Orange Healthcare & Wellness Centre, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 920 West La Veta Street, Orange, California 92868
- CMS Provider Number
- 055252
- Inspections on file
- 39
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Orange Healthcare & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident's pressure ulcer progressed from Stage 3 to Stage 4 with muscle exposure, and the physician was not notified of this significant change in condition as required by facility policy. The DON confirmed that the health record lacked documentation of physician notification regarding the change in the pressure ulcer's stage.
Two residents' call lights were not answered in a timely manner despite being audible at the nurses station and observed by staff, resulting in delays of up to 20 minutes before assistance was provided. Staff interviews confirmed awareness of the call lights and the expectation for prompt response, but the facility's policy was not followed.
Licensed nurses did not document their initials on the TARs after providing prescribed skin treatments to two residents, resulting in incomplete and inaccurate medical records as required by facility policy. The DON confirmed that documentation was missing for several dates on the evening shift.
Staff failed to follow infection control protocols, including an LVN not wearing a gown during wound care for a resident with a stage four pressure injury under Enhanced Barrier Precautions, and another LVN wearing PPE in the hallway after preparing to enter a COVID-19 isolation room. These actions were not in accordance with facility policy and were confirmed by facility leadership.
A resident reported physical abuse by a CNA, but instead of being suspended as required by facility policy, the CNA was reassigned to a different duty during the investigation. Staff interviews confirmed the CNA remained on duty, and the Administrator acknowledged the failure to follow protocol.
The facility failed to maintain infection control practices, as staff neglected hand hygiene during wound care. A nurse did not wash hands before treating a resident's wound, and another nurse and CNA failed to perform hand hygiene before applying barrier cream and accessing clean linens. Both staff members acknowledged their lapses, and the facility's IP and DON confirmed the importance of hand hygiene to prevent disease transmission.
A resident with dysphagia did not receive oral care every shift as ordered, with care only provided during day and evening shifts on specific dates. Observations confirmed the resident's mouth was dirty, and the lips were dry with white patches. The facility's LVN, RN, and DON acknowledged the failure to adhere to the three-shift oral care requirement.
The facility failed to prevent UTIs for two residents with urinary catheters by improperly positioning drainage bags on their beds, visible from public areas, and not covering them with dignity bags. Additionally, staff did not monitor one resident's urine color, which was dark yellow-brown, contrary to facility policy requiring regular assessment of urinary output. The DON and a treatment nurse confirmed these deficiencies.
Two residents' medical records were found incomplete due to missing documentation in the TAR for assessments and care related to urinary drainage and Foley catheter maintenance. These omissions occurred on multiple dates and were confirmed by a treatment nurse and the DON.
A facility failed to report the results of an investigation into possible financial abuse of a resident by a family member within the required five working days. Despite the facility's policy, the investigation remained incomplete beyond the mandated timeline, posing a risk of unaddressed abuse. The resident involved had severe cognitive impairment, and the delay in reporting was confirmed by the DON and Administrator.
A facility failed to develop a care plan for a resident at risk of financial abuse by a family member, despite being informed of an investigation. The resident had severe cognitive impairment and lacked decision-making capacity, yet no care plan was documented to address this risk. The DON confirmed the absence of a care plan during a review.
Two residents' rooms in the facility were found to have peeling paint above the headboards, compromising the homelike environment. Observations confirmed by an LVN and a CNA revealed the deficiency, which was acknowledged by the DON, who noted that maintenance should be notified to fix the issue.
The facility failed to follow its policy and procedures for bed rail use, affecting five residents. Staff did not attempt alternative measures, obtain informed consent, or complete necessary assessments and care plans. This oversight was confirmed through staff interviews and medical record reviews.
The facility failed to ensure proper medication storage and temperature control in three medication rooms. Syringes for a discharged resident were not discarded, and oral medications were improperly stored with external patches. Refrigerator temperatures were significantly above the required range, risking medication efficacy. Staff confirmed the issues, and temperature checks were not consistently logged.
The facility failed to follow food safety and sanitation guidelines, including a lack of backflow prevention in a food prep sink, unclean drying racks, and improper storage of perishable food in a resident's room. These issues were confirmed by staff and posed a risk of contamination for 83 residents consuming food from the kitchen.
The facility failed to maintain an accurate infection control surveillance program, only including residents prescribed antimicrobial medications. In the laundry room, personal items were found on a clean table, violating infection control practices. Additionally, an RN entered a COVID-19 isolation room without wearing an N95 mask, despite knowing the requirement. These deficiencies were acknowledged by staff.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection. The Infection Preventionist did not document whether the criteria were met or notify physicians to reassess the need for antibiotics. Monthly reports showed cases of unnecessary antibiotic prescriptions, and the Director of Nursing acknowledged incomplete documentation.
The facility failed to conduct accurate entrapment assessments for residents using bed rails, as required by FDA guidelines. Six residents were observed with grab bars installed without proper documentation of entrapment assessments, potentially leading to serious injury or death. The Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars, and the DON was informed of these findings.
A resident with an indwelling urinary catheter was observed with the collection bag not placed inside a privacy bag, compromising dignity. A CNA confirmed the oversight, and the DON acknowledged the expectation for privacy bags to be used for all catheter collection bags.
The facility failed to ensure call lights were within reach for five residents, as required by their policy. Observations showed call lights were inaccessible for several residents, with staff confirming these findings. The DON acknowledged the issue, but no corrective actions were mentioned.
The facility failed to provide and maintain documentation of advance directives for several residents, as required by policy. This included not obtaining copies of existing directives and not offering information on formulating directives to residents or their representatives. These deficiencies were identified through interviews and medical record reviews, highlighting a lack of systematic follow-up and documentation.
The facility failed to maintain proper IV access and medication labeling for two residents. One resident's PICC line measurement was not documented upon admission, and another resident's IV antibiotic bag was unlabeled. These oversights were confirmed by staff and violated the facility's policies.
The facility failed to provide appropriate respiratory care for several residents, including undated and improperly stored oxygen and nebulizer equipment. Observations revealed that oxygen tubing was left on the floor, nebulizer masks were not stored in setup bags, and CPAP equipment was improperly handled. These actions were contrary to the facility's policy, which requires proper labeling and storage of respiratory equipment. The Director of Nursing confirmed these expectations, highlighting deficiencies in respiratory care practices.
A resident receiving Norco for pain management was not monitored for side effects, and non-pharmacological interventions were not consistently provided. Despite the facility's policy, these interventions ceased after a reassessment, and no side effect monitoring was ordered or conducted.
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record for Medication Carts 1 and 3. This deficiency was confirmed by the DON and indicates non-compliance with the facility's protocols for medication accountability.
A facility failed to monitor a resident's orthostatic blood pressure as ordered by the physician for a resident on risperidone, an antipsychotic medication. The medical records showed inconsistent documentation of blood pressure readings, with some marked as 'NA' without explanation. Interviews with the LVN and DON confirmed that the readings should have been obtained and compared to prevent potential adverse complications.
A resident was served Brussels sprouts and low-fat milk despite documented preferences for nonfat milk and a dislike for Brussels sprouts. The discrepancy was confirmed by an MDS Coordinator, who took steps to rectify the situation. The DON acknowledged the failure to honor the resident's preferences.
The facility failed to educate staff and visitors on safe food handling practices for food brought from outside, risking residents' exposure to foodborne illnesses. Interviews revealed that staff, including an RN and the DON, were unaware of or had not received training on these practices, and the DSD confirmed no training had been conducted.
The facility failed to maintain essential kitchen equipment and a low air loss mattress in proper working condition. The ice machine was unclean, with a damaged rubber strip and residue, and the walk-in freezer floor was not cleanable. A resident's low air loss mattress pump malfunctioned with a muted alarm, unnoticed by staff. These issues highlight lapses in equipment maintenance and monitoring.
A facility failed to document a medication reconciliation for a resident upon discharge, as required by its policies. The resident's medical records lacked evidence of a completed reconciliation, which was confirmed by the MDS Coordinator during a review. This oversight risked discrepancies in medication orders, potentially impacting the resident's well-being.
The facility failed to maintain accurate and complete POLST forms for two residents. One resident's POLST was incomplete, lacking information on an advance directive or health care agent. Another resident's POLST was outdated, not reflecting an executed advance directive. The SSD acknowledged these issues, and the DON confirmed the need for immediate updates.
The facility failed to provide written notification of room changes to two residents, violating their rights. Despite the facility's policy requiring written notice, staff only informed residents verbally. One resident lacked the capacity to make decisions, and the other was not given written notice, highlighting a failure in adhering to established procedures.
A resident with moderate cognitive impairment and multiple chronic conditions experienced an unwitnessed fall. Despite recommendations from the IDT to update the care plan with specific interventions, the facility failed to revise the care plan accordingly, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents, leading to potential risks. One resident's elopement evaluation was inconsistent with their history, while another resident's fall risk evaluation was inaccurately documented. The DON confirmed that nurses did not verify medical histories before completing assessments, resulting in incorrect evaluations.
A facility failed to provide visual privacy for a resident during care, compromising the resident's dignity. The resident's door was left halfway open, and no curtain was drawn while a CNA assisted the resident with their diaper, exposing the resident's left buttock. The resident was cognitively intact, and the Infection Preventionist acknowledged the need for privacy measures.
The facility failed to maintain infection control practices, as staff did not perform hand hygiene during resident care, and a basin with medical items was left unlabeled in a resident's room. These actions were confirmed by the Infection Preventionist, indicating lapses in adherence to infection control policies.
Failure to Notify Physician of Pressure Ulcer Progression
Penalty
Summary
The facility failed to notify the attending physician of a significant change in a resident's condition, specifically when a pressure ulcer progressed from Stage 3 to Stage 4. According to the facility's policy, the physician must be notified of any significant change in a resident's condition, including changes in pressure ulcer staging that require medical assessment and potential changes in the treatment plan. Review of the resident's health record showed that the pressure ulcer on the right gluteus was documented as Stage 3 on one date and then as Stage 4 with muscle exposure on a subsequent date. The wound consultant performed debridement, and the ulcer was reclassified as Stage 4. Despite these changes, there was no documentation that the physician was notified of the progression from Stage 3 to Stage 4. During an interview and concurrent record review, the DON confirmed that the physician should have been notified of the change in the pressure ulcer's stage and verified that the health record did not show such notification. This failure to notify the physician was identified for one of five sampled residents.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of two out of thirteen sampled residents by not ensuring that their call lights were answered in a timely manner. Observations revealed that for one resident with severe cognitive impairment who required substantial to maximum assistance with activities of daily living, the call light was activated and audible at the nurses station, but two staff members passed by the room without responding. The resident began screaming and was not assisted until 20 minutes later, when a CNA responded and confirmed the resident needed to be changed. In a separate incident, another resident activated the call light, which was also audible at the nurses station where two LVNs were present. An RNA passed by the room without responding, and the call light remained unanswered for 20 minutes until a CNA responded to remove the resident's lunch tray. Interviews with the involved staff confirmed they heard the call light but did not respond promptly, despite acknowledging that call lights should be answered right away. The facility's policy required prompt response to call lights, but this was not followed in these instances.
Failure to Document Treatments on TARs for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not ensuring that licensed nurses documented their initials on the Treatment Administration Records (TARs) after providing prescribed treatments. For one resident, the TAR for July did not show documentation that the evening shift nurse performed the ordered sacrum cleansing and application of barrier cream on four specific dates. For another resident, the TAR lacked documentation for the cleansing and barrier cream application to the sacrococcyx and buttocks on two dates during the evening shift. These omissions were identified through medical record review and confirmed by the Director of Nursing (DON). The facility's policy and procedure required that medical records be completed and corrected in a standardized manner, with entries recorded promptly as events occur. The DON verified that after providing treatment, licensed nurses are expected to document the care provided in the resident's medical record. The absence of nurse initials on the TARs indicated that the required documentation was not completed as per facility policy, resulting in incomplete and potentially inaccurate medical records for the affected residents.
Failure to Follow Infection Control Practices During Wound Care and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were followed as outlined in its own policies and procedures. During wound care for a resident with a stage four pressure injury, an LVN did not wear a gown as required under Enhanced Barrier Precautions (EBP), despite signage and supplies being available at the resident's door. The LVN confirmed awareness that the resident was on EBP for a wound but still did not don the appropriate personal protective equipment (PPE) during the procedure. In a separate incident, another LVN was observed wearing PPE in the hallway after preparing to enter a resident's room under COVID-19 isolation but did not enter the room, instead proceeding to the medication room while still wearing PPE. Facility policy specifies that gowns and gloves should not be routinely worn in the hallway and should only be donned immediately before high-contact care tasks. Both the Infection Preventionist and the Administrator confirmed these observations and acknowledged that the correct infection control practices were not followed.
Failure to Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse protocol during the investigation of an alleged physical abuse incident involving a resident and a CNA. According to the facility's policy, any staff member accused of abuse must be suspended and removed from the premises during the investigation. However, after a resident reported an allegation of physical abuse by a CNA to an LVN during the night shift, the CNA was not suspended but was instead reassigned to a different assignment for the remainder of the shift. The facility's investigation documents did not show evidence that the CNA was suspended immediately after the allegation was made. Interviews with staff confirmed that the CNA continued to work in the facility after the allegation, although not directly with the resident who made the report. The LVN and RN involved in the incident acknowledged that the CNA was not suspended and that the Administrator was not informed immediately after the allegation. The resident involved had the capacity to make their own medical decisions, and an assessment following the report showed no injury. The Administrator later acknowledged the findings of the investigation.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff neglecting to perform hand hygiene during wound care procedures. Treatment Nurse 1 was observed initiating wound care on a resident's left shin without washing hands before donning gloves. After cleaning the wound, the nurse removed the soiled gloves but did not perform hand hygiene before putting on a new pair of gloves to continue the treatment. This lapse in protocol was acknowledged by the nurse during an interview, who admitted the importance of hand hygiene in preventing infection spread. Similarly, Treatment Nurse 2 and a CNA were involved in another incident where hand hygiene was not performed before wound care. Treatment Nurse 2 applied barrier cream to a resident's buttock area without washing hands first. The CNA, after cleaning the resident's buttock area, attempted to access the clean linen cart with soiled gloves, only stopping when reminded to change gloves and perform hand hygiene. Both staff members acknowledged their failure to adhere to hand hygiene protocols during interviews. The facility's Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene before and between tasks to prevent disease transmission.
Failure to Provide Consistent Oral Care for Resident
Penalty
Summary
The facility failed to provide oral care every shift for a resident diagnosed with dysphagia, as per the medical orders. The resident was admitted with an order dated 10/17/24, specifying that oral care should be provided every shift using a swab/suction as appropriate. However, a review of the resident's oral hygiene interventions for January 2025 revealed that oral care was only provided during the day and evening shifts on specific dates, and not consistently every shift as ordered. Observations and interviews conducted with the facility's LVN and RN confirmed that the resident's oral care was not provided every shift. During an observation on 1/8/25, the LVN noted that the resident's mouth was dirty, and the lips were dry with white patches, indicating a lack of oral care. The RN acknowledged the importance of oral care in preventing mouth infections and sores, and the DON confirmed that the facility's three-shift system was not adhered to in providing the required oral care for the resident.
Failure in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling urinary catheters. Observations revealed that the urinary drainage bags for both residents were improperly positioned on top of their beds, visible from the hallway and patio, and not covered with dignity bags. This improper positioning risked urine flowing back into the bladder, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Additionally, the facility's policy required that catheter bags be kept below the bladder level and away from entrance doors, which was not adhered to in these cases. Furthermore, the staff failed to monitor and assess the urinary output of one resident, whose urine was observed to be dark yellow-brown, indicating a potential issue. The facility's policy mandated that nursing staff assess urinary drainage for signs of infection, including color, cloudiness, and other factors, every shift. However, this was not done, as evidenced by the lack of monitoring of the resident's urine color. The Director of Nursing (DON) and a treatment nurse acknowledged these deficiencies during interviews, confirming the failure to follow the facility's policies and procedures for catheter care.
Incomplete Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Treatment Administration Records (TAR) for two residents. For the first resident, there were missing entries regarding the assessment of urinary drainage for signs of infection and the provision of Foley catheter care on multiple dates in November 2024. These assessments and care were required every shift as per the physician's order dated October 4, 2024. The specific dates of missing documentation included November 3rd, 4th, 15th, and 28th, during various shifts. Similarly, for the second resident, the TAR lacked documentation for the assessment of urinary drainage, Foley catheter care, and monitoring for signs and symptoms of a urinary tract infection (UTI) on November 7th and 15th, 2024. These tasks were mandated by physician orders dated May 8, 2024, and July 23, 2024, to be performed every shift. The absence of these records was confirmed during interviews with Treatment Nurse 2 and the Director of Nursing (DON), who acknowledged the deficiencies in the residents' medical records.
Failure to Timely Report Financial Abuse Investigation
Penalty
Summary
The facility failed to provide a thorough investigation and report the results of an investigation regarding an allegation of possible financial abuse involving a resident's family member. The facility's policy and procedure on abuse reporting and investigations, revised in March 2018, requires that the results of all abuse investigations be reported to the California Department of Public Health (CDPH) Licensing and Certification Program within five working days of the reported allegation. However, the facility did not comply with this requirement for one of the two sampled residents, identified as Resident 2, who was involved in an allegation of financial abuse. Resident 2, who was admitted to the facility with severe cognitive impairment, was the subject of an open investigation for possible financial abuse by a family member, as informed by a Court Investigator. Despite the facility's Social Services Director completing a Report of Suspected Dependent Adult/Elder Abuse form on the date of the incident, the Director of Nursing (DON) confirmed during an interview that the facility's internal investigation was still ongoing beyond the five-day reporting requirement. The Administrator verified that the investigation had not been completed, indicating a failure to meet the mandated timeline for reporting the investigation results to the CDPH, thus posing a risk for potential abuse to remain unidentified and for the resident to go unprotected.
Failure to Address Financial Abuse Risk in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was at risk of financial abuse by a family member. Despite being informed by a Court Investigator about an open investigation into possible financial abuse, the facility did not create a care plan to address this risk. The facility's policy requires that care plans be updated to reflect new problems or changes in a resident's condition, but this was not done in this case. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1, and lacked the capacity to understand and make decisions. Despite these vulnerabilities, the facility did not document any care plan addressing the risk of financial abuse. The Director of Nursing confirmed the absence of such a care plan during a record review and interview, acknowledging the oversight.
Failure to Maintain Homelike Environment Due to Peeling Paint
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, as observed during a survey. Resident 3's room was found to have chipped paint on the wall above the headboard during an observation conducted on October 2, 2024. This observation was verified by LVN 2, who confirmed the presence of chipped paint in Resident 3's room. The facility's policy and procedure on Resident Rights Personal Property, revised in January 2012, emphasizes ensuring the quality of life for all residents by allowing them to create a homelike environment. Similarly, Resident B's room was observed to have peeling paint above the headboard. This was confirmed through interviews and observations with CNA 2 and LVN 3. The Director of Nursing (DON) was informed of these findings and acknowledged that peeling paint does not constitute a homelike environment. The DON stated that the process would involve notifying the maintenance department to address the issue.
Failure to Follow Bed Rail Policy and Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of bed rails, which are intended to be used as mobility enablers. The policy requires that before bed rails are used, staff must attempt appropriate alternatives, assess the resident for safety risks, obtain a physician's order, and secure informed consent from the resident or their representative. Additionally, a care plan should be initiated to address the use of bed rails. However, the facility did not complete these steps for five of the six residents reviewed for side rail use, potentially putting them at risk for serious injuries. For Resident 64, the facility did not document any attempts to use alternative measures before installing bilateral grab bars. There was no physician's order, informed consent, or care plan addressing the use of these grab bars, despite the resident using them for repositioning and turning. Similarly, Resident 45 had a physician's order and a care plan for the use of grab bars, but the facility failed to obtain informed consent. Resident 47 had a physician's order for grab bars, but the assessment did not indicate a need for them, and there was no care plan or informed consent documented. Resident 78 had a physician's order and a care plan for a left-side grab bar, but informed consent was not obtained. Lastly, Resident 601 had a physician's order for bilateral grab bars, but the assessment did not support their use, and there was no care plan or informed consent documented. These deficiencies were verified through interviews and medical record reviews with various staff members, including LVNs and the DON, who acknowledged the findings.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage in three medication storage rooms, leading to potential risks for residents. During an inspection, it was observed that syringes with needles labeled for a discharged resident were not discarded and remained on the medication room shelf. Additionally, oral lactulose solution was improperly stored next to lidocaine patches, violating the facility's policy of separating orally administered medications from externally used ones. The inspection also revealed that the temperatures of the medication refrigerators in all three medication rooms were out of the required range. In one room, the refrigerator temperature was recorded at 64 degrees Fahrenheit, while in another, it was 55 degrees Fahrenheit, and in the third, it was 50 degrees Fahrenheit. These temperatures were significantly higher than the required range of 36 to 46 degrees Fahrenheit for most medications stored, including insulin, antibiotics, and other injectable medications. The discrepancies in temperature logs and actual readings indicated a failure in monitoring and maintaining appropriate storage conditions. Interviews with staff, including the Infection Preventionist, Registered Nurses, and Licensed Vocational Nurses, confirmed the findings. The staff acknowledged the improper storage and temperature issues but were unable to provide explanations for the discrepancies. The facility's policy required regular checks and logging of refrigerator temperatures, but it was noted that the Pharmacy Nurse Consultant's checks were not logged, contributing to the oversight.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by three specific deficiencies. Firstly, a food preparation sink located near the DSS's office was found to lack backflow prevention, which is a requirement according to the USDA Food Code 2022. The Maintenance Assistant confirmed that the backflow prevention device had been removed, posing a risk of contamination. Secondly, a rack used for drying plate covers was observed to have a greasy residue and food debris, which violates the USDA Food Code's requirement for nonfood contact surfaces to be free of dirt and debris. The DSS acknowledged this finding during the inspection. Additionally, the facility did not comply with its own policy regarding perishable food brought in by visitors. A resident's room was found to contain perishable food items, such as a block of cheese, that were not stored in a refrigerator as required. The resident confirmed that the cheese needed refrigeration, and both LVN 1 and MDS Coordinator 2 acknowledged the oversight. These deficiencies posed a risk of cross-contamination and potential food poisoning for the 83 residents who consumed food from the facility's kitchen.
Infection Control Deficiencies in Surveillance, Laundry, and PPE Use
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program from January 2024 through August 2024. The surveillance was only conducted on residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. Residents who showed signs and symptoms of infection but were not prescribed antimicrobial medications were not included in the facility's infection control surveillance log. The Surveillance Data Collection Form was incomplete and inaccurate, failing to determine whether the resident's infection met the McGeer's criteria for true infection. The facility also failed to implement proper infection control practices in the laundry room. During an inspection, personal items such as eyeglasses and an employee phone were found on the clean table area where clean clothes or linens were folded. This was verified by Laundry Services Personnel 1, who acknowledged that these items should not be on the table used for folding clean laundry. Additionally, the facility did not ensure that RN 2 wore the appropriate PPE when entering a COVID-19 isolation room for a resident. RN 2 entered the room without wearing an N95 mask, despite knowing the requirement to do so. The resident was on COVID-19 isolation, and the required PPE included an N95 mask, face shield, goggles, gown, and gloves. This oversight was acknowledged by RN 2 and confirmed by IP 1.
Failure to Inform Physician of Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for one of the 19 final sampled residents and three non-sampled residents. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs and symptoms of an infection. However, the IP did not document whether the residents' conditions met McGeer's Criteria, and there was no evidence that the physician was notified to reassess the need for antibiotics. The facility's Monthly Antibiotic Stewardship Reports for June and July 2024 showed cases where residents were prescribed antibiotics without meeting the criteria for a true infection. Specifically, Residents 77, 87, and 603 were prescribed antibiotics without meeting the criteria, and there was no documentation of physician notification. Additionally, Resident 87's Surveillance Data Collection Form indicated that a urine culture was not obtained. The Director of Nursing (DON) acknowledged the findings and the incomplete and inaccurate documentation in the facility's Infection Control Surveillance Form.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, as required by the FDA's Hospital Bed System Dimensional and Assessment Guidance. The report highlights that six residents were observed with grab bars installed on their beds without proper documentation of entrapment assessments. This oversight could potentially lead to entrapment, serious injury, or death, especially for vulnerable populations such as the elderly or those with uncontrolled body movements. For Resident 64, the medical record review showed no physician's order for the use of bilateral bed grab bars, and the bed rail assessment indicated no siderail or assist bars were needed. However, observations confirmed the presence of grab bars, and the Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars. Similar issues were found with Residents 45, 47, 63, 78, and 601, where either the entrapment assessments were missing or the residents' preferences and needs were not accurately documented. The Maintenance Director acknowledged the lack of documentation for grab bar measurements, and the Director of Nursing (DON) was informed of these findings. The facility's policy requires annual bed measurement inspections to document entrapment areas, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure care was provided in a manner that promoted dignity and respect for a resident who was using an indwelling urinary catheter. During an initial tour of the facility, the resident was observed lying in bed with a urinary catheter draining into a collection bag that was not placed inside a privacy bag. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the collection bag should have been inside the privacy bag to maintain the resident's privacy. The resident, who was unable to make his own decisions, had a physician's order for a 16 Fr indwelling/suprapubic catheter due to benign prostatic hyperplasia. The Director of Nursing (DON) stated that it was expected for all catheter collection bags to be inside privacy bags to provide dignity to residents. The DON was informed of the findings and acknowledged the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for five residents, which could potentially impact their psychosocial well-being or delay the provision of care. The facility's policy and procedure (P&P) on the communication-call system, revised on January 1, 2012, mandates that call cords be placed within the resident's reach. However, observations and interviews revealed that the call lights for Residents 16, 38, 76, 39, and 61 were not accessible. Resident 16's call light was clipped on the edge of the head of the bed, out of reach. Resident 38's call light was found underneath the pillow, making it inaccessible. Resident 76's call light was placed on top of the bedside drawer, not within reach, despite the resident's need for dependent assistance for bed mobility. Further observations showed that Resident 39's call light button was on top of the bedside drawer, out of reach, and Resident 61's call light cord was clipped to the wall at the head of the bed, with the button hanging and inaccessible. Interviews with staff, including LVN 7, CNA 2, MDS Coordinator 3, and CNA 5, confirmed these findings. The Director of Nursing (DON) acknowledged the deficiencies, stating that call lights should be within residents' reach, but the report does not mention any corrective actions taken to address these issues.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to provide written information regarding advance directives and did not obtain or maintain copies of these directives in the medical records for five residents. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy required that upon admission, residents be informed of their rights to make medical decisions, including the formulation of advance directives. However, the facility did not adhere to this policy, resulting in incomplete documentation and follow-up regarding residents' advance directives. For Resident 17, the facility did not maintain a copy of the advance directive in the medical record, despite acknowledging its existence and requesting it. Similarly, Resident 76's records lacked documentation of whether the resident or their representative was offered information on formulating an advance directive. Resident 45's records showed an undated acknowledgment form indicating a request for more information on advance directives, but there was no evidence of follow-up or provision of the requested information. Resident 601's records indicated an advance directive was in place, but the facility failed to maintain a copy in the medical record. Additionally, Resident 351's records did not document whether an advance directive was offered to the resident's representative, despite the resident's severe cognitive impairment. These failures highlight the facility's lack of a systematic approach to ensuring residents' advance directives are documented and honored, potentially impacting the residents' healthcare decisions.
Deficiencies in IV Access and Medication Labeling
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous (IV) access for two residents. For Resident 600, the facility did not document the measurement of the peripherally inserted central catheter (PICC) line's external catheter length upon admission, as required by the facility's policy and procedure (P&P) for PICC dressing changes. This oversight was confirmed during an interview with RN 2, who acknowledged the absence of the required documentation in Resident 600's medical record. Resident 600 had orders for total parenteral nutrition (TPN) via the PICC line and weekly measurements of the arm circumference and external lumen catheter, but the initial measurement was not recorded. For Resident 89, the facility failed to properly label the IV antibiotic medication bag. During an observation, it was noted that Resident 89 was receiving an IV antibiotic at a specified rate, but the medication bag was neither labeled nor dated, contrary to the facility's P&P for administering intermittent infusions. RN 2 admitted to forgetting to label the medication bag. Resident 89 had a physician's order for cefoxitin sodium to be administered intravenously for an infection of the spine, but the lack of labeling was confirmed during a review with the Director of Nursing (DON).
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as observed during a survey. Resident 58's oxygen nasal cannula tubing was found undated, unlabeled, and not stored in a setup bag when not in use, contrary to the facility's policy. Additionally, the oxygen machine was left on while the resident was not in the room, with the nasal cannula left on the bed. Resident 351's nebulizer mask and tubing were also not stored in a setup bag, and there was no care plan in place for the use of nebulizer therapy, despite a physician's order for breathing treatment medication. Resident 352's oxygen tubing was observed touching the floor, which was verified by RN 2, who then replaced it with new tubing. Resident 75's nebulizer mask and tubing were undated and left on top of the nebulizer machine, with no physician's orders for medications requiring nebulizer use. Resident 69's CPAP mask was found touching the bedside table, and the tubing was undated, which was confirmed by the MDS Coordinator and the Director of Central Supply, who stated that the CPAP tubing should be dated and stored in a plastic bag. The facility's policy on oxygen therapy, revised in November 2017, requires that oxygen supplies be dated and stored safely. The Director of Nursing confirmed the expectation that all respiratory equipment should be labeled and stored properly when not in use. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident, identified as Resident 600, who was receiving narcotic pain medication. The facility did not monitor Resident 600 for side effects related to the use of Norco, a narcotic medication prescribed for moderate to severe pain. Additionally, the facility did not consistently implement non-pharmacological interventions for pain management, as required by their policy and procedure. These interventions were only provided until 9/3/24, despite the resident continuing to receive Norco on subsequent dates. During an interview and medical record review, RN 2 confirmed that non-pharmacological interventions should have been continued alongside the narcotic medication. However, these interventions were not reinstated after a 14-day reassessment of the resident's pain management. Furthermore, there was no physician's order to monitor for side effects of the Norco medication, nor was any monitoring completed. This oversight in pain management practices was identified as a deficiency by the surveyors.
Failure to Ensure Proper Accounting of Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record. This deficiency was observed during a medication cart inspection of Medication Carts 1 and 3. Specifically, the controlled drugs count record for Medication Cart 3 had missing signatures on several dates, including 8/21, 8/22, 9/1, and 9/7. Similarly, Medication Cart 1 had missing signatures on 8/6, 8/18, 8/22, 8/24, 8/31, and 9/1. These findings were verified by the respective LVNs during the inspection. The facility's policy and procedure, as well as the Narcotic Book Guide, require that a physical inventory of all controlled medications be conducted by two licensed nurses at each shift change, with both nurses signing the controlled drugs count record. However, the failure to consistently follow this procedure was confirmed by the Director of Nursing (DON) during an interview and document review. The absence of signatures indicates a lack of compliance with the facility's established protocols for medication accountability, potentially leading to drug diversion.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs by not monitoring the resident's orthostatic blood pressure as ordered by the physician. The resident was prescribed risperidone, an antipsychotic medication, and the physician had ordered weekly monitoring of the resident's orthostatic blood pressure in lying, sitting, and standing positions. However, the medical records showed that the blood pressure readings were not consistently documented, with some readings marked as 'NA' without explanation. Interviews with the LVN and the DON confirmed that the blood pressure readings should not have been documented as 'NA' and should have been obtained and compared as per the physician's order. The facility's policy required monitoring for orthostatic hypotension, especially for residents on antipsychotic medications, to prevent adverse complications. The failure to monitor the resident's orthostatic blood pressure as ordered had the potential to result in adverse complications from the medication.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 30, which is a violation of their dietary policy. Resident 30, who has the capacity to understand and make decisions, was served Brussels sprouts and low-fat milk for lunch, despite having documented preferences for nonfat milk and a dislike for Brussels sprouts. This discrepancy was observed during a lunch observation in Resident 30's room, where the meal tray did not align with the resident's stated preferences as indicated on the meal ticket. The issue was confirmed by MDS Coordinator 2, who acknowledged that Resident 30 should have been provided with an alternative vegetable. The MDS Coordinator took immediate steps to rectify the situation by asking Resident 30 for her choice of an alternative vegetable and providing her with nonfat milk. The Director of Nursing (DON) was later informed of the findings and acknowledged that the resident's food preferences and dislikes should have been honored, as per the facility's policy.
Lack of Safe Food Handling Education for Staff and Visitors
Penalty
Summary
The facility failed to ensure that both employees and visitors bringing food from outside were educated on safe food handling practices, posing a risk of foodborne illness to residents. The facility's policy titled 'Food Brought by Visitors,' revised in June 2018, included guidelines for safe food handling, reheating, and storage. However, interviews with staff revealed a lack of awareness and training on these practices. RN 2 was unable to confirm receiving any education on safe food handling and was unsure if visitors were informed about these practices. The Director of Staff Development (DSD) confirmed that no training had been provided to staff during her two-month tenure. Further interviews with the Director of Nursing (DON) and the DSD highlighted the absence of a structured approach to ensure compliance with the facility's policy. The DON could only specify that food should be clean and in a sealed container but could not elaborate on how safe food handling was enforced. The DSD verified that no training records existed for educating staff on safe food handling practices. This lack of education and enforcement of the policy created a potential risk for residents consuming food brought in by visitors.
Deficiencies in Equipment Maintenance and Monitoring
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper working condition, as observed during a survey. The ice machine in the kitchen was found to be unclean, with a rubber strip on the harvester curtain not intact and covered in a white residue identified as dried glue. The ice machine chute also had a grayish, white residue. The Maintenance Assistant, who cleaned the ice machine monthly, admitted to not following the manufacturer's cleaning instructions due to a language barrier and used an incorrect cleaning solution. Consequently, the ice machine was taken out of service. Additionally, the walk-in freezer floor was not in a cleanable condition. The floor had black anti-slip tape that was not intact, exposing a metal floor with a hard, thick brown residue resembling rust. The linoleum floor beyond the ramp was cracked and not intact, with a brown residue. The Maintenance Director was unaware of the condition of the freezer floor, indicating a lack of communication or oversight in maintenance procedures. The facility also failed to ensure the proper functioning of a low air loss mattress for a resident. The mattress pump had a red light blinking, indicating a malfunction, and the alarm was muted. Despite daily checks by an LVN, the malfunction went unnoticed until it was observed by the MDS Coordinator. The LVN was unaware of any issues with the mattress pump or muted alarms, suggesting a gap in monitoring and reporting procedures for essential medical equipment.
Failure to Document Medication Reconciliation at Discharge
Penalty
Summary
The facility failed to ensure a thorough and documented medication reconciliation for Resident 99 upon discharge. Resident 99 was admitted to the facility and later discharged home. A review of the facility's policies and procedures indicated that the discharge summary should include a comprehensive medication reconciliation, detailing the resident's drug therapy and any changes from pre-discharge to post-discharge medication regimens. However, upon reviewing Resident 99's medical records, there was no documented evidence that such a reconciliation had been completed at the time of discharge. During an interview and concurrent medical record review with the MDS Coordinator, it was confirmed that the discharge nurse was responsible for completing and documenting the medication reconciliation. Despite this responsibility, the records for Resident 99 did not reflect any such documentation, indicating a lapse in following the facility's discharge procedures. This oversight posed a risk of not identifying discrepancies in medication orders, potentially affecting the resident's well-being.
Incomplete and Outdated POLST Forms for Two Residents
Penalty
Summary
The facility failed to ensure the medical records for two residents were accurate and complete, specifically regarding their Physician Orders for Life-Sustaining Treatment (POLST) forms. For Resident 64, the POLST form was incomplete as it did not indicate whether the resident had an advance directive or a health care agent. This was acknowledged by the Social Services Director (SSD) during an interview and concurrent medical record review. For Resident 63, the POLST form was outdated and did not reflect the resident's advance directive, which had been executed and documented in the resident's progress notes. The SSD admitted that the nursing staff completed the POLST form and that she failed to inform them of the advance directive update or update the POLST herself. The Director of Nursing (DON) confirmed that the facility should have updated the POLST immediately upon obtaining the advance directive.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes to two residents, violating their rights. According to the facility's policy, residents and their representatives should receive timely advance written notice of any room or roommate changes, including the reasons for such changes. However, for two residents, this procedure was not followed. Resident 7, who was nonverbal and lacked the mental capacity to make decisions, did not have documentation showing that their representative was notified of the room change. Similarly, Resident 8, who had the mental capacity to make decisions, was not provided with written notice of the room change. Interviews with facility staff, including the Social Services Director (SSD) and the Admissions Director, revealed that the facility's practice was to inform residents and their families of room changes verbally, without providing written documentation. The SSD confirmed that there was no room change form used to document these changes, and the Admissions Director acknowledged that written notifications were not provided. This lack of adherence to the facility's policy resulted in the failure to properly notify Residents 7 and 8 of their room changes in writing.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect current assessments, placing the resident at risk for unmet medical and physical needs. The facility's policies require that after a change in condition, such as a fall, the licensed nurse must assess the situation, document it, and update the care plan accordingly. However, in the case of Resident 3, who had an unwitnessed fall resulting in head discoloration and pain, the care plan was not updated with the necessary goals and interventions recommended by the Interdisciplinary Team (IDT). Resident 3, who has moderate cognitive impairment and multiple diagnoses including dementia and chronic conditions, experienced a fall while attempting to go to the restroom. Despite the IDT's recommendations to implement neuro-checks, pain management, and environmental adjustments to prevent further falls, these were not incorporated into the resident's care plan. The Director of Nursing confirmed that the care plan was not updated as required, highlighting a lapse in following the facility's procedures for managing changes in a resident's condition.
Inaccurate Medical Records for Elopement and Fall Risk
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, leading to potential risks of elopement and falls. For one resident, the elopement evaluation was inconsistent with their history. Despite having a documented history of elopement, the evaluation on a recent date incorrectly indicated no risk of elopement. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the nurse responsible for the evaluation did not verify the resident's medical history before completing the assessment. Another resident's fall risk evaluation was inaccurately documented. The resident, who had a history of falls and several medical conditions that increased their fall risk, was given a fall risk score that did not reflect their true condition. The DON confirmed that the nurse had incorrectly answered specific items related to the resident's medical history and medications, resulting in an inaccurate fall risk score. These inaccuracies in medical records could lead to inadequate preventive measures being implemented for the residents.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure visual privacy for a resident during care, which posed a risk to the resident's dignity. The facility's policy and procedure on Resident Rights, revised on January 1, 2012, mandates that employees treat all residents with kindness, respect, and dignity, including ensuring privacy and confidentiality. On June 11, 2024, an observation was made where a resident's door was halfway open, and no curtain was pulled for privacy while a CNA was assisting the resident with their diaper, resulting in the resident's left buttock being exposed. The resident was cognitively intact, as indicated by a BIMS Summary Score of 15. The Infection Preventionist confirmed that the CNA should have pulled the curtain to provide privacy for the resident.
Infection Control Deficiencies in Hand Hygiene and Equipment Labeling
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not performing hand hygiene during resident care. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene after assisting a resident with a breakfast meal tray and before retrieving a clean towel. Another CNA failed to perform hand hygiene after assisting a resident with adjusting their diaper and before handling a soiled linen bin. These actions were observed and confirmed by the Infection Preventionist, who acknowledged that hand hygiene should have been performed in these instances. Additionally, the facility did not label a basin found on a common dresser table in a resident's room. The basin contained an opened tissue box, a towel, and a kidney basin, which were not labeled, potentially leading to the transmission of infection. The Infection Preventionist verified that the items should have been labeled to prevent infection spread. These deficiencies highlight lapses in adherence to the facility's infection control policies and procedures.
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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