Monterey Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 1267 San Gabriel Blvd, Rosemead, California 91770
- CMS Provider Number
- 555897
- Inspections on file
- 37
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Monterey Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to implement and update person-centered care plans for three residents with significant clinical and psychosocial needs. A resident with hemolytic anemia had a care plan directing staff to monitor and document specific anemia symptoms, yet staff and the ADON acknowledged that only routine labs were obtained and there was no documented monitoring for the listed signs and symptoms, even after a hospitalization for critically low HGB/HCT. Another resident with schizophrenia and depression developed new verbal threats toward staff, repeatedly saying "I want to hit you," but an LVN did not complete a change in condition form, did not notify the physician, and did not update the care plan, despite facility protocol for such behaviors; later, this resident threw coffee toward another resident during an activity and was transferred for psychiatric evaluation. A third resident with schizophrenia, lack of coordination, and documented impaired vision reported difficulty seeing, inability to participate fully in activities, and feeling unheard, while activity staff and the AD noted poor participation and low self-esteem related to vision problems; the DON confirmed there was no care plan addressing this resident’s visual impairment, contrary to facility policy on comprehensive person-centered care planning.
A resident with schizophrenia, depression, and auditory hallucinations, whose care plan required monitoring and reporting of any risk of harm to others, began making new verbal threats such as “I want to hit you” toward staff about a month after admission. An LVN observed this behavior but did not document it, did not complete a Change in Condition form, did not update the care plan, and did not notify the physician, despite facility policy requiring physician notification for significant mental or psychosocial changes. Later, after the resident threw coffee toward another resident during an activity, a Change in Condition form was completed and the NP ordered transfer to a hospital, but the earlier unreported verbal threats formed the basis of the deficiency.
A resident with schizophrenia, bipolar disorder, anxiety, depression, and documented delusions had a care plan identifying risk for verbal and physical aggression, but over a period of weeks developed increased verbal aggression, delusional accusations that others were stealing her medications, and episodes of withdrawal. Nursing notes, CoC documentation, and the MAR recorded multiple episodes of cursing, yelling, and aggression toward staff and other residents, with staff sometimes unable to redirect her. Although the ADON contacted the psychiatrist about possible medication changes, the psychiatrist did not complete an in‑person evaluation during this period, and the ADON did not escalate concerns to the NP or psychiatric medical director despite recognizing that existing interventions were ineffective and the resident could harm others. Ultimately, the resident approached another resident who was quietly reading, used a racial slur, and elbowed her in the face, demonstrating the facility’s failure to implement adequate interventions and supervision to prevent accidents and resident‑to‑resident aggression.
A resident with severe cognitive impairment, gait abnormalities, and paranoid schizophrenia walked into an open door during the night shift, sustaining a bleeding cut above the right eye. A CNA witnessed the incident and brought the resident to the nurses’ station, where an RN and an LVN assessed the wound and provided first aid but did not initiate a change-in-condition evaluation or notify the MD, and did not document the accident in the record. The injury was later identified on the morning shift when staff observed the resident’s eyebrow laceration and eyelid discoloration, completed a change-in-condition form, and contacted the MD, who ordered transfer to a hospital. This sequence of events occurred despite a facility policy requiring licensed nurses to notify the MD and a family representative after any incident or accident resulting in injury with potential need for physician intervention.
A facility failed to verify a resident's admission orders by not reviewing complete discharge documents from a GACH. The nurse relied on a clinical summary and previous records, communicating orders to the physician via SMS without verbal confirmation. The DON stated that protocol required discussing discharge summaries with the physician, which was not followed, risking incorrect medication administration.
A facility failed to provide appropriate training for its staff to care for a resident with PTSD, resulting in inadequate care. The resident, with multiple mental health diagnoses, did not receive trauma-informed care due to the absence of specific in-services on PTSD. Interviews with CNAs and the DSD revealed a lack of awareness and training on PTSD, despite facility policies indicating the need for such education.
The facility did not post daily nurse staffing information in a location accessible to both residents and visitors, as required by their policy. The ADON and DSD acknowledged the oversight, with the DSD admitting to posting the information only on a window accessible to visitors. The Administrator confirmed that residents have the right to access this information.
The facility failed to ensure proper sanitation and food handling practices by not securing all hair within a hairnet during meal preparation. A Dietary Aide was observed with exposed hair while assisting in meal preparation for 69 residents, posing a risk of contamination. Interviews with staff confirmed awareness of the risks, and the facility's policy requires effective hair restraints in kitchen areas.
The facility failed to implement a proper Water Management Program to prevent Legionella growth, as the IP was unaware of national standards and risk assessments. The facility only tested for Legionella with 10 or more pneumonia cases, and there was no evidence of water heater flushing for February. The policy referenced ASRAE guidelines, but there was no evidence of their implementation.
The facility failed to ensure the lint screens in laundry machines were cleaned as scheduled, as evidenced by incomplete documentation in the Lint Cleaning Log. This oversight was confirmed by the Laundry Services and Infection Preventionist, who acknowledged the absence of documented evidence for the cleaning of lint screens, posing a potential fire hazard.
A resident with intact cognition and independence in daily activities was observed wearing loose jeans held up by an elastic glove, leading to exposure of private areas. Despite staff awareness, no measures were taken to provide properly fitting clothing, compromising the resident's dignity.
A resident with cognitive impairments was allowed to sign informed consent for psychotropic medications without a surrogate decision-maker or interdisciplinary team meeting, despite documented evidence of their inability to make medical decisions. The facility failed to verify the resident's mental status before obtaining consent, violating their rights and potentially exposing them to inappropriate care.
A resident's safety was compromised when the call light in a shower room was positioned too high, making it unreachable. The facility's policy required call lights to be within reach, but this was not followed, as confirmed by a CNA and Maintenance Staff. The resident, with intact cognition and requiring assistance, expressed concerns about safety due to the inaccessible call light.
Two residents experienced privacy violations in a facility due to peeling stained-glass window films in common restroom and shower areas, allowing visibility from the patio. Despite awareness of the issue, staff were unsure of how long the films had been in disrepair, compromising residents' privacy rights.
The facility failed to create comprehensive care plans for two residents. One resident was discharged without a detailed discharge plan, and another resident with PTSD did not have a specific care plan addressing PTSD management. The facility's policy required comprehensive care plans, but this was not followed, leading to potential confusion and inadequate care.
A resident with PTSD, schizoaffective disorder, and other mental health conditions experienced re-traumatization and increased hallucinations due to the facility's failure to provide trauma-informed and culturally competent care. The facility did not adequately assess or document the resident's trauma history or triggers, and staff were unaware of the resident's PTSD diagnosis. This led to the resident experiencing distress and behavioral issues, resulting in multiple hospitalizations.
A facility failed to provide necessary behavioral health care for a resident with PTSD, schizoaffective disorder, and other mental health issues. The resident exhibited agitation and made homophobic comments, but the facility did not document or address PTSD triggers. Family and staff interviews revealed a lack of inquiry into the resident's trauma history, and care plans did not adequately involve family or address PTSD. Observations showed the resident's distress, and staff acknowledged the importance of identifying triggers to prevent re-traumatization.
A resident received Bactrim for nearly a year without a stop date, contrary to the facility's Antibiotic Stewardship policy. The prolonged use, identified during a review, exceeded the recommended 14-day course, posing a risk of antibiotic resistance. The Infection Preventionist Nurse was unaware of the extended administration due to the lack of a documented end date.
The facility was found to have four rooms exceeding the regulatory limit of four residents per room, with two rooms housing twelve residents each, one with seven, and another with six. Despite this, residents reported no concerns, and observations indicated adequate space and care. The facility had a waiver and planned to request another, asserting no impact on care quality.
The facility did not meet the required minimum of 80 square feet per resident in twelve rooms, affecting various bed capacities. Despite the deficiency, residents reported no concerns about space, and no adverse effects were observed during the survey. The Administrator acknowledged the issue and mentioned a room waiver in place.
A resident with a history of falls and severely impaired cognition fell and suffered an acute subdural hematoma after attempting to stand without supervision on the facility's patio. Despite documented needs for supervision, staff were not in close proximity, violating the facility's safety policy.
Two residents at high risk for elopement left the facility unsupervised due to inadequate monitoring and supervision. One resident, with fluctuating decision-making capacity and suicidal ideation, climbed the roof and escaped during a shift change. A week later, another resident with no decision-making capacity and similar diagnoses eloped from the same location. The facility lacked dedicated staff to monitor the patio during the night shift, and the patio doors were left unlocked, contributing to these incidents.
A facility failed to create a care plan for a resident with a history of drug abuse who was allowed to go out on pass. Despite the resident's medical history, including schizophrenia and drug abuse, the facility did not document specific interventions to monitor the resident's behavior. The DON acknowledged the lack of a care plan and stated that interventions were communicated verbally, without a written policy.
A resident with a history of suicidal ideations and fluctuating decision-making capacity eloped from an ambulance en route to a hospital. The LTC facility failed to promptly investigate or locate the resident after being informed that the resident was not admitted to the hospital. The facility's ADM and AC did not follow up with the hospital or ambulance company, and the incident was not reported to law enforcement. The facility lacked a policy for ensuring safe resident transfers.
A resident with psychosis, major depressive disorder, and dementia eloped from the facility due to inadequate monitoring and supervision. The resident was found the next day at a nearby school football field. The facility lacked scheduled monitoring for the breezeway area and continuous surveillance camera monitoring during the day and evening shifts.
Failure to Implement and Update Person-Centered Care Plans for Anemia, Behavioral Changes, and Vision Impairment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for three residents with identified needs. For one resident with acquired hemolytic anemia, the care plan initiated at readmission included detailed interventions to educate the resident and caregivers about expected stool changes and to monitor, document, and report specific signs and symptoms of anemia such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feelings of cold, low HGB/HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. The resident’s MDS showed intact cognition and active diagnoses including anemia, heart failure, HTN, and renal insufficiency. A change of condition evaluation documented abnormal vital signs and a critical lab result that led to transfer to a GACH, and the care plan was later revised to note very low HGB and HCT values. However, there was no evidence that new or updated interventions were added after the hospitalization and readmission, and interviews with the ADON and nursing staff confirmed that, although routine labs were ordered every three months, there was no documented monitoring for the physical signs and symptoms of anemia as specified in the care plan. For a second resident with schizophrenia, depression, and auditory hallucinations, the MDS indicated moderately impaired cognition and a need for supervision or touch assistance with most cares, and it documented that the resident did not exhibit verbal behavioral symptoms directed toward others at that time. The existing care plan addressed a mood disorder with interventions to monitor and report risks of harming others, such as increased anger, labile mood, agitation, feeling threatened, or thoughts of harming someone. Progress notes from a provider visit indicated no suicidal or homicidal ideations and no violent behavior. According to an LVN, about a month after admission the resident began expressing frustration by saying "I want to hit you" to staff, which was described as a new behavior. The LVN acknowledged there was no documentation of these verbal threats in progress notes, no change in condition form was completed, and the care plan was not updated to reflect the new threatening behavior or to prompt physician notification, despite facility protocol that residents expressing intent to harm themselves or others should be placed on one-to-one supervision and have a CIC completed. A later CIC documented that during a coffee social activity the resident stood up, spoke loudly, and threw a cup of coffee toward another resident, leading to notification of the NP and transfer to a GACH on a 5150 hold. For a third resident admitted with schizophrenia, lack of coordination, depression, and anxiety, the MDS documented intact cognition and impaired vision, with the ability to see large print but not regular print. Observations during a karaoke activity showed the resident sitting close to the TV, holding a microphone, looking down, not singing, and stating to activity staff that he wanted to hear the song but could not sing along because he could not read the words on the TV; he was also observed squinting at the TV and at staff. In interviews, the resident reported being partially blind, having difficulty seeing, wanting to participate in more activities but being unable to due to impaired vision, and feeling that staff did not listen to his concerns. Activity staff reported that the resident often complained about not being able to see well, did not participate in some activities because of poor vision, and would not attend group activities that could not accommodate his visual impairment. The activities director stated that one-to-one activity visits were needed because the resident was not actively participating in group activities and presented with low self-esteem, expressing that he felt like a burden. During a record review, the DON confirmed there was no care plan addressing the resident’s poor vision, despite the facility’s policy requiring development and implementation of a comprehensive person-centered care plan to support residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.
Failure to Notify Physician of Resident’s New Verbal Threats and Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s new behavior of making verbal threats toward staff, as required by the resident’s care plan and the facility’s change in condition policy. The resident was admitted with schizophrenia, depression, and auditory hallucinations, and had a care plan initiated in January that directed staff to monitor, record, and report to the physician any risk of the resident harming others, including increased anger, labile mood, agitation, or thoughts of harming someone. The resident’s MDS from late January indicated moderately impaired cognition and no verbal behavioral symptoms directed toward others. However, according to an LVN, beginning about one month after admission, the resident began verbalizing “I want to hit you” to staff when he did not get what he wanted. The LVN acknowledged that this was a new threatening behavior that started in February, but there was no documentation of these verbal threats in the progress notes, no Change in Condition (CIC) form was completed, and the care plan was not updated to reflect this new behavior. The DON stated she was not aware that the resident was making verbal threats and confirmed that facility protocol required staff to create a CIC, update the care plan, and notify the physician when a resident expressed verbal threats such as “I want to hit you.” The facility’s written Change in Condition policy required the licensed nurse to notify the resident’s physician and legal representative when there is an incident involving the resident or a significant change in the resident’s mental or psychosocial status. On a later date, a CIC was completed after the resident threw coffee toward another resident during an activity, and the NP was notified and ordered transfer to a general acute care hospital for evaluation. Prior to this incident, however, the new pattern of verbal threats toward staff was not reported to the physician or documented as a change in condition, constituting the cited failure to immediately notify the physician of a significant change in the resident’s behavior.
Failure to Manage Escalating Aggression and Delusions Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions and supervision for a resident with escalating verbal aggression and delusions, which resulted in that resident physically striking another resident. Resident 54 was admitted with schizophrenia, anxiety disorder, bipolar disorder, depression, psychotic disorder, and documented delusions, and had a conservatorship order stating she was gravely disabled and unable to provide for basic personal needs. Her care plan, initiated on 2/13/2026, identified potential for verbal and physical aggression related to ineffective coping skills, mental and emotional illness, and poor impulse control, with goals that she not harm herself or others. Interventions listed included analyzing triggers and circumstances, assessing coping skills and support systems, anticipating and assessing needs, and identifying and addressing contributing sensory deficits. In the days leading up to the incident, multiple records documented a clear increase in Resident 54’s verbal aggression and delusional thinking. A Change of Condition (CoC) evaluation on 3/9/2026 at 5:30 PM recorded that she was verbally aggressive, cursing, yelling, and shouting at staff and other residents, with staff attempting redirection and close monitoring for safety. Nursing progress notes from 3/9/2026 through 3/12/2026 described multiple episodes of increased verbal aggression toward staff and residents, with staff sometimes able to redirect her and sometimes unable to do so. The Medication Administration Record for March 2026 documented 13–16 episodes of increased delusions and aggression toward staff and residents between 3/9/2026 and 3/15/2026. Staff interviews confirmed that for approximately one to three weeks before the physical incident, Resident 54 had increased verbal aggression, increased delusions, and periods of withdrawal and staying in bed, and that she sometimes did not comply with redirection. Despite these documented changes, the facility did not implement additional or modified interventions beyond redirection and monitoring, nor did it effectively escalate concerns for timely psychiatric evaluation. The Assistant Director of Nursing (ADON) spoke with the psychiatrist (Physician 5) on 3/10/2026 about possible medication adjustments, and the psychiatrist stated he would conduct an in‑person evaluation before making changes, but he did not come to the facility between 3/10/2026 and 3/13/2026. A nursing note on 3/13/2026 documented that the ADON attempted to call the psychiatrist and was unable to reach him, and the ADON acknowledged he did not notify the psychiatrist’s nurse practitioner or the psychiatric medical director, even though existing interventions were not effective and the resident had the potential to harm others. On 3/16/2026 at 7:00 AM, a CoC record documented that a CNA witnessed Resident 54 elbow Resident 25 in the right cheek while Resident 25 was quietly reading her Bible in her wheelchair in an alcove. Statements from staff and residents indicated that Resident 54 approached Resident 25, used a racial slur, and then struck her with an elbow to the right side of the face. The facility’s Resident Safety policy required evaluation when there is a change of condition to identify circumstances that pose a risk for safety and well‑being, but the documented escalation in aggression and delusions was not met with effective interventions to prevent the physical assault.
Failure to Notify MD After Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician at the time of an accident that resulted in a head injury. The resident had paranoid schizophrenia, lack of coordination, and gait and mobility abnormalities, and an MDS dated 1/29/26 documented severe cognitive impairment and a need for supervision with most activities of daily living. On 3/7/26 around 3 AM, a CNA observed the resident turn a corner in the hallway and bump his face into the edge of an open door that protruded into the hallway, resulting in a cut above the right eye with bleeding. The CNA brought the resident to the nurses’ station, where an LVN and an RN assessed the cut and provided first aid. Despite the observed accident and visible injury, the LVN and RN on the night shift did not initiate a Change in Condition Evaluation (CIC) form and did not notify the resident’s physician of the incident. There was no documentation in the resident’s progress notes or CIC records related to the 3 AM accident. As a result, the day shift staff initially considered the injury to be of unknown origin because they were unaware of how the resident sustained the right eye injury. The facility’s later investigation confirmed that the injury occurred when the resident walked into the door during the night shift. Later that morning, at 8:45 AM, a CIC was completed when the resident was seen in the shower room rubbing his right eyebrow, with bleeding noted and a 1.2 cm cut on the right eyebrow and discoloration of the right upper eyelid. The CIC documented that the skin change and a neurological assessment were relevant to the change in condition, and the physician was notified at 9 AM and recommended transfer to a general acute care hospital for medical clearance. The facility’s policy titled “Change in Condition” required licensed nurses to notify the physician and the resident’s representative when there is an incident or accident involving the resident, or an accident resulting in injury with potential need for physician intervention. The failure of the night-shift licensed nurses to initiate a CIC and notify the physician at the time of the accident constituted the cited deficiency.
Failure to Verify Admission Orders
Penalty
Summary
The facility failed to ensure that licensed staff verified a resident's admission orders by reviewing the resident's medical history and discharge orders from a general acute care hospital (GACH) upon readmission. The resident, who had diagnoses including schizophrenia and bipolar disorder, was readmitted to the facility with specific medication orders from the hospital. However, the nurse responsible for the admission did not review the complete discharge documents and only relied on a clinical summary report and previous medication records to input the resident's readmission orders. The nurse communicated the orders to the physician via SMS, assuming agreement if the message was read, without verbal confirmation. The Director of Nursing (DON) indicated that the facility's protocol required licensed nurses to discuss discharge summaries with the admitting physician to confirm medication orders. The facility's policy also stated that the attending physician should provide medication orders upon admission. The failure to follow these procedures resulted in a potential risk of the resident not receiving the correct medications and care needed for their diagnosis.
Lack of PTSD Training for Staff
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for a resident diagnosed with PTSD, as identified through resident assessments. Resident 11, who was admitted and readmitted with multiple mental health diagnoses including PTSD, did not receive care from staff trained in trauma-informed care. The facility's Director of Staff Development (DSD) admitted that there were no in-services related to trauma or PTSD provided to the staff, and the topic was not brought up to the Administrator or Director of Nursing. Interviews with Certified Nurse Assistants (CNAs) revealed a lack of awareness and training regarding trauma or PTSD. CNA 2, CNA 3, and CNA 4 all stated they had not received specific training on how to care for residents with PTSD, and they were not aware of any residents diagnosed with PTSD in the facility. This lack of training and awareness among the staff resulted in Resident 11 not receiving the appropriate care needed for their condition. The facility's policy and procedures on Trauma-Informed Care indicated that staff should be educated on the specific needs of residents who have experienced trauma, including PTSD. However, the facility's failure to implement these policies and provide necessary training led to a deficiency in care for Resident 11, as the staff did not have the competencies required to manage the resident's PTSD and related behaviors effectively.
Failure to Post Nurse Staffing Information Accessibly
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to both residents and visitors, as required by their policy and procedure titled 'Nursing Department - Staffing, Scheduling & Postings.' During an observation and interview with the Assistant Director of Nurses (ADON), it was noted that there was no visible daily nurse staffing information posted. The ADON acknowledged that the postings should be accessible and visible for residents and visitors. The Director of Staff Development (DSD) admitted to posting the nurse staffing information on the visiting window, which was only accessible to visitors and not to residents. The DSD was unaware that residents should have access to this information. The Administrator confirmed that it was a resident's right to be informed about nurse staffing, and the postings should be accessible in the residents' area. The facility's policy, revised in 2018, indicated that nurse staffing postings must be in a prominent place readily accessible to residents and visitors.
Improper Hair Restraint in Food Preparation
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, specifically in ensuring that all hair was properly secured within a hairnet during meal preparation. During a dining observation, a Dietary Aide (DA 1) was seen with hair exposed outside of the hairnet while assisting in the preparation of meal trays for all 69 residents in the facility. This observation was confirmed during an interview with DA 1, who acknowledged the importance of securing all hair to prevent contamination and the associated risks of infection or illness. Further interviews revealed that the kitchen staff, including the cook, were aware of the risks associated with exposed hair in food preparation areas. The Assistant Director of Nursing (ADON) also emphasized the requirement for anyone entering the kitchen to wear a hairnet and ensure no hair is exposed. A review of the facility's policy and procedures, revised in 2024, confirmed the requirement for effective hair restraints in kitchen and food storage areas, highlighting a lapse in adherence to these standards.
Inadequate Legionella Management in Water System
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring its Water Management Program adhered to national, state, and local measures to prevent and monitor the growth of Legionella. During an interview, the Infection Preventionist (IP) revealed that the facility only tested for Legionella if there were 10 or more pneumonia cases, citing cost concerns. The facility had five water heaters, which were reportedly flushed monthly, but there was no documented evidence of flushing for February 2025. The IP was unaware of the meaning of terms like 'good' or 'bad' in the Water Heater Legionella Management Plan and did not know if the plan was based on a national standard. The facility's Water Management Plan, revised in February 2024, lacked specific measures for Legionella management, and the IP was unfamiliar with the risk assessment process outlined in the facility's policy and procedure. The policy indicated the need for a risk assessment to determine Legionella growth risk and the use of national guidelines to develop control measures. However, the IP was unaware of these requirements. The facility's policy also referenced the American Association of Heating Refrigeration and Air-Conditioning Engineers (ASRAE) guidelines for Legionella prevention, which included quarterly water quality measurements and maintenance of chemical levels, but there was no evidence these measures were implemented. The State Operational Manual required a documented water management program based on national standards, but the facility failed to demonstrate compliance with these requirements.
Failure to Document Lint Screen Cleaning in Laundry Machines
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for all 69 residents, staff, and the public by not ensuring that the lint screens in the laundry machines were cleaned as per the established schedule. The Lint Cleaning Log for the dates 2/12/2025 and 2/13/2025 was incomplete, lacking documentation that the lint screens were cleaned for two out of three dryer machines on 2/12/2025 and for all three machines on 2/13/2025. This oversight was confirmed during interviews with the Laundry Services (LS) and the Infection Preventionist (IP), who both acknowledged the absence of documented evidence for the cleaning of lint screens. The facility's policy, titled 'Laundry - Safety' and revised on 1/1/2012, mandates that all machines and appliances be checked daily to ensure they are clean and free of defects. However, the failure to document the cleaning of lint screens as per the schedule posed a potential fire hazard, as acknowledged by both the LS and the IP. The LS emphasized the importance of regular lint screen cleaning to prevent fires, while the IP noted the uncertainty of whether the last scheduled person on 2/12/2025 had completed the task due to the lack of documentation.
Resident Dignity Compromised by Ill-Fitting Clothing
Penalty
Summary
The facility failed to promote respect and dignity for a resident who was observed wearing jeans that were too loose and held up with an elastic glove tied to the belt loops. This resulted in the resident's jeans frequently falling down, exposing his buttocks and groin area in front of other residents, staff, and visitors. The resident expressed a desire for properly fitting pants, indicating awareness and discomfort with the situation. The resident, who has diagnoses of paranoid schizophrenia and hyperlipidemia, was noted to have intact cognition and was independent in various activities of daily living. Despite this, the staff, including a CNA, acknowledged the issue with the resident's clothing but did not take appropriate measures to ensure the resident's dignity was maintained. The facility's policy emphasizes the importance of providing care that promotes dignity and respect, which was not adhered to in this instance.
Failure to Verify Resident's Capacity for Informed Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 56, was fully informed and understood their health status, care, and treatments. Despite the resident's documented lack of mental capacity to make medical decisions, as indicated in multiple assessments including the Health & Physical assessment, psychiatric notes, and a neuropsychological evaluation, the facility allowed the resident to sign informed consent for psychotropic medications without the involvement of a surrogate decision-maker or an interdisciplinary team meeting. This oversight occurred even though the resident's medical records consistently highlighted cognitive impairments such as loose associations, distractibility, and hallucinations. The Social Service Director acknowledged that the mental status assessment was not verified by the physician before obtaining informed consent, which placed the resident at risk of making uninformed medical decisions. The facility's policy required a clear determination of the resident's capacity and the identification of a decision-maker, which was not adhered to in this case. The failure to conduct an interdisciplinary team meeting or arrange for a surrogate decision-maker when the resident lacked capacity violated the resident's rights and potentially exposed them to inappropriate medical care.
Inaccessible Call Light in Shower Room
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring that the call light was within reach in the shower room. This deficiency was identified during an observation and interview with a Certified Nursing Assistant (CNA) who was unable to reach the call light switch lever, which was positioned too high on the wall. The Maintenance Staff confirmed that a string or cord should have been attached to the call light switch lever to make it accessible for residents. The facility's policy required that call alert devices be placed within the resident's reach, but this was not adhered to in the shower room. The resident involved, who had been admitted with diagnoses including schizophrenia and hypertension, had intact cognition and required assistance with various activities of daily living. During an interview, the resident expressed that having the call light within reach would make them feel safer in the shower room. The Assistant Director of Nursing (ADON) acknowledged that all call lights should be accessible to ensure residents' needs and safety, especially during emergencies. The facility's failure to comply with its policy and procedure on the communication-call system resulted in a deficiency that could potentially impact resident safety.
Privacy Violation Due to Peeling Window Films
Penalty
Summary
The facility failed to ensure the privacy of two residents, identified as Resident 41 and Resident 119, when using common restroom and shower facilities. The deficiency was observed in the [NAME] Wing's shower room and the East Wing's restroom, where the stained-glass window films were peeling off, allowing visibility from the front patio. This issue was noted during observations on February 11, 2025, and confirmed through interviews with staff, including a Certified Nursing Assistant (CNA) and the Maintenance personnel, who acknowledged the problem but were unsure of how long the films had been in disrepair. Resident 41, admitted with schizoaffective disorder and hyperlipidemia, was found to have intact cognition and required assistance with personal care tasks. During an interview, Resident 41 expressed concern about privacy, stating she would not shower if she knew others could see through the window. Similarly, Resident 119, who had schizophrenia and hypertension, also had intact cognition and required assistance with personal care. He expressed discomfort with the possibility of being seen while using the restroom. The facility's policy on resident rights, which includes privacy and confidentiality, was not adhered to, as confirmed by the Assistant Director of Nursing (ADON) and the Housekeeper (HSKP). The HSKP mentioned that addressing the peeling window films was an ongoing project since a previous survey identified the issue. Despite this, the problem persisted, compromising the residents' right to privacy as guaranteed by state and federal laws.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 68, who was admitted with schizophrenia and depression. Although the resident was discharged to a transition care facility, the staff did not create a detailed care plan addressing discharge planning. The Assistant Director of Nursing (ADON) acknowledged that the Social Services Director (SSD) was responsible for initiating the discharge care plan, which was not done. This oversight could lead to confusion in the resident's care and discharge process, as the interdisciplinary team did not have a structured plan to follow. For Resident 11, the facility did not develop a specific care plan to address the management and triggers of Post-Traumatic Stress Syndrome (PTSD). Resident 11, who had a history of childhood trauma and PTSD, was admitted with multiple mental health diagnoses, including schizophrenia, schizoaffective disorder, and bipolar disorder. The care plan included interventions for behavioral problems but did not specifically address PTSD. The ADON stated that a separate care plan for PTSD was expected to guide staff in managing the resident's care and identifying potential triggers. The facility's policy on Comprehensive Person-Centered Care Planning required that all goals and interventions from the baseline care plan be included in the comprehensive care plan. However, the facility did not adhere to this policy for both residents. The lack of specific care plans for discharge planning and PTSD management indicates a failure to provide resident-specific care, which is essential for maintaining continuity of care and communication among staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident experienced re-traumatization and increased hallucinations and delusions, leading to multiple hospitalizations. The facility did not adequately assess or document the resident's trauma history or triggers, despite the resident's history of childhood trauma and PTSD being known to family members. The resident's care plans and assessments lacked documentation of trauma triggers, and staff members were unaware of the resident's PTSD diagnosis and potential triggers. Interviews with staff revealed a lack of awareness and training regarding trauma-informed care, with staff unable to identify residents with PTSD or their specific needs. The facility's policy on trauma-informed care was not effectively implemented, as staff did not assess the resident's trauma history or engage with family members to understand the resident's triggers. Observations and interviews indicated that the resident exhibited aggressive and homophobic behavior, which was not adequately addressed by the facility. The facility's failure to provide appropriate care and interventions for the resident's PTSD and trauma history resulted in the resident experiencing distress and behavioral issues. The facility's policies on trauma-informed care were not followed, leading to a deficiency in providing culturally competent and trauma-informed care to the resident.
Failure to Address PTSD Triggers in Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with multiple mental health disorders, including PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident, who had a history of recent trauma, exhibited behaviors such as agitation, yelling, and attempts to hit staff members. Despite these behaviors, there was no documented evidence of the resident's triggers, which are crucial for managing PTSD and preventing re-traumatization. The resident's care plans, initiated upon readmission, included interventions such as anticipating needs, assisting in developing coping skills, and monitoring behavior episodes. However, these plans did not adequately address the resident's PTSD triggers or involve the family in understanding the resident's history of trauma. Interviews with family members and staff revealed that the facility did not inquire about the resident's PTSD history or address the deep trauma and homophobia that the resident experienced. Observations of the resident's behavior included arguing, talking to himself, and making homophobic comments towards staff members. Interviews with facility staff, including the ADON and the Administrator, highlighted the importance of identifying PTSD triggers to prevent re-traumatization and potential harm. The facility's policy on behavior management indicated that assessments should be conducted to address mood or behavior problems, but the implementation of these assessments and interventions was insufficient for this resident.
Prolonged Antibiotic Use Without Reassessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Bactrim, an antibiotic. The resident, who was admitted with diagnoses including heart failure, asthma, schizophrenia, and depression, was prescribed Bactrim for HIV without a specified stop date. This oversight led to the resident receiving the antibiotic for nearly a year, far exceeding the recommended 14-day course. The Infection Preventionist Nurse was unaware of the prolonged administration due to the lack of a documented end date. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce resistance, was not adhered to in this case. The prolonged use of Bactrim without reassessment or a stop date posed a risk of developing antibiotic resistance. The deficiency was identified during a review of the resident's records and an interview with the Infection Preventionist Nurse, who acknowledged the oversight and the potential for adverse health outcomes due to the extended use of the antibiotic.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey, it was observed that four rooms in the facility exceeded this limit, with two rooms accommodating twelve residents each, one room with seven residents, and another with six residents. The facility's administrator acknowledged the situation and mentioned that a waiver was in place, with plans to request an additional waiver. Despite the non-compliance, the administrator claimed that the number of residents per room did not impact the care provided. Interviews with residents in the affected rooms revealed that they did not have concerns about the number of residents sharing their space. Observations during the survey indicated that the rooms provided adequate space for movement and the use of mobility aids, such as wheelchairs and walkers. The survey did not find any adverse effects on the residents' care, comfort, or privacy due to the room arrangements. The facility's request for a waiver highlighted that the room sizes allowed for adequate nursing care and accessibility, and the survey confirmed that the care and services provided were not compromised.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in twelve out of twenty-two resident rooms. These rooms included a variety of bed capacities, ranging from two to twelve beds per room. The Administrator acknowledged the deficiency, stating that the facility had a room waiver in place and intended to request an additional waiver. Despite the deficiency, the Administrator claimed that the room size did not impact the care provided to residents. Observations and interviews with residents in the affected rooms revealed that they did not express concerns about the space available to them. Residents were able to move freely with assistive devices such as wheelchairs and walkers. The facility's Client Accommodations Analysis confirmed that the rooms did not meet the required square footage per resident. However, during the survey, no adverse effects related to the inadequate room size were observed, and residents were seen to have enough space to move freely and receive care without restrictions.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to implement its policy and procedure on resident safety by not providing adequate supervision to a resident at high risk for falls. This resulted in the resident suffering an acute subdural hematoma after falling while attempting to stand up from a sitting position on the facility's patio without staff supervision. The incident occurred when a staff member observed the resident sitting on the patio's brick seating area and later saw the resident fall on his right side after standing up using a front-wheeled walker. The resident was subsequently sent to a general acute care hospital for further evaluation. The resident had a history of falls and was known to have severely impaired cognition, requiring supervision or touching assistance when standing from a sitting position. Previous assessments, including a Minimum Data Set and a Physical Therapy Evaluation, indicated the need for supervision due to the resident's balance issues and decreased muscular coordination. Despite these documented needs, the resident was left unsupervised, leading to the fall and subsequent injury. Interviews with staff confirmed that they were not in close proximity to the resident at the time of the fall, which was contrary to the facility's policy on resident safety that required a person-centered observation system to address identified risk factors.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents, both assessed at high risk for elopement, from leaving the facility unsupervised. Resident 1, who had fluctuating capacity to understand and make decisions and was diagnosed with suicidal ideation, eloped from the facility during a shift change. The resident climbed the roof from the facility's main patio, jumped into the parking lot, and climbed over the fence. This incident occurred despite the resident's care plan indicating a need for monitoring and supervision to prevent elopement. Resident 2, who had no capacity to understand and make decisions and was also diagnosed with suicidal ideations, eloped from the same location a week later. The resident used water pipes attached to the building to climb to the roof and escape. The facility's lack of dedicated staff to monitor the patio during the night shift contributed to this incident. The patio doors remained unlocked 24 hours a day, allowing residents to access the area freely, which further facilitated the elopement. The facility did not thoroughly investigate the first elopement incident to prevent a recurrence. Staff monitoring the breezeway and patio areas did not have a full view of the patio, and there was no dedicated staff assigned to monitor the patio during the night shift. Additionally, the facility's closed-circuit television did not cover the area where the residents climbed to the roof, and there was a lack of communication among staff regarding the residents' elopement risks.
Removal Plan
- Residents were monitored and supervised when in Patio 1 at all times, in all three shifts.
- Heightened awareness on security and oversight of all facility exit doors for all three shifts.
- Residents at risk for elopement are frequently monitored and their whereabouts are always accounted for.
- Staff were in-serviced on how to care for residents at risk for elopement.
- Measures are in place to prevent residents from leaving the facility unsupervised for 22 residents at risk for elopement.
- Police notified and missing person's report filed.
- Facility contacted local hospitals during every shift to locate the resident.
- Maintenance Staff removed clutter/items in Patio 1 that may potentially be used by the residents to gain access to climbing over the roof.
- Patio 1 was assigned 24-hour monitoring to ensure residents are monitored and supervised and for staff to be on the outer perimeter of Patio 1 on all three shifts when in Patio 1.
- Outgoing staff monitoring patio stays in Patio 1 until incoming staff to patio monitor arrives.
- During shift change, incoming and outgoing staff that monitors patio are to position themselves in a spot where they have clear vision of Patio 1 while they are endorsing to other staff.
- When the staff monitoring patio goes on break, a staff is assigned to relieve them prior to leaving Patio 1.
- Administrator contacted security agency to secure a contract for unarmed security to provide heightened awareness for security oversight of all facility exit doors and facility egress for all three shifts including supervision and monitoring of resident areas.
- Administrator secured a quote for fencing. The contractor is arriving to evaluate the area of concern on the identified area of fencing. A work order will be completed.
- Corporate policy committee will be consulted regarding a more updated Elopement policy.
- DON/Designees conducted an audit of the Elopement Binder to ensure that current residents that are at risk for elopement were included and had a photo identifier unless they refused to have their photo taken.
- Administrator/designee conducted an observation of the patio area (Patio 1) during the shift change to ensure that the patio is monitored, and residents were always supervised by the staff.
- Administrator and DON initiated an in-service education to RNs, Licensed Vocational Nurses (LVNs), CNAs, Rehabilitation and Activity staffs, Activities, Business Office, Dietary, Housekeeping, Laundry, Maintenance, Receptionist, Social Services, Medical Records staff regarding the facility's policy and procedures for Wandering and Elopement, with emphasis on the importance of having the patio area always supervised in all three shifts, caring for residents at risk for elopement, and recognizing changes in condition that may potentially increase the risk of residents leaving the facility unsupervised.
- DON initiated an in-service to the nursing staff regarding hourly monitoring of residents who are at risk for elopement. This will be documented on the 'Residents who are at Risk for Elopement Monitoring' form.
- CNAs will conduct room rounds hourly every shift to ascertain all residents are accounted for.
- The Elopement Binder is placed at each Nurses Station and are reviewed with staff during shift change for any concerns, changes, or new admissions. These binders are updated by the DON/Designee as needed.
- The ADM will be responsible for monitoring and sustaining compliance.
Failure to Develop Care Plan for Resident with Drug Abuse History
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of drug abuse and who was permitted to go out on pass. Despite the resident's history of schizophrenia, depression, and drug abuse, the facility did not include specific interventions in the care plan to monitor the resident's behaviors when going out on pass. The Director of Nursing (DON) acknowledged the absence of a documented care plan addressing the resident's history of drug use and the out on pass situation, stating that the facility had not initiated care plans for such scenarios. The resident's medical records indicated a history of schizophrenia, hypertension, hyperthyroidism, depression, and drug abuse, with a social history of smoking, alcohol, and methamphetamine use. The DON admitted that while there was verbal communication among staff regarding interventions for residents returning from out on pass, there was no written policy or care plan. The facility's policy on comprehensive person-centered care planning emphasized the need for interdisciplinary care to meet residents' health, safety, psychosocial, behavioral, and environmental needs, which was not adhered to in this case.
Failure to Investigate and Locate Missing Resident
Penalty
Summary
The facility failed to investigate and locate a resident who was at risk for elopement and had a history of suicidal ideations. The resident, who had fluctuating capacity to understand and make decisions, was transferred to a General Acute Care Hospital (GACH 2) for evaluation due to claims of abuse and pain. However, upon arrival at the hospital, the resident eloped from the ambulance and was not admitted to the hospital. The facility did not take immediate action to locate the resident after being informed that the resident was not admitted to GACH 2. The facility's Administrator (ADM) and Admission Coordinator (AC) were aware of the situation but did not follow up with the hospital or the ambulance company promptly. The ADM believed that the responsibility for the resident's whereabouts lay with the hospital since the resident had been discharged from the facility's care. The facility's Medical Records Director (MRD) was involved in a group text message with the physician and hospital liaison, where it was confirmed that the resident had eloped from the hospital. Despite this information, the facility did not report the incident to law enforcement or take further steps to locate the resident. The facility lacked a policy on ensuring a safe discharge or transfer of residents to other facilities. The existing policy on resident safety did not address the procedures for handling such situations. This deficiency in policy and the failure to act promptly upon learning of the resident's elopement contributed to the resident remaining missing, with potential risks to their safety.
Failure to Monitor and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to monitor and supervise a resident who was identified and assessed at risk for elopement. The resident, who had diagnoses of unspecified psychosis, major depressive disorder, and dementia, eloped from the facility and was missing for an extended period. The resident was last seen in the facility's breezeway area and was later found at a nearby school football field the following day. The facility's staff did not have a scheduled monitor for the breezeway area, and the surveillance cameras were not continuously monitored during the day and evening shifts, contributing to the resident's ability to leave the facility undetected. The resident's elopement was discovered during a medication pass when the Licensed Vocational Nurse (LVN) could not locate the resident. A Code [NAME] was initiated, and local law enforcement was called for assistance. The facility staff conducted a search of the premises and the surrounding neighborhood but did not find the resident until the next morning. The resident was compliant and returned to the facility without injuries, stating that he left because he was hungry and did not know why he had left initially. Interviews with the facility's Administrator (ADM) and staff revealed that the breezeway area did not have assigned staff for monitoring, and the surveillance cameras were only continuously monitored during the night shift. The facility's policy on wandering and elopement indicated that residents at risk for elopement should be identified and measures taken to minimize injury, but these protocols were not effectively implemented in this case. The resident demonstrated how he had kicked open a locked door and climbed onto the roof to leave the facility, highlighting gaps in the facility's security and supervision measures.
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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