia, had a care plan goal to remain free of complications related to tube feeding. However, during a medication administration observation, a Licensed Vocational Nurse (LVN) mixed the resident's medications with apple sauce instead of using water, as required by the facility's policy. This practice was not supported by a physician's order and contradicted the facility's procedures for administering medications through an enteral tube. The LVN stated that the tablets were not crushed because they were coated and that this method was how they were taught. The Registered Nurse Supervisor confirmed that a physician's order was necessary to mix medications with apple sauce for G-Tube administration. The Director of Staff Development also stated that using apple sauce could lead to clogging the G-Tube and decrease the potency of the medication. The facility's policy indicated that medications should be diluted with warm, purified water, and did not mention using apple sauce. This deficient practice had the potential to cause tube-associated complications such as feeding tube occlusions for the resident.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appetizing temperature. During an observation, it was noted that the last cart sent out from the kitchen contained food items that were not at appropriate temperatures. Specifically, the chicken was measured at 103 degrees Fahrenheit, green beans at 104 degrees Fahrenheit, and mashed potatoes at 134 degrees Fahrenheit. According to the facility's policy, the danger zone for food temperatures is between 41 and 135 degrees Fahrenheit, which promotes the rapid growth of pathogenic microorganisms that can cause foodborne illness. The deficiency was further supported by the facility's Resident Council Minutes from December 2024 and January 2025, which documented resident complaints about receiving cold food. The Dietary Supervisor acknowledged that the chicken was not cold but not warm either, and expressed concern that cold food would not be appetizing to residents, potentially leading to them not eating and experiencing weight loss. This practice had the potential to result in food that was not palatable or appetizing, thereby affecting residents' caloric intake and nutritional goals.
Non-Functional Call Light in Resident's Room
Penalty
Summary
The facility failed to provide a functioning call light for a resident, identified as Resident 7, which had the potential to delay care and services necessary for the resident's needs. Resident 7 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, epilepsy, and muscle weakness. During an interview, Resident 7 reported that the call light had not been working since the previous night, and a Certified Nursing Assistant (CNA) had instructed him to yell for assistance. This situation caused distress to Resident 7, who expressed a desire for the call light to be repaired. An observation confirmed that the call light in Resident 7's room was non-functional, as pressing the button did not activate the light inside the room or above the door. CNA 6 acknowledged the importance of a working call light, especially in emergencies, and stated that she would inform the maintenance director about the issue. The facility's policy on answering call lights, revised in September 2022, emphasizes the need for call lights to be plugged in and functioning at all times, with defective call lights to be reported promptly to the nurse supervisor.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in Kitchen 1, as evidenced by the presence of two dead cockroaches found during a tour. The cockroaches were located at the back of the walk-in freezer, visible in a 3-inch gap between the freezer and the wall. A Dietary Aide used a broom, which had dust and green beans on it, to sweep the dead cockroaches from the area. During an interview, the Dietary Aide confirmed the presence of the dead cockroaches. The Dietary Supervisor suggested that the cockroaches might have emerged after a recent pest control visit conducted more than a week prior. The facility's Policy and Procedure on Sanitization, dated October 2008, requires all kitchen and dining areas to be kept clean and free from pests, which was not adhered to in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
