Palos Verdes Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lomita, California.
- Location
- 26303 Western Ave., Lomita, California 90717
- CMS Provider Number
- 555028
- Inspections on file
- 36
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Palos Verdes Health Care Center during CMS and state inspections, most recent first.
Two residents who were incontinent and dependent on staff for toileting and hygiene reported that CNAs used excessive force and inserted fingers into their rectum during cleaning after bowel movements, one during bed care and one in the shower. Both residents, who had significant medical conditions and impaired or fluctuating decision-making capacity, stated they felt humiliated, violated, and fearful. The CNAs acknowledged providing the care in question, and the DON and nursing staff received reports from family members that the care was rough and involved fingers in the rectal area. These actions did not align with facility policies requiring that residents be treated with dignity, respect, and in a manner that maintains their self-esteem.
A resident with Parkinson's disease, moderately impaired cognition, and dependence on staff for ADLs had Social Security benefits totaling over $27,000 deposited by SSA into the facility's payroll bank account over several months, where the funds were used for employee paychecks instead of being placed in a separate trust or personal funds account. A business manager later discovered the deposits in payroll bank statements and reported them to leadership, but no action was taken to return the money to the resident's estate, and a subsequent review confirmed no reimbursement had occurred. The administrator acknowledged that the resident's funds were co-mingled with facility funds, contrary to the facility's written policy prohibiting resident trust funds from being combined with facility funds.
A resident with Parkinson’s disease and moderately impaired cognition had multiple SSA payments totaling over $27,000 deposited into the facility’s payroll account rather than into a resident trust account. Review of financial records showed no evidence that these funds were ever transferred to the resident’s trust account or refunded after discharge, and a later trust account check covered only a small portion of the amount. Business office staff confirmed that a check from the payroll account to the resident’s trust account was never created, despite facility policy requiring resident refunds within a specified timeframe after discharge.
Three residents with specialized needs did not have individualized care plans in place, including a resident with PTSD, another with intentional weight loss, and a third receiving RNA services for Parkinson's disease. Staff interviews and record reviews confirmed the lack of care plans addressing these specific needs, despite ongoing interventions and clinical documentation.
Surveyors found that multiple food items, including juices, fruits, cooked meats, and cereals, were not properly labeled with open or use-by dates, and some expired items remained in storage. Staff interviews confirmed that these practices did not follow facility policy, which requires all opened and stored foods to be dated to ensure safety.
A resident with right-sided hemiparesis and impaired decision-making capacity was found with her call light placed on her affected side, making it inaccessible. Staff and DON interviews confirmed the expectation that call lights be within reach, and facility policy supported this requirement. The deficiency was identified through observation, interview, and record review.
A resident with diagnoses of schizophrenia and depression was not properly screened for mental illness upon readmission, as the initial PASARR Level I failed to identify these conditions and a new PASARR was not submitted. The DON confirmed the oversight, and facility policy requiring screening for mental disorders on admission and readmission was not followed.
The facility did not complete required annual performance evaluations for several CNAs, as confirmed by both the DSD and DON during interviews and record reviews. This was in direct violation of the facility's policy, which mandates annual evaluations to assess and improve staff performance.
A resident with multiple chronic conditions did not receive full doses of several prescribed oral medications when an LVN left residual medication in the cups during administration, resulting in a medication error rate of 26.92%, far exceeding the acceptable limit. The resident was dependent on staff for care and unable to communicate needs, and the facility's policy for safe and complete medication administration was not followed.
A resident with multiple chronic conditions did not receive the full dose of several prescribed medications during a medication pass, as confirmed by both the LVN and DON. The resident, who was dependent on staff for care and communication, was left with medication remaining in the cups after administration, contrary to facility policy requiring medications to be given as prescribed.
A resident with multiple comorbidities and dependent on staff for care was prescribed and administered Gentamicin for an eye infection without meeting McGeer criteria, as no laboratory culture was performed. Staff interviews and record reviews confirmed the facility did not follow its antibiotic stewardship protocol, which requires proper assessment before antibiotic use.
The facility did not ensure that CNAs completed the required hours of dementia and abuse prevention training, with several staff missing portions or all of the mandated education. This was confirmed through interviews and record reviews, which showed incomplete training documentation and a lack of compliance with facility policies for annual in-service education.
Eighteen resident rooms, including both two-bed and one four-bed room, were found to be below the required 80 square feet per resident. Despite the facility's waiver request and observations indicating residents had enough space for movement and use of mobility aids, the rooms did not meet regulatory size standards.
A resident sustained a fracture and laceration to the left great toe after being hit by a malfunctioning shower room door. The CNA failed to request assistance while transporting the resident, and both the CNA and LVN did not report the door issue in the Maintenance Logbook. The Maintenance Supervisor was aware of the problem but did not ensure it was resolved, leading to the accident.
A resident sustained injuries during transport in a facility van due to the failure to secure her wheelchair with four-point straps. The driver only used a lap seatbelt, and the accompanying CNA was not trained to verify proper securement. As a result, the wheelchair tipped over during a turn, causing the resident to suffer a scalp laceration, hematoma, neck sprain, and shoulder sprain.
A resident sustained injuries due to improper securing of their wheelchair during transport in a facility van. The CNA escorting the resident was unfamiliar with the necessary securing straps, and the driver could not confirm proper anchoring. The facility lacked documentation of training on using the van's seatbelts and four-point straps, contrary to its policy.
A resident with type 2 diabetes and a venous ulcer did not receive proper wound care as per physician's orders, leading to the presence of maggots and a hospital transfer. A nurse's personal emergency and miscommunication between staff resulted in the wound being neglected, causing pain and infection.
The facility failed to implement effective infection control practices, including the use of Enhanced Barrier Precautions (EBP), for residents with wounds and indwelling medical devices, leading to potential cross-contamination. Staff were observed providing care without proper PPE, and there was a lack of EBP signage and isolation carts. The facility also lacked comprehensive policies and procedures for managing residents colonized with MDROs.
The facility did not post daily staffing information, preventing residents and visitors from accessing staffing details to ensure safe ratios. Observations showed no postings at nursing stations, and interviews with the DSD and Assistant DSD revealed a lack of awareness about posting locations. The DON confirmed that actual nursing hours were not posted as required by facility policy.
The facility failed to provide required dementia care training to all CNAs, as revealed through interviews and record reviews. CNAs acknowledged the need for training to improve care for residents with dementia. The DON confirmed the importance of such training, but documentation was lacking. The facility's policy required initial and annual training, which was not adhered to, potentially affecting care quality.
The facility failed to ensure functional and accessible call lights for two residents, one with acute respiratory failure and another with severe cognitive impairment. A resident's call light was not plugged in, preventing them from requesting pain medication, while another's call light was out of reach, hindering their ability to call for help. The DON confirmed the importance of operational call lights to meet residents' needs and prevent potential falls.
The facility failed to implement Gradual Dose Reductions (GDR) for psychotropic medications for three residents, despite recommendations and policy requirements. A resident on Zoloft for depression did not have a GDR attempted, and the physician was not notified of the pharmacist's recommendations. Two other residents on multiple psychotropic medications also lacked GDR attempts or documentation of contraindications. The DON confirmed the absence of necessary documentation and follow-through.
The facility failed to store food in a sanitary manner, with several items in the refrigerator and freezer not dated or labeled, and some expired. This was confirmed by a Dietary Aid and acknowledged by the COO, who stated it was the kitchen staff's responsibility to ensure food items were labeled, dated, and fresh. The DON also emphasized the importance of labeling to prevent residents from consuming expired foods, as per the facility's policy.
The facility's QAA and QAPI committees failed to address systemic issues in infection control, nursing staff monitoring, and injury reporting. Infection control practices, including Enhanced Barrier Precaution for residents with wounds and indwelling devices, were not maintained, and there was no system to ensure call lights were within reach. The Administrator admitted to not identifying these issues before the survey, acknowledging improvement opportunities.
The facility failed to follow its Antibiotic Stewardship protocol for five residents, prescribing antibiotics without meeting the McGeer Criteria. This included administering antibiotics without necessary culture and sensitivity tests or documentation, potentially leading to antibiotic resistance. The Infection Preventionist confirmed the lack of compliance with the facility's policy, which requires antibiotics to be prescribed under the guidance of the stewardship program.
A resident with cognitive impairments and a history of hemiplegia was found with facial bruising and swelling, which was not reported to the CDPH within the required timeframe. Despite staff recognizing the injury as of unknown origin, it was not reported or investigated promptly, contrary to facility policy. This oversight resulted in a deficiency due to the potential risk of unidentified abuse.
A facility failed to label and change a resident's humidifier and oxygen tubing as required, risking respiratory infection. The resident, with a history of respiratory failure, was observed receiving oxygen without proper equipment labeling. The facility's policy mandates changing the equipment every seven days.
A resident with mobility issues and obesity was not provided with a suitable wheelchair, despite expressing discomfort and requesting a larger one. The request was communicated to the Social Service Director, but the Director of Nursing acknowledged it was not addressed appropriately, leading to a deficiency in care.
A facility failed to label a morphine sulfate solution with an open date, as observed during a medication cart review. A resident, admitted with cancer and chronic pain, was at risk of receiving expired medication. The LVN and DON acknowledged the importance of labeling to ensure medication efficacy, as per facility policy.
The facility did not meet the required room size of 80 square feet per resident for 18 rooms, potentially affecting safe nursing care and privacy. Despite a waiver request, observations showed residents had enough space for mobility and no concerns were raised by the Resident Council President.
Failure to Maintain Resident Dignity During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents’ dignity during incontinent care and bowel movement cleanup. Resident 1, who had diagnoses including cerebral infarction, seizures, left-sided hemiplegia, and brain compression, was assessed as dependent on staff for toileting, showering, personal and oral hygiene, and dressing, and was always incontinent of urine and bowel. The resident’s H&P indicated he did not have capacity to understand and make decisions. During an interview, Resident 1 reported that CNA 1 wiped him hard after a bowel movement, stated that CNA 1 was “digging in his rectum,” and said he told CNA 1 to stop and to get out of his room, but CNA 1 laughed at him. Resident 1 stated he felt violated, upset, mad, and expressed wanting to kill CNA 1. Resident 1’s responsible party later reported to LVN 1 that CNA 1 was digging too deep in the anal area and did not stop when Resident 1 said stop. Resident 2 had diagnoses including generalized muscle weakness, lack of coordination, difficulty walking, and end-stage renal disease, and was documented as having fluctuating capacity to understand and make decisions. The MDS indicated Resident 2 could express ideas and wants, required substantial to maximal assistance with toileting, showering, and dressing, and was frequently incontinent of urine and always incontinent of bowel. Resident 2 reported that CNA 2 wiped him with force and placed two fingers in his rectum in the shower, stating this occurred four times during cleaning. Resident 2 stated he felt humiliated and was afraid CNA 2 would find out his personal information and where he lives. CNA 1 acknowledged being assigned to Resident 1 on two days and stated Resident 1 accused him of inserting his fingers in the resident’s rectum. CNA 2 acknowledged being assigned to Resident 2 on a day when the resident had a bowel movement, and described placing the bed flat, removing the diaper, and using wipes to clean the perineal area while Resident 2 was tense and instructed to relax. The DON stated that a family member of Resident 2 reported CNA 2 was rough and put two fingers in Resident 2’s rectum. The DON also described that proper handling and cleaning require explaining to residents before touching them, asking if they are comfortable, and stopping and calling the charge nurse if a resident is uncomfortable and says stop. Facility policies on Quality of Life – Dignity and Resident Rights required that residents be treated with dignity, respect, kindness, and in a manner that promotes and enhances self-esteem and self-worth, which was not followed in these incidents.
Co-mingling of Resident Social Security Funds with Facility Payroll Account
Penalty
Summary
The facility failed to properly manage and safeguard a resident's personal funds by allowing the resident's Social Security benefits to be deposited into the facility's payroll account and used for employee paychecks over a six-month period. The resident, who had Parkinson's disease, moderately impaired cognition, and was dependent on staff for ADLs, had Social Security payments totaling $27,568.37 deposited by the Social Security Administration into the facility's payroll bank account on multiple occasions. Bank statements showed deposits made on behalf of the resident in one large lump sum followed by monthly deposits, all going into the payroll account rather than a separate resident trust or personal funds account. The business manager who discovered the issue while reviewing payroll bank statements reported that the deposits occurred over several months and informed the former administrator, the facility owner, and the payroll assistant, but no efforts were made to return the funds to the resident's estate. A subsequent review by a new business manager confirmed there was no evidence that the resident's Social Security funds had been returned, and no check had been issued from the payroll account to the resident's trust account. The current administrator acknowledged that the resident's Social Security funds were co-mingled with the facility's payroll account and stated that the appropriate action would have been to return the funds to the resident's trust or estate. The facility's undated policy on resident trust funds stated that money deposited to the account should not be used or combined with facility funds, which was not followed in this case.
Failure to Reconcile and Return Resident SSA Funds After Discharge
Penalty
Summary
The facility failed to ensure that a resident’s personal funds were properly managed, reconciled, and returned upon discharge. The resident, who had Parkinson’s disease, was admitted in 2020 and had moderately impaired cognition and dependence on staff for ADLs per an MDS dated 4/2/2024. The census showed the resident was discharged on 4/28/2024. Review of the facility’s payroll bank account statements from 7/14/2021 through 12/3/2021 showed that multiple SSA payments totaling $27,568.37 were deposited into the facility’s payroll account on behalf of this resident. These deposits included one large payment of $19,913.37 and subsequent monthly deposits of $1,531.00. There was no evidence that these SSA funds were ever transferred into the resident’s trust account while the resident was in the facility. Further review of the facility’s transaction report for 1/1/2020 through 1/31/2026 indicated that as of 10/2025, the total due for the resident’s share of cost was zero and the total owed to the resident was zero, despite the SSA deposits into the payroll account. The resident’s trust account showed only a copied check dated 12/10/2024 in the amount of $1,843.70, issued more than seven months after the resident’s discharge, with no documentation that the SSA funds deposited between 7/2021 and 12/2021 were ever credited to the trust account or refunded to the resident within the facility’s policy timeframes. Interviews with the former and current business office managers confirmed that the SSA checks had been deposited into the payroll account, that a trust account for the resident was opened in 1/2022, and that no check from the payroll account was created and deposited into the resident’s trust account to return those funds. The facility’s policy stated that upon permanent discharge, a refund must be issued within three days, and within 30 days when a resident expires, which was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents with specific clinical needs. One resident with a diagnosis of post-traumatic stress disorder (PTSD), depression, anxiety, and dementia did not have a care plan addressing PTSD, despite staff interviews confirming that certain care approaches could trigger the resident's PTSD symptoms. The absence of a care plan for PTSD was acknowledged by both nursing and social services staff, as well as the Director of Nursing, who stated that such a plan was necessary for staff to understand and meet the resident's needs. Another resident, admitted with morbid obesity, bilateral artificial knee joints, and anxiety, experienced intentional weight loss as part of a personal health goal. The resident's weight loss was documented in the medical record and discussed with the registered dietician and dietary staff. However, there was no care plan in place to guide staff on monitoring the weight loss, ensuring it remained within safe parameters, or supporting the resident's goals, as confirmed by nursing staff and the DON. A third resident, diagnosed with Parkinson's disease, dementia, and muscle weakness, was receiving Restorative Nursing Aide (RNA) services for bilateral upper extremity active range of motion exercises. Despite active physician orders and ongoing RNA interventions, there was no care plan outlining the goals or interventions for these services. Nursing staff and the DON confirmed the absence of a care plan, noting that such documentation is necessary to ensure proper care and to track the resident's progress.
Failure to Properly Date and Remove Food Items in Storage
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and labeling practices. During an inspection of the refrigerator and freezer, a tray of individually poured orange and cranberry juices, as well as trays with open containers of fruit, were found without dates. A container of cooked ham remained in the refrigerator past its use-by date, and a container of cooked chicken with mushrooms lacked a use-by date. Additionally, several containers of cold breakfast cereals and bags of cooked fish and roast beef in the freezer were not labeled with use-by dates. Staff interviews confirmed that these items should have been labeled with open and best-by dates to ensure food safety. The Dietary Supervisor acknowledged awareness of the unlabeled and expired food items, stating that all opened food must be dated to ensure it is safe for consumption. Review of the facility's policy and procedure on food receiving and storage confirmed that all foods stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The observed failures to date and remove expired food items were not in accordance with the facility's established policies.
Call Light Not Within Reach for Resident with Hemiparesis
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by policy and procedure. Resident 42, who had a history of cerebral infarction resulting in hemiparesis of the right arm and lacked decision-making capacity, was observed with her call light placed on her right side, the side affected by weakness. The resident required partial to moderate assistance with activities of daily living, according to her Minimum Data Set assessment. Staff interviews confirmed that all facility staff were responsible for ensuring call lights were within easy reach of residents, and the Director of Nursing emphasized the importance of this practice. The facility's policy also specified that call lights should be within easy reach when residents are in bed or confined to a chair. The failure to position the call light appropriately for Resident 42 was identified through observation, interview, and record review.
Failure to Complete Required PASARR Level II Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders received a required Level II Preadmission Screening and Resident Review (PASARR) evaluation. The resident was originally admitted and later readmitted with diagnoses including schizophrenia, depression, and seizures. Despite these diagnoses, the admission record and subsequent assessments did not trigger a PASARR Level II evaluation, as the initial PASARR Level I incorrectly indicated the absence of mental disorders. The Director of Nursing (DON) acknowledged responsibility for reviewing PASARRs and confirmed that a new PASARR should have been submitted upon the resident's readmission, especially after the diagnoses of schizophrenia and depression were established. The resident's medical records indicated significant cognitive and functional impairments, including dependence on staff for multiple activities of daily living and a lack of capacity to make decisions. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process. However, this process was not followed for the resident in question, resulting in the resident not being appropriately screened for mental illness upon readmission.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for Certified Nursing Assistants (CNAs), specifically for CNA 1, CNA 2, and CNA 4. During a review of employee files with the Director of Staff Development (DSD), it was found that none of these CNAs had an annual performance evaluation for 2024, despite the facility's policy requiring such evaluations at least annually. The DSD acknowledged not being aware that performance evaluations were to be conducted annually. The Director of Nursing (DON) confirmed that annual evaluations are expected and are used to recognize staff strengths and address weaknesses. The facility's policy, dated September 2001, also specifies that performance evaluations are to be completed at least annually and are tied to compensation reviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to properly administer medications to a resident with multiple diagnoses, including diabetes mellitus, rheumatoid arthritis, and dementia. The LVN crushed and prepared each of the resident's prescribed medications in separate cups with applesauce, but did not ensure that the full doses were administered. After the medication pass, it was observed and confirmed by the LVN that residual medication remained in the cups, resulting in incomplete dosing for the resident. This incident led to seven medication errors out of 26 opportunities, resulting in a medication error rate of 26.92%, which is significantly above the acceptable threshold of less than 5%. The resident was dependent on staff for all activities of daily living and had limited ability to communicate or understand others, further emphasizing the need for accurate medication administration. The facility's policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.
Failure to Administer Complete Medication Dose
Penalty
Summary
A resident with diagnoses including diabetes mellitus, rheumatoid arthritis, and dementia was admitted to the facility and had multiple physician orders for medications such as hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone, and senna. The resident was assessed as rarely or never able to express ideas or understand others and was dependent on nursing staff for daily activities. During a medication pass, an LVN crushed and administered the resident's medications, but did not ensure the full dose was given, as some medication remained in the medicine cups after administration. The LVN confirmed that the resident did not receive the complete dose of the prescribed medications, which was also acknowledged by the DON. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The failure to administer the full dose of medication was directly observed and confirmed through staff interviews and record review.
Failure to Follow Antibiotic Stewardship Protocol for Ocular Infection
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for one resident who was prescribed an antibiotic without meeting the required McGeer criteria. The resident, who had a history of schizophrenia, depression, and seizures, was dependent on nursing staff for most activities of daily living and lacked the capacity to make decisions. The resident was prescribed and administered Gentamicin Sulfate Solution for a right eye infection, despite only presenting with symptoms of a swollen and teary eye and without a laboratory culture being performed to confirm the infection. Interviews with facility staff, including the Infection Preventionist Nurse and the Director of Nursing, confirmed that the Surveillance Data Collection Form did not indicate a culture was done and that the resident did not meet the McGeer criteria for antibiotic use. The facility's policy required antibiotics to be prescribed and administered under the guidance of the antibiotic stewardship program, which was not followed in this case.
Failure to Ensure Completion of Required Dementia and Abuse Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required dementia and abuse prevention trainings upon hire and annually, as evidenced by a review of four CNA employee files. Specifically, one CNA had only four out of the five required hours of dementia training, another had only two out of five required hours, a third had no dementia or abuse training, and a fourth had only three out of five required hours of dementia training and no abuse training. These findings were confirmed during interviews with the Director of Staff Development (DSD) and the Administrator, both of whom acknowledged the importance of these trainings and the facility's policy requirements. Record reviews further indicated that the DSD was responsible for maintaining current Department of Health-approved orientation and in-service training programs, including 24 hours of annual in-service education for CNAs. Facility policies required annual in-services to ensure nurse aide competence, including training in dementia management and resident abuse. Documentation of training participation, including hours completed and competency assessments, was also required but not consistently present in the reviewed files.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 18 out of 24 resident rooms met the required minimum of 80 square feet per resident for multiple occupancy rooms, as specified by regulations. During the survey, it was found that these rooms, which included both two-bed and one four-bed room, were below the required square footage per resident. The measurements of these rooms ranged from approximately 147 to 159 square feet for two-bed rooms and 318.55 square feet for the four-bed room, all falling short of the standard. The deficiency was identified through observation, interviews, and review of facility records, including a waiver request submitted by the Administrator for room size variances. Interviews with facility staff and the Resident Council President revealed no reported concerns regarding the room sizes. Observations conducted over several days indicated that residents had sufficient space to move freely within their rooms, with adequate room for beds, side tables, and the use of mobility aids such as wheelchairs, walkers, or canes. The report did not note any impact on the provision of nursing care or resident privacy as a result of the room sizes.
Resident Injury Due to Malfunctioning Shower Room Door
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was being transported to a shower room, resulting in an accident. The incident involved a Certified Nurse Assistant (CNA) who was pulling the resident on a shower chair into the shower room when the door, which was malfunctioning, hit the resident's left foot. This resulted in a fracture and laceration of the resident's left great toe, requiring medical attention and suturing at a general acute care hospital. The resident had a history of Alzheimer's Disease and osteoporosis, requiring substantial assistance with daily activities. The deficiency was further compounded by the failure of the CNA and a Licensed Vocational Nurse (LVN) to report the malfunctioning door in the Maintenance Logbook, as per the facility's policy. The CNA admitted to using his foot to stop the door and acknowledged that he should have requested assistance to prevent the accident. The LVN also failed to recognize the door's malfunction as a problem, as it had always functioned in that manner, and did not report it as broken. The Maintenance Supervisor was aware of the door issue but did not ensure it was resolved, as the door stopper was reattached after being removed. The Registered Nurse Supervisor and the Administrator confirmed that the incident could have been avoided if the malfunctioning door had been reported and addressed. The facility's policy required maintaining the building in a safe and operable manner, which was not adhered to in this case.
Failure to Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation from a medical appointment, resulting in the resident sustaining injuries. The incident involved a resident who was transported in a facility van while seated in a wheelchair. The driver did not secure the wheelchair using the required four-point straps, which are designed to anchor the wheelchair at four separate points to the vehicle. Additionally, the resident was only secured with a lap seatbelt, which was insufficient to prevent the wheelchair from tipping over during transit. The resident, who had multiple medical conditions including end-stage renal disease, muscle weakness, and osteoporosis, was accompanied by a Certified Nursing Assistant (CNA) who was not adequately trained in securing the wheelchair. The CNA did not verify that the wheelchair was properly anchored before the van departed. As the van approached the facility and made a left turn on an uphill slope, the wheelchair tilted backward, causing the resident to hit her head on the van lift. This resulted in a scalp laceration, hematoma, neck sprain, and shoulder sprain. Interviews with the CNA, the driver, and other staff members revealed a lack of adherence to the facility's transportation policy, which mandates the use of seatbelts and proper wheelchair securement. The driver admitted to not using the four-point straps, and the CNA acknowledged her unfamiliarity with the securement process. The facility's investigation confirmed that the driver had been trained on the proper use of the straps but failed to apply this knowledge during the incident.
Failure to Ensure Proper Training for Resident Transport
Penalty
Summary
The facility failed to ensure that staff, including a Certified Nursing Assistant (CNA), had the necessary training and competency evaluation for transporting residents using the facility van. This deficiency resulted in an incident where a resident's wheelchair was not properly secured during transport, leading to the wheelchair tilting back and the resident sustaining injuries. The resident, who had end-stage renal disease, muscle weakness, and other conditions, was being transported back to the facility when the wheelchair was not anchored correctly, causing it to tilt and the resident to hit her head, resulting in a scalp laceration, hematoma, neck sprain, and shoulder sprain. The CNA involved in the incident admitted to not being familiar with the straps used to secure the wheelchair and failed to ensure the resident was strapped in with a seatbelt. The driver of the van also could not confirm if the wheelchair was anchored properly. The Director of Staff Development acknowledged that there was no documentation of in-service training regarding the use of the van's seatbelts and four-point straps prior to the incident. The facility's policy required that wheelchairs be properly strapped during transport, but this was not adhered to, leading to the resident's injuries.
Failure to Provide Proper Wound Care Leads to Hospital Transfer
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident with a right medial leg venous ulcer, as per the physician's orders and care plan. The resident, who had a diagnosis of type 2 diabetes mellitus and was at risk for developing pressure ulcers, was admitted and readmitted to the facility. The care plan indicated that the resident's wound should be treated with Gentamicin Sulfate External Ointment and covered with a dressing, but this was not consistently done. On one occasion, a Licensed Vocational Nurse (LVN 1) was unable to change the resident's dressing due to a personal emergency and asked another nurse (LVN 2) to complete the task. However, LVN 2 mistakenly treated a different wound on the resident's foot, leading to the right medial leg wound being neglected. This oversight resulted in the wound developing a foul odor, green exudate, and the presence of maggots, causing the resident to experience pain and requiring transfer to a General Acute Care Hospital for further evaluation. Interviews with the nursing staff and a review of the physician's orders revealed that the complete wound care treatment was not properly documented or communicated, leading to the failure in treatment. The Director of Nursing acknowledged that the nursing staff did not ensure the accuracy of the wound care treatment as per the physician's orders, which contributed to the resident's wound not being treated on the specified date.
Inadequate Infection Control Practices for MDROs
Penalty
Summary
The facility failed to implement effective infection control practices to prevent the spread of multidrug-resistant organisms (MDROs) among residents. Specifically, the facility did not ensure that personal protective equipment (PPE) was accessible and readily available to staff providing direct care to residents at high risk of acquiring MDROs. Observations revealed that there were no Enhanced Barrier Precaution (EBP) signages or isolation carts outside the rooms of residents with wounds and indwelling medical devices, such as urinary catheters and gastrostomy tubes. This lack of proper signage and equipment availability led to staff entering rooms without the necessary protective gear, increasing the risk of cross-contamination. The deficiency involved 11 residents who were not placed on EBP despite having conditions that warranted such precautions. These residents included individuals with deep tissue injuries, stage 3 and 4 pressure ulcers, tracheostomies, and other indwelling devices. Interviews with staff, including physical and occupational therapists, revealed a lack of awareness and adherence to EBP protocols. Staff members were observed performing care activities, such as wound dressing changes and physical therapy, without wearing the required gowns and gloves, further contributing to the potential spread of infections. Additionally, the facility lacked comprehensive policies and procedures regarding the application of EBP for residents known to be colonized with MDROs or those with open wounds and indwelling medical devices. The Infection Prevention Nurse admitted that EBP had not been implemented for the affected residents, and there were no care plans in place to address their specific needs. This oversight in infection control practices posed a significant risk of cross-contamination and transmission of MDROs within the facility.
Removal Plan
- Residents 247, 246, 36, 37, 38, 1, 9, 346, 96, 17, and 42 were placed on EBP. EBP signages were posted on all the resident's rooms and isolation carts were available outside each room.
- All residents identified had a physician order with reason for EBP.
- Comprehensive plan of care were initiated for all 11 identified residents.
- Self-responsible residents were informed of EBP, and resident representatives were informed for residents who were not responsible.
- In-services with teach back were initiated to all staff regarding EBP.
- EBP policy and procedure was initiated and reviewed by Interdisciplinary Team (IDT) which included the ADM, the DON, the Social Services Designees, the Activities Director, the Infection Preventionist (IP), the Director of Staff Development (DSD) and representatives from the rehabilitation department.
- The DON in-serviced the IP designee for the following identified noncompliance: Line listing, infection control rounding, and EBP.
- EBP brochures were available to families, visitors, vendors, and staff at the front lobby of the facility.
- Adherence monitoring of EBP including donning of PPE during high contact activities will be performed by IP, charge nurse, and Registered Nurse supervisor daily every shift.
- The DON and/or designee will perform random adherence monitoring for all facility staff until substantial compliance was observed.
- Adherence monitoring tool will be kept in a binder upon completion and will be reviewed weekly by IDT to ensure identification of need for continued education of all staff. Facility staff will be in-serviced as needed.
- Possible admission inquiry to the facility will be reviewed by DON, Admission coordinator, and/or Administrator for MDRO, wounds, indwelling medical devices and EBP will be initiated accordingly.
- Residents admitted without wound and/or indwelling medical devices but acquire during facility stay will be placed on EBP.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted and updated daily, which resulted in residents and visitors being unable to access the facility's staffing information to verify safe staffing ratios. During an observation, it was noted that there was no posting of nursing hours at either of the two nursing stations. Interviews with the Director of Staff Development (DSD) and the Assistant DSD revealed that they were unaware of where the nursing hours were posted, and it was confirmed that actual daily staffing hours were not posted prior to each shift. Additionally, the type of nurses working each shift was not posted. The Director of Nursing (DON) acknowledged that nursing hours should be posted in areas visible to both staff and visitors, but confirmed that the facility was not posting the actual hours of each nursing staff working prior to each shift. A review of the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers' indicated that the facility was required to post daily for each shift the number of nursing personnel responsible for providing direct care to residents.
Deficiency in Dementia Care Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required dementia care training necessary to maintain the competence of the nursing staff's knowledge and skills. This deficiency was identified through interviews and record reviews, revealing that several CNAs had not completed the necessary training. During interviews, CNAs expressed that they had not received all dementia care training and acknowledged that such training would be beneficial in improving their ability to care for residents with dementia. The facility's Director of Nursing (DON) confirmed that dementia care training was required for all CNAs and emphasized its importance in enhancing staff competency and the quality of care for residents with dementia. Further investigation into facility staffing files showed a lack of documentation confirming that all CNAs had completed the required dementia care training. The Director of Staff Development (DSD) also confirmed the absence of such documentation. The facility's policy and procedure on dementia care, revised in November 2018, indicated that nursing assistants should receive initial training in dementia care, with annual in-services and performance reviews to guide further education. Despite this policy, the facility did not ensure compliance, potentially leading to delays and interruptions in the provision of necessary care for residents with dementia.
Failure to Ensure Functional and Accessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents by not ensuring their call lights were functional and within reach. Resident 42, who was admitted with acute respiratory failure, chronic kidney disease, hypertension, and hyperlipidemia, had a call light that was not plugged in completely, rendering it non-functional. This was observed during a visit by a CNA, who acknowledged the importance of having a working call light to ensure the resident's needs, such as pain medication, were met. The Director of Nursing (DON) confirmed that all staff were responsible for ensuring call lights were operational, as non-functional call lights could prevent timely assistance and recognition of changes in a resident's condition. Resident 16, who had severe cognitive impairment and required maximum assistance for all activities of daily living, was observed multiple times with a call light that was unplugged and out of reach. This resident, diagnosed with unspecified vascular dementia, dysphagia, and essential hypertension, was unable to call for help due to the inaccessible call light. The DON acknowledged that if a resident cannot reach the call light, it could lead to unmet needs and potential falls. The facility's policy on answering call lights emphasized the importance of ensuring call lights are plugged in, functional, and within easy reach of residents.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident 21, Resident 4, and Resident 18, underwent a Gradual Dose Reduction (GDR) for their psychotropic medications within the required timeframe. Resident 21 was admitted with diagnoses including anxiety, depression, schizophrenia, and bipolar disorder and was prescribed Zoloft for depression. Despite recommendations for a GDR, there was no documentation that the physician was notified of these recommendations, and no GDR was attempted. The Director of Nursing (DON) confirmed the lack of follow-through from the licensed staff regarding the pharmacist's recommendations. Similarly, Resident 4, with diagnoses of schizophrenia, bipolar disorder, depression, and anxiety, was prescribed multiple psychotropic medications, including fluoxetine, quetiapine, and risperidone. The Minimum Data Set (MDS) indicated no GDR was attempted, nor was it documented as clinically contraindicated. Resident 18, diagnosed with dementia, depression, and anxiety, was also on quetiapine without a GDR attempt or documentation of contraindication. The DON acknowledged the absence of GDR documentation for Residents 4 and 18. The facility's policy on antipsychotic medication use required appropriate physician response to medication issues, which was not adhered to in these cases.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of infectious agents causing foodborne illnesses. During an observation and interview with a Dietary Aid, it was confirmed that several food items in the refrigerator and freezer were not dated or labeled, and some were expired. Items such as red pepper, lettuce, ground beef, egg trays, enchilada sauce, apple sauces, pork beans, tuna chunks, green beans, broccoli, and vanilla ice cream were found without delivery dates or use-by dates. This lack of proper labeling and expiration management was acknowledged by the Chief Operating Officer (COO), who stated that it was the responsibility of all kitchen staff to ensure food items were labeled, dated, and fresh. The Director of Nursing Service (DON) also confirmed the necessity of labeling food items with delivery dates, use-by dates, and opened dates to prevent residents from consuming expired foods. The facility's policy and procedure on food storage indicated that leftover food should be labeled and dated before refrigeration and used within three days or discarded. However, the facility failed to adhere to these guidelines, potentially exposing residents to spoiled food and the risk of foodborne illness.
Failure in Infection Control and Monitoring Systems
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for systemic problems identified in infection control practices, monitoring of nursing staff, and reporting and investigating injuries of unknown origin. Specifically, the facility did not maintain a system to implement infection control practices, including Enhanced Barrier Precaution (EBP) for residents with wounds, indwelling devices, and tracheostomies to prevent the spread of multidrug-resistant organisms (MDROs). Additionally, there was no system in place to ensure that nursing staff kept call lights within residents' reach, and there was a lack of a systemic approach to reporting and investigating injuries of unknown origin. During an interview, the Administrator admitted to not being able to identify systemic issues prior to the recertification survey and acknowledged the facility's opportunities for improvement in the deficient practices mentioned. The facility's policy on Quality Assurance and Performance Improvement (QAPI) Program indicated that the QAPI Committee is responsible for overseeing and implementing the program, collecting and analyzing performance data, and identifying and resolving care quality problems. However, the failure to address these systemic issues placed residents at risk for not receiving the necessary quality treatment and increased the risk of cross-contamination and infection.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for five residents who were prescribed antibiotics without meeting the McGeer Criteria. These criteria are essential for determining the necessity of antibiotic treatment in long-term care facilities. The deficiency was identified through interviews and record reviews, revealing that antibiotics were administered without proper justification, such as culture and sensitivity tests, which are required by the facility's policy. Resident 11 was prescribed Levaquin for a sore throat and productive cough without a culture and sensitivity test or a chest x-ray, as required by the McGeer Criteria. The resident expressed reluctance to take the medication, and the Infection Preventionist confirmed that the necessary criteria were not met. Similarly, Resident 19 was started on Azithromycin for pneumonia without documentation of meeting the McGeer Criteria. Residents 25, 247, and 346 were also prescribed antibiotics without meeting the required criteria. Resident 25 was given Levaquin for pneumonia, Resident 247 was prescribed Amoxicillin-Pot Clavulanate, and Resident 346 received levofloxacin via a jejunostomy tube. The Infection Preventionist acknowledged the lack of documentation for meeting the McGeer Criteria for all five residents, which could lead to antibiotic resistance and other health risks. The facility's policy on Antibiotic Stewardship, revised in 2016, mandates that antibiotics be prescribed and administered under the guidance of the program, with lab results communicated to the prescriber to determine the necessity of antibiotic therapy.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the California Department of Public Health (CDPH) within the required two-hour timeframe for a resident who exhibited swelling and bruising on the right facial cheek area. The resident, who was not cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, was transferred to a General Acute Care Hospital (GACH) with these injuries. The incident was initially observed by a Certified Nursing Assistant (CNA) and reported to a Licensed Vocational Nurse (LVN), who failed to notify the Director of Nursing (DON) or report the incident to CDPH, despite recognizing it as an injury of unknown origin. Interviews with facility staff, including the DON and the Administrator, confirmed that the incident should have been reported and investigated to rule out potential abuse. The facility's policy and procedure on reporting and investigating abuse, neglect, and injuries of unknown origin require immediate reporting to the administrator and relevant authorities. The policy defines immediate reporting as within two hours for incidents involving abuse or serious bodily injury. The failure to adhere to these procedures resulted in a deficiency, as the injury was not reported or investigated in a timely manner, potentially leaving the resident and others at risk of unidentified abuse.
Failure to Label and Change Oxygen Equipment
Penalty
Summary
The facility failed to ensure that the humidifier and oxygen tubing for a resident were labeled with the date of change, which is a requirement according to the facility's policy. This oversight was identified during an observation and interview with an LVN, who noted that the resident was receiving oxygen at 5 liters per minute via humidified nasal cannulas, and the equipment was not labeled with a date. The LVN acknowledged that the oxygen tubing and humidifier should be changed every seven days to prevent possible respiratory infections. The resident involved had a medical history that included acute respiratory failure, chronic kidney disease, hypertension, and hyperlipidemia. The resident required partial assistance with daily activities and had a physician's order for oxygen therapy to maintain adequate oxygen saturation levels. The Director of Nursing confirmed that charge nurses are responsible for checking the dates on humidifiers and oxygen tubing to ensure they are changed as required. The facility's policy, revised in 2010, mandates that oxygen equipment be dated and replaced every seven days.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to provide a larger sized wheelchair for a resident, identified as Resident 4, which was necessary to promote mobility and maintain independence. Resident 4 was admitted with diagnoses including lack of coordination, muscle wasting and atrophy, difficulty walking, and obesity. The Minimum Data Set (MDS) assessment indicated that Resident 4 was dependent on nursing staff for various activities, including transferring from the bed to a chair. During an interview, Resident 4 expressed a desire to get out of bed but reported that the provided wheelchair caused pain and was not suitable, indicating a need for a special, larger wheelchair. The Restorative Nurse Aide (RNA 1) confirmed that Resident 4 had requested a bigger wheelchair and had communicated this request to the Social Service Director (SSD). The SSD acknowledged awareness of the request and stated that she was working on it. However, the Director of Nursing (DON) later admitted that Resident 4's request for a different wheelchair was not addressed appropriately. The facility's policy on social services emphasizes identifying and meeting the medical-related social needs of residents, which was not fulfilled in this case, leading to the deficiency.
Failure to Label Morphine Sulfate Solution with Open Date
Penalty
Summary
The facility failed to ensure that the morphine sulfate solution used for a resident was labeled with an open date, as required by professional principles and the facility's policy. This oversight was identified during an observation of the medication cart, where it was noted that the bottle of morphine sulfate solution did not have an open date label. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been labeled with the date it was opened to track its usability and ensure it is not expired. Resident 22, who was receiving the morphine sulfate solution, had been admitted with diagnoses including malignant neoplasm of the colon, chronic obstructive pulmonary disease, and chronic pain. The resident's cognitive status was intact, and they required assistance with personal hygiene tasks. The Director of Nursing (DON) confirmed the importance of labeling medications with the open date to prevent the administration of outdated medication, which could lead to reduced efficacy and potential adverse reactions. The facility's policy on administering medication also emphasized the need to record the open date on multi-dose containers.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that 18 out of 24 residents' rooms met the required space of 80 square feet per resident. The rooms in question included 18 rooms with two beds each and one room with four beds, all of which were below the required square footage per resident. This deficiency was identified through observation, interviews, and record reviews, indicating a potential risk for inadequate provision of safe nursing care and privacy for the residents. During the survey, the facility's administrator provided a waiver request for room variances, asserting that the reduced room sizes would not compromise the health, welfare, and safety of the residents. Despite the waiver, the surveyors noted that the rooms did not meet the regulatory requirements. However, observations during the survey period showed that residents had enough space to move freely, and there were no concerns from the Resident Council President regarding room sizes. Each room was equipped with beds, side tables, and had adequate space for mobility aids, suggesting that the room size did not affect the nursing care or privacy provided to the residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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