Park Anaheim Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 3435 W Ball Road, Anaheim, California 92804
- CMS Provider Number
- 555035
- Inspections on file
- 19
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Park Anaheim Healthcare Center during CMS and state inspections, most recent first.
A resident on a ventilator did not have their suction canister changed in accordance with facility policy, resulting in the canister becoming full before it was replaced. Staff confirmed the canister had not been changed as required, and acknowledged it should have been replaced when 3/4 full or as needed.
A resident's room contained an air fryer and Keurig coffee machine that had not been approved or inspected according to facility policy. Staff, including LVNs and CNAs, had not received training on the safe use or maintenance of these appliances, and the Maintenance Director was unaware of their presence. The appliances were used by the resident with staff assistance, but no procedures were in place to ensure their safe operation.
A facility failed to document and monitor a resident's change in condition as per protocol. The resident, who had a physician's order for Levofloxacin due to fever and cough, lacked proper documentation for the change in condition, an updated care plan, and nurse progress notes. Interviews with staff confirmed the oversight, highlighting a failure to adhere to facility policies.
A facility failed to implement proper infection control practices for a resident with an indwelling suprapubic urinary catheter. Despite signage indicating the need for Enhanced Barrier Precautions (EBP), a CNA was observed changing the resident's brief while only wearing gloves, failing to don a gown as required. The Infection Preventionist confirmed the expectation for staff to wear both gloves and a gown during high-contact care activities, acknowledging the lapse in following infection prevention protocols.
The facility failed to ensure the DSS was competent in supervising kitchen operations, leading to potential foodborne illness risks for residents. The DSS used raw shelled eggs that were not fully cooked, demonstrated incorrect thermometer calibration, and was unaware of health shake guidelines. Additionally, worn equipment was not replaced, and beard coverings were unavailable for staff with facial hair. The Administrator did not evaluate the DSS's competency, relying on the RD, who had not conducted a formal evaluation.
The facility failed to ensure kitchen staff competence, leading to unsafe food handling practices. Cook 1 did not follow hand hygiene protocols, inaccurately took food temperatures, and did not follow recipes or test sanitizing solutions correctly. DA 1 was unable to read the dish machine temperature dial, posing a risk for improper dishwashing procedures.
The facility did not adhere to the prescribed recipes for pureed diets, affecting the nutritional needs of 15 residents. Observations revealed that pureed sweet and sour chicken, vegetables, and noodles were not prepared according to the recipes, with incorrect consistencies and high sodium content due to the use of unmeasured thickeners and inappropriate broth. The RD and DSS confirmed the necessity of following recipes to meet residents' nutritional needs.
The facility failed to meet food safety and sanitation standards, with issues such as undercooked eggs, improper hand hygiene, and inadequate food storage and preparation procedures. Kitchen equipment was not maintained in a sanitary condition, and staff did not use hair restraints. A resident's personal refrigerator was not kept at the correct temperature, with no corrective actions documented. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to maintain the dignity and privacy of two residents. A resident with an indwelling urinary catheter had an uncovered drainage bag, compromising dignity. Another resident was exposed during a transfer to a shower bed, with the door left open, violating privacy. Staff acknowledged these oversights, which were against facility policies.
The facility failed to ensure informed consents were properly completed for several residents, as required by policy. Informed consents for treatments, including the use of gerichairs, side rails, and medications, were not signed and dated by physicians for multiple residents, some of whom lacked decision-making capacity. These deficiencies were confirmed by nursing staff and acknowledged by the administration.
A facility failed to maintain a copy of a resident's advance directive in their medical record, as required by the facility's policies. Despite the resident having an advance directive, confirmed by a POLST and an Advance Directive Acknowledgement, the document was not found in the medical record. The Social Service Director verified the absence, and the Director of Nursing acknowledged the deficiency.
The facility failed to manage and document the use of restraints for three residents, leading to potential risks of injury and decreased range of motion. A resident had an elbow splint without a current physician's order or documentation of removal and assessment. Two other residents had hand mitten restraints without proper documentation of removal and assessment every two hours, as required by facility policy. Staff interviews confirmed the lack of adherence to restraint policies.
A facility failed to develop a comprehensive care plan for a resident, omitting details about nighttime ventilator use and an elbow splint. Observations and interviews revealed the resident regularly used an elbow splint, which was not documented in the care plan. Additionally, the care plan did not reflect the resident's current ventilator schedule, as confirmed by the Respiratory Lead.
A resident at high risk for falls did not have their tab alarm properly applied as ordered by the physician. Observations showed the alarm was not consistently attached, and staff interviews confirmed the improper application. This failure placed the resident at risk for serious injuries.
A facility failed to verify the placement, patency, and gastric residuals of a GT before starting enteral feeding for a resident. The LVN connected the feeding formula and water flush tubing without performing the necessary checks, contrary to the facility's protocol and physician's orders. The ADON confirmed the protocol required these checks to prevent potential adverse outcomes.
The facility failed to provide appropriate respiratory care for three residents. Two residents had unlabeled oxygen tubing, which is required for infection control, and staff could not confirm when it was last changed. Another resident received oxygen at a rate higher than the physician's order. The DON acknowledged these deficiencies.
A resident experiencing pain did not receive non-pharmacological interventions as outlined in the facility's pain management policy. Despite having a care plan that included non-pharmacological methods like positioning, hot packs, and massage, these interventions were not documented or provided when the resident reported significant pain levels. The RN confirmed the oversight, and the DON acknowledged the findings.
A facility failed to ensure licensed staff were competent in assessing a resident's hemodialysis access site, leading to inadequate care. Despite a policy requiring training for staff caring for residents with ESRD, interviews revealed inconsistencies in understanding how to check for bruit and thrill. The deficiency was identified through medical record reviews and staff interviews, with the DON acknowledging the need for further training.
The facility failed to document attempts of alternative measures before applying side rails for several residents, despite policy requirements. Residents with varying cognitive and physical abilities were subjected to side rail use without proper assessments or documentation, potentially exposing them to risks associated with side rails.
The facility failed to ensure physician's orders matched medication labels and administered medications as ordered for two residents. One resident received digoxin with a label discrepancy, while another was given metoprolol tartrate without food, contrary to physician's orders. Staff acknowledged the errors, and the administration was informed.
The facility failed to properly store and separate medications, maintain clean medication carts, and accurately document blood glucose meter serial numbers for two residents. Medications were improperly mixed in storage areas, and multiple medication carts were found with unsanitary residues. Additionally, discrepancies in serial numbers for blood glucose meters were identified, indicating lapses in record-keeping.
The facility failed to preserve the nutrient content of pureed vegetables for 15 residents on a pureed diet. Pureed vegetables were prepared over an hour before meal service and stored in an oven at 500°F, which was not ideal for nutrient preservation. This practice was confirmed by the RD and posed a risk to the residents' nutritional needs.
Two residents were not provided with meals that met their specific dietary needs, risking aspiration or choking. One resident, awaiting oral surgery, received improperly minced chicken, while another was given inappropriate snacks contrary to her mechanical soft diet order. Staff confirmed the discrepancies, highlighting a failure in adhering to dietary orders.
A resident's request for collard greens was not honored by the facility, despite being documented in a Resident Council meeting. The Dietary Services Supervisor acknowledged the request but did not purchase the item or follow up with the resident. The resident's care plan indicated a risk for nutritional issues, yet the facility failed to accommodate the dietary preference, potentially affecting the resident's wellbeing.
The facility failed to ensure safe storage and handling of food brought in by visitors for three residents, potentially exposing them to foodborne illnesses. Despite a policy discouraging outside food, residents received food without proper guidance on safe handling. Staff interviews revealed a lack of procedures and training, with no refrigeration for outside food and unclean microwaves used for heating. The Director of Staff Development confirmed no staff training on safe food handling guidelines.
The facility failed to properly dispose of garbage and refuse, with open dumpsters and improper handling of organic and recyclable waste. Observations showed trash bags and cardboard boxes stored improperly, leading to potential unsanitary conditions. The Maintenance Director and Administrator confirmed these findings.
The facility failed to maintain accurate medical records and assess entrapment risks for residents using side rails. A resident was incorrectly documented as being on a ventilator, and multiple residents had inaccurate side rail assessments, with all zones marked despite not all being applicable. These inaccuracies were confirmed by staff interviews, posing potential risks to resident care.
The facility failed to maintain infection control practices, with used items found in clean areas, improper maintenance of a water feature, and inaccurate infection surveillance. An LVN used enteral tubing from the floor for a resident's GT feeding, and another did not perform hand hygiene before medication administration. Unlabeled basins were improperly stored in shared restrooms. These issues were confirmed by staff and management.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for several residents. The Infection Preventionist did not notify physicians to reassess antibiotic treatments for infections that did not meet McGeer's criteria, resulting in unnecessary antibiotic exposure.
The facility failed to maintain essential equipment in a clean and safe condition. The ice machine was not cleaned per guidelines, with black residue found in the chute. The walk-in refrigerator floor was worn and not cleanable, with no communication between departments about its condition. A microwave used for residents' food was dirty, with unclear cleaning responsibilities.
The facility failed to properly cover three out of four dumpsters, which were filled above the maximum loading level. An LVN confirmed that the dumpsters were overflowing, with lids not properly closed and two lids bent. This posed a risk of attracting pests and rodents carrying diseases.
Failure to Timely Change Suction Canister for Resident on Ventilator
Penalty
Summary
The facility failed to provide necessary respiratory care and services for one resident by not ensuring that the resident's suction canister was changed according to facility policy. The policy required suction canisters to be changed weekly, when 3/4 full, or as needed (PRN). Medical record review showed the suction canister was last changed on 5/2/25, and on 5/7/25, the canister was observed to be full while the resident was on a ventilator. The respiratory therapist (RT 1) confirmed the canister had not been changed since 5/2/25 and stated it was scheduled to be changed later that day, but acknowledged it should be changed when full. Further interview with the RT Supervisor confirmed that the canister should be changed when full, and failure to do so could result in the equipment being unable to suction and posed a potential for infection. The RT Supervisor acknowledged that the canister should have been changed when it was 3/4 full, as per policy. The resident involved was on a ventilator and had the capacity to make and understand their own decisions at the time of the deficiency.
Failure to Maintain Safe Resident Equipment and Ensure Staff Training
Penalty
Summary
The facility failed to ensure that resident equipment was maintained in a safe operating condition, as required by its own policy. An air fryer and a Keurig coffee machine were observed in a resident's room, both of which had not been approved by the administrator or designee as stipulated in the facility's electrical appliance policy. Staff interviews revealed that the appliances had been present in the room prior to the current staff's employment, and no staff had received training or in-service on the safe use or maintenance of these appliances. The resident reported using the air fryer to heat food and the coffee machine for personal use, with facility staff assisting in their operation. Further investigation showed that the Maintenance Director was unaware of the presence of these appliances and had not inspected them, although he did check the resident's refrigerator daily. The Maintenance Director stated that he relied on notification from Social Services to inspect resident equipment and only checked electrical outlets for compatibility, not the appliances themselves. The Director of Nursing and Administrator confirmed the presence of multiple personal appliances in the resident's room and acknowledged the lack of staff training regarding their safe use and maintenance.
Failure to Document and Monitor Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. Specifically, the facility did not complete proper documentation as per their protocol for a resident who experienced a change in condition. The resident, who was admitted to the facility in November 2024, had a physician's order for Levofloxacin due to fever and cough, along with a chest x-ray and various tests. However, the medical record review revealed a lack of documentation for the change in condition, an updated care plan, and nurse progress notes to monitor the resident's condition. Interviews with facility staff, including an LVN and the ADON, confirmed that the resident should have had a change of condition report, an updated care plan, and 72-hour monitoring as per the facility's protocol. The absence of these critical documentation and monitoring steps indicates a failure to adhere to the facility's policies and procedures, potentially impacting the resident's care and monitoring during their change in condition.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control practices as outlined in their policies and procedures, specifically regarding the use of Enhanced Barrier Precautions (EBP) during high-contact resident care activities. This deficiency was observed in the care of a resident who had an indwelling suprapubic urinary catheter, which required the use of gown and gloves during care activities to prevent the transmission of multi-drug resistant organisms (MDROs). Despite the presence of signage indicating the need for EBP, a Certified Nursing Assistant (CNA) was observed changing the resident's brief while only wearing gloves, failing to don a gown as required. The Infection Preventionist (IP) confirmed the expectation that staff should perform hand hygiene and wear both gloves and a gown during high-contact care activities for residents on EBP. The failure to adhere to these precautions was verified during an interview with the IP, who acknowledged the lapse in following the facility's infection prevention protocols. This oversight posed a risk for the transmission of diseases and infections within the facility.
Incompetence in Dietary Supervision Poses Risk to Residents
Penalty
Summary
The facility failed to ensure the Dietary Services Supervisor (DSS) was competent in supervising the kitchen operations, which posed a risk to the residents. The DSS was unable to order pasteurized eggs due to an egg shortage, resulting in the use of raw shelled eggs that were not fully cooked, as observed in the breakfast meal of a resident. The DSS also demonstrated a lack of knowledge in calibrating thermometers correctly, leading to inaccurate temperature readings of food items, which could potentially expose residents to foodborne illnesses. Additionally, the DSS was unaware of the manufacturer guidelines for health shakes, leading to expired products being stored in the refrigerator. The DSS also failed to replace worn food preparation equipment, such as a can opener blade and a Robot Coupe blade assembly, which were observed to be excessively worn and had residue that could not be cleaned off. Furthermore, the DSS did not ensure that beard coverings were available for kitchen staff with facial hair, as required by the facility's policy and USDA Food Code. The Administrator did not evaluate the DSS's competency, relying instead on the Registered Dietitian (RD) to assess the DSS. However, the RD had only been with the facility for two weeks and had not conducted a formal competency evaluation. The lack of a written competency evaluation for the DSS by the Administrator further highlights the facility's failure to ensure that the DSS was competent in managing the dietary department, thereby putting residents at risk of exposure to foodborne illnesses.
Incompetence in Kitchen Staff Leads to Unsafe Food Handling Practices
Penalty
Summary
The facility failed to ensure that two kitchen employees, Cook 1 and Dietary Aide 1 (DA 1), were competent in their daily job duties, which posed a risk for unsafe food handling practices. Cook 1 did not follow proper hand hygiene protocols, as observed when he touched a trash can lid and then proceeded to wash a dirty peeler without changing gloves or washing hands. Additionally, Cook 1 did not take food temperatures correctly during meal service, as he used an analog thermometer that touched the hot pan, and he was unable to read the temperature on the thermometer dial. Further observations revealed that Cook 1 did not prepare resident meals according to the facility recipes, as he failed to follow the recipes for puree sweet and sour chicken, puree stir fry vegetables, and puree sesame noodles. Cook 1 also inaccurately tested the sanitizing solution used to sanitize food preparation surfaces, as he did not follow the correct procedure for testing the ppm of the sanitizing solution. Moreover, Cook 1 did not utilize the manual dishwashing process correctly, as he dipped a dirty peeler in a cleaning solution and rinsed it off with a faucet before drying it with a paper towel, instead of following the manual dishwashing procedure. DA 1 was unable to read the temperature dial of the dish machine, which was located under the machine near the floor. During an observation, DA 1 was unable to stoop down to read the dish machine temperature dial, and the temperature of the wash water was found to be 100 degrees F, which was too low. The facility's dish machine temperature log showed that the automatic dishwashing machine temperature was consistently between 120-123 degrees F, which was within the required range, but DA 1's inability to read the temperature dial posed a risk for improper dishwashing procedures.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to the prescribed recipes for pureed diets, which are essential for meeting the nutritional needs of residents on such diets. During an observation, it was noted that the preparation of pureed sweet and sour chicken did not follow the specified recipe, resulting in an incorrect consistency. The staff member responsible for the preparation used an unmeasured amount of thickener to adjust the consistency, which was not in accordance with the recipe guidelines. This inconsistency in preparation could potentially affect the nutritional intake of the 15 residents who were prescribed a pureed diet. Additionally, the preparation of pureed vegetables and starches also deviated from the established recipes. The vegetables were cooked in high-sodium chicken broth instead of water or low-sodium broth, as preferred by the Registered Dietitian (RD). Similarly, the pureed noodles were prepared using chicken flavored bouillon with high sodium content, contrary to the recipe's requirement for low-sodium broth or milk. These deviations from the recipes were confirmed by the RD and Dietary Services Supervisor (DSS), who acknowledged that all recipes should be strictly followed to ensure the nutritional needs of the residents are met.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements were met in the kitchen, leading to potential foodborne illnesses for residents. Observations revealed that eggs served were not fully cooked, and there were no pasteurized eggs available, which is a requirement in licensed healthcare facilities to prevent Salmonella infections. Additionally, hand hygiene protocols were not followed during food preparation, as staff members were observed not washing hands or changing gloves after handling trash or switching tasks, increasing the risk of cross-contamination. The facility also failed to adhere to proper food storage and preparation procedures. Fish thawing processes were not followed, as there was no indication of when the fish was removed from the freezer to thaw. The dishwashing machine did not reach the required temperature, and manual dishwashing procedures were not properly executed, with staff not following the correct steps for sanitizing utensils. Refrigerated food items were not stored properly, with some items being kept beyond their safe usage dates, and the ice storage was found to be unsanitary. Furthermore, the facility did not maintain kitchen equipment in a sanitary condition, with observations of unclean utensils and equipment. Hair restraints were not worn by staff, and food items in the walk-in freezer were not properly labeled or sealed. Resident 7's personal refrigerator was not maintained at the appropriate temperature, with logs showing temperatures outside the acceptable range, and there was no documentation of corrective actions taken. These deficiencies highlight significant lapses in the facility's adherence to food safety and sanitation standards, posing a risk to resident health.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, leading to deficiencies in care. Resident 84, who was cognitively intact and required extensive assistance with activities of daily living, had an indwelling urinary catheter with a drainage bag that was not fully covered. This was observed on multiple occasions, and the facility's policy on dignity, which requires urinary bags to be covered, was not followed. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged the oversight, confirming that the uncovered drainage bag compromised the resident's dignity. In another incident, Resident 71, who had the capacity to understand and make decisions and was diagnosed with unspecified depression, was transferred from a bed to a shower bed using a Hoyer lift. During the transfer, the resident's abdomen and legs were exposed, and the door to the room was left open, allowing visibility from the hallway. Both the Speech-Language Pathologist (SLP) and a Licensed Vocational Nurse (LVN) involved in the transfer acknowledged that the door should have been closed to maintain the resident's privacy. The resident expressed disappointment over the lack of privacy, indicating a failure to uphold the resident's right to dignity and privacy as per the facility's policies.
Informed Consent Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that informed consents were properly completed for several residents, as per the facility's policies and procedures. Specifically, the informed consents for four sampled residents and one non-sampled resident were not signed and dated by the physician, which is a requirement according to the facility's policy. This oversight was identified through interviews, medical record reviews, and facility document reviews. Resident 10, who had the capacity to understand and make decisions, had informed consents for treatments that were not signed and dated by the physician. These treatments included the use of a gerichair for socialization and activities, and the use of bilateral upper half side rails for positioning and mobility. Similarly, Resident 72, who lacked the capacity to make decisions, had informed consents for various treatments, including the use of a hand mitten and side rails, that were not signed and dated by the physician. Additionally, Resident 20, who also lacked decision-making capacity, had informed consents for treatments such as the use of side rails and a gerichair that were not properly signed and dated. Resident 85, with no capacity to understand and make decisions, had similar issues with unsigned informed consents for treatments involving side rails and a gerichair. Lastly, Resident 44, who was moderately cognitively impaired, had an informed consent for the use of Abilify that was not signed or dated by the physician. These deficiencies were verified by nursing staff and acknowledged by the facility's administration.
Failure to Maintain Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one of the six sampled residents, specifically Resident 34, who was reviewed for advance directives. This oversight was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). According to the facility's P&P, revised in September 2022, the Social Service Director (SSD) or designee is responsible for inquiring about the existence of any written advance directives upon a resident's admission. If an advance directive exists, it should be obtained and maintained in the resident's medical record, ensuring it is readily retrievable by facility staff. During the review, it was found that Resident 34, who was readmitted to the facility, had an advance directive as indicated by the Physician Orders for Life-Sustaining Treatment (POLST) dated February 24, 2025, and an Advance Directive Acknowledgement dated the same day. Despite this, a copy of the advance directive was not found in Resident 34's medical record. The SSD confirmed the absence of the document in both the physical and electronic medical records (EMR) during an interview on March 12, 2024. The Director of Nursing (DON) was informed of these findings on March 14, 2025, and acknowledged the deficiency.
Failure to Document and Manage Restraint Use
Penalty
Summary
The facility failed to ensure the appropriate use of physical restraints for three residents, leading to potential risks of skin and soft tissue injury and decreased range of motion. Resident 100 was observed with an elbow splint on the left arm without a current physician's order or consent. There was no documentation of the splint's removal or any assessment and exercise of the arm every two hours as required by the facility's policy. Interviews with staff revealed that the splint was typically removed by the resident's family, but there was no formal documentation of this process. Residents 41 and 72 were both subjected to hand mitten restraints without proper documentation of their removal and assessment every two hours. Resident 41's medical records showed a physician's order for a right hand-mitten restraint, but the Medication Administration Record (MAR) lacked specific times and outcomes of the restraint's removal and the necessary assessments. Similarly, Resident 72 had a physician's order for a left hand mitten restraint, but the MAR did not document the removal times or the condition of the resident's hand, despite multiple observations of the restraint being in place. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), confirmed the lack of documentation and adherence to the facility's policy on restraint use. The DON acknowledged the absence of records showing the required two-hourly removal and assessment of the restraints. The facility's failure to document and follow proper procedures for restraint use was acknowledged by the Administrator and DON, indicating a systemic issue in maintaining compliance with restraint policies.
Care Plan Deficiency for Ventilator and Elbow Splint Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 100, which did not address the resident's use of a ventilator at night and the application of an elbow splint. This deficiency was identified through observations, interviews, and medical record reviews. On multiple occasions, Resident 100 was observed with an elbow splint on the left arm, which was not documented in the care plan. Interviews with CNA 6 and RN 3 confirmed that the elbow splint was applied regularly, yet there was no corresponding care plan to guide its use. Additionally, the care plan did not reflect the resident's current ventilator use, as per the physician's orders. The resident was supposed to be on a ventilator at night and on supplemental oxygen during the day, but this was not documented in the care plan. The Respiratory Lead confirmed that the resident's care plan failed to address the current ventilator schedule, which had been adjusted from 24-hour use to nighttime use only. This lack of documentation could lead to miscommunication among the interdisciplinary team regarding the resident's care needs.
Failure to Properly Apply Fall Prevention Device
Penalty
Summary
The facility failed to ensure that a tab alarm, a fall prevention device, was properly applied for one of the residents, identified as Resident 47. The physician had ordered the use of a tab alarm to monitor the resident every shift due to their high risk of falls, as evidenced by multiple falls on previous dates. Despite this order, observations revealed that the tab alarm was not consistently applied as required. On one occasion, the resident was observed sitting in a wheelchair without the tab alarm attached, and on another occasion, the tab alarm was not clipped onto the resident's clothing as it should have been. Interviews with facility staff, including an LVN and a CNA, confirmed the improper application of the tab alarm. The LVN acknowledged that the tab alarm was not correctly applied, as it should have been hung on the wheelchair handle and clipped onto the resident's clothing. Similarly, the CNA admitted to not clipping the tab alarm onto the resident after assisting them, despite knowing the resident's high fall risk status. These lapses in following the physician's order and the facility's policy for alarm monitors contributed to the deficiency in ensuring the resident's safety from accident hazards.
Failure to Verify GT Placement and Residuals Before Feeding
Penalty
Summary
The facility failed to adhere to its protocol for verifying the placement, patency, and gastric residuals of a gastrostomy tube (GT) before initiating enteral tube feeding for Resident 100. The facility's policy, revised in March 2023, requires verification of GT placement and flushing the tubing with at least 30 ml of water before starting the feeding. However, during an observation on March 11, 2025, LVN 5 was seen connecting the enteral feeding formula and water flush tubing to Resident 100's GT and starting the feeding pump without checking the GT for placement, patency, or residuals. LVN 5 confirmed that these checks were not performed, stating that they were done earlier in the shift during the administration of morning medications. Resident 100 had specific physician's orders to check the GT feeding residual every shift and to hold the enteral feeding for one hour if residuals exceeded 100 ml. Additionally, the orders included running 40 ml of water every hour to provide 800 ml/day and administering Peptamen AF 1.2 at 70 ml/hr for 20 hours daily via GT. The Assistant Director of Nursing (ADON) confirmed that the protocol was to check tube placement using a stethoscope and an air bolus into the GT, as well as checking gastric residuals before starting the feeding. The failure to follow these procedures had the potential for adverse outcomes related to a dislodged GT or increased gastric residuals.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. For two residents, the oxygen tubing was not labeled and dated, which is a requirement for infection prevention and control. During observations, it was noted that the nasal cannulas for these residents were unlabeled, and the staff member interviewed was unable to confirm when the tubing was last changed. The Director of Nursing (DON) acknowledged that the tubing should have been labeled and dated. Additionally, another resident was not administered oxygen according to the physician's order. The resident was observed receiving oxygen at a rate of 3 LPM, contrary to the physician's order of 2 LPM continuously. The Licensed Vocational Nurse (LVN) confirmed the discrepancy and acknowledged that the physician's order was not followed. The DON emphasized the importance of adhering to physician's orders and acknowledged the findings.
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide non-pharmacological interventions for pain management to a resident, identified as Resident 34, who was experiencing pain. According to the facility's policy and procedure (P&P) titled Pain - Clinical Protocol, dated March 2018, the physician is responsible for ordering appropriate non-pharmacologic and medication interventions to address an individual's pain. The P&P also states that staff should provide elements of a comforting environment and appropriate physical and complementary interventions, such as positioning/repositioning, local heat or ice, and opportunities to discuss chronic pain. However, during an observation on March 11, 2024, Resident 34 reported pain on the right side of her body to RN 1, who only checked for pain medication and did not offer any non-pharmacological interventions. A review of Resident 34's medical records revealed a care plan problem addressing her pain, with goals to reduce episodes of pain or discomfort through appropriate interventions daily, including non-pharmacological methods like positioning for comfort, hot packs, cold packs, massage, and distraction. Despite this, there was no documented evidence that these interventions were provided when Resident 34 reported a pain level of 7 on multiple occasions. RN 1 confirmed the lack of documentation and stated that non-pharmacological interventions should have been provided. The Director of Nursing (DON) was informed and acknowledged these findings.
Inadequate Hemodialysis Care Due to Staff Competency Issues
Penalty
Summary
The facility failed to provide adequate hemodialysis care for a resident with End-Stage Renal Disease (ESRD), specifically in assessing the hemodialysis access site. The facility's policy and procedure for the care of residents with ESRD required staff to be trained in the care and special needs of these residents, including the assessment of grafts and fistulas. However, interviews with licensed staff revealed a lack of competency in assessing the hemodialysis access site, as there were inconsistencies in their understanding of how to check for bruit and thrill, which are critical indicators of the functionality of the access site. The deficiency was identified during a review of Resident 10's medical records and interviews with staff. Resident 10, who was cognitively intact and capable of making decisions, had a physician's order to monitor the shunt or graft for bruit and thrill every shift. Despite this, interviews with three licensed nurses showed a lack of proper understanding of the assessment process. The Director of Nursing (DON) acknowledged the findings and indicated a need for further in-service training for the licensed nurses on the proper assessment of hemodialysis access sites.
Failure to Document Alternatives Before Side Rail Use
Penalty
Summary
The facility failed to ensure that seven out of eight residents reviewed for side rail use were free from the accident hazards associated with elevated side rails. The facility's policy requires that alternatives to side rails be attempted, an interdisciplinary evaluation be conducted, a resident assessment be completed, and informed consent be obtained before using side rails. However, these steps were not adequately documented or followed for the residents in question. For Resident 51, the facility did not document any attempts to use alternatives before applying bilateral half upper side rails, despite the resident being cognitively intact and capable of making decisions. Similarly, Resident 52, who had severe physical impairments and was unable to use the side rails, was still subjected to their use without documented attempts of alternative measures. The Director of Nursing acknowledged that Resident 52 was not appropriate for side rail use and planned to inform the physician to discontinue them. Other residents, including Residents 45, 47, 9, 99, and 89, also had side rails applied without documented evidence of alternative measures being attempted. In some cases, such as with Resident 45, the facility's documentation indicated that alternatives were considered, but there was no evidence that they were actually attempted. The lack of proper assessments and documentation for these residents indicates a systemic failure to adhere to the facility's policy on side rail use, potentially putting residents at risk for entrapment and serious injuries.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that the physician's orders matched the medication labels provided by the pharmacy and that medications were administered as ordered by the physician for two residents. For Resident 18, there was a discrepancy between the physician's order and the medication label for digoxin. The physician's order specified two tablets of 125 mcg digoxin, while the pharmacy label indicated one tablet of 250 mcg. This inconsistency was verified by LVN 8 during a medication administration observation, who acknowledged that the orders and instructions did not match, and there was no evidence of a change of direction label on the medication bubble pack. For Resident 48, the facility failed to administer metoprolol tartrate with food as ordered by the physician. The physician's order required the medication to be given with food, but during a medication administration observation, LVN 1 was seen administering the medication without food. LVN 1 confirmed the oversight and acknowledged that food should have been provided with the medication. Both the Administrator and DON, along with the Regional Director of Operations, were made aware of these findings.
Medication Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed in Medication Storage Room A and Medication Cart G. In Medication Storage Room A, boxes of bisacodyl stimulant laxative suppositories were stored together with artificial tears lubricant eyedrops, which was acknowledged by RN 1 as inappropriate. Similarly, Medication Cart G contained a mix of loperamide tablets, fluticasone nasal spray, and artificial tears, which LVN 6 confirmed should not be stored together. The facility also failed to maintain cleanliness and sanitation of medication carts, as evidenced by observations of sticky and dried medication residues on various carts. Medication Carts A, B, C, D, E, G, and H were found with residues and spills, which were verified by the respective nursing staff. These unsanitary conditions were noted to potentially compromise infection prevention and control measures. Additionally, there were discrepancies in the documentation of serial numbers for blood glucose monitoring systems for two residents. Resident 98's and Resident 19's Assure Platinum Blood Glucose Meter Machines had incorrect serial numbers recorded in their medical records, which were verified by LVNs 7 and 8. The Director of Nursing confirmed these findings, indicating a lapse in accurate record-keeping for medical equipment used by the residents.
Improper Storage of Pureed Vegetables Affects Nutrient Preservation
Penalty
Summary
The facility failed to ensure the nutrient content of pureed vegetables was preserved for 15 residents on a pureed diet. The deficiency was identified when it was observed that pureed vegetables were prepared more than one hour prior to meal service and held in an oven at 500 degrees Fahrenheit. This method of storage was not ideal for preserving nutrients, as confirmed by the Registered Dietitian (RD). The observation and interview with a staff member revealed that 13 portions of pureed stir fry vegetables were blended to a pudding consistency and stored in the oven until the lunch meal tray line began. The RD agreed that this practice was not suitable for maintaining the nutritional value of the pureed vegetables, posing a risk to the residents' nutritional needs.
Failure to Provide Appropriate Dietary Needs
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of two residents, placing them at risk for aspiration or choking. Resident 11, who was edentulous and awaiting oral surgery, was supposed to receive a minced and moist diet as per her physician's order. However, during an observation, it was noted that her meal included chicken pieces that were not finely minced and moist, making it difficult for her to swallow. This was confirmed by the Director of Staff Development (DSD) and the Dietary Services Supervisor (DSS), who acknowledged the meal did not meet the required dietary specifications. Resident 85, who had a physician's order for a puree texture diet with occasional mechanical soft snacks, was observed eating saltine crackers, which were not appropriate for her dietary needs. The Licensed Vocational Nurse (LVN) and the Registered Dietitian (RD) confirmed that the saltine crackers were not suitable for a mechanical soft snack diet. The Speech-Language Pathologist (SLP) mentioned that the crackers could be consumed if dipped in water, but this instruction was not included in the diet order, leading to confusion among the staff. Both residents were at risk due to the facility's failure to adhere to their specific dietary requirements. The deficiencies were acknowledged by the Director of Nursing (DON) and the facility's administration, indicating a lapse in ensuring that dietary orders were properly followed and communicated among the staff.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 10, which was documented as a deficiency. Upon admission and periodically, the facility's policy requires the Dietary Services Supervisor (DSS) to meet with residents to discuss and ensure their food preferences are honored. However, despite Resident 10's request for collard greens during a Resident Council meeting, the facility did not fulfill this request. The DSS acknowledged receiving the request but confirmed that the collard greens were not purchased, and there was no documentation of follow-up with the resident regarding the request. Resident 10's medical records indicated a risk for alteration in nutritional status, weight loss, and malnutrition, with specific dietary preferences and restrictions documented. Despite these risks, the facility did not provide the requested food item, potentially impacting the resident's nutritional intake and psychosocial wellbeing. Interviews with the resident and facility staff, including the Administrator and Director of Nursing (DON), confirmed the oversight and lack of communication regarding the resident's food preference request.
Failure to Ensure Safe Handling of Outside Food
Penalty
Summary
The facility failed to ensure proper storage and handling of food brought in by visitors for three nonsampled residents, potentially exposing them to foodborne illnesses. The facility's policy discourages outside food due to safety and infection control concerns, yet it allows residents to consume such food at their own risk. Observations revealed that Resident 70, who was on a No Added Salt diet, received a piece of cake from a family member who was unsure about safe food handling guidelines. Resident 65, with diabetes and liver disease, was observed eating BBQ ribs and macaroni salad brought by a friend, who had not received any information from the facility regarding safe food handling. Resident 57, with hemiplegia and diabetes, received pureed chicken and rice from a family member who had only been informed about the resident's diet. Interviews with facility staff highlighted a lack of proper procedures and training regarding the handling of outside food. RN 1 stated that outside food must be consumed in one sitting as there was no refrigeration available for storage, and the facility did not allow storage of such food. Additionally, the microwave used for heating outside food was found to be unclean, with excess food debris inside. The Director of Staff Development confirmed that no staff training had been provided on safe food handling guidelines, further contributing to the facility's failure to ensure the safety of food brought in from outside sources.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by several observations of open and improperly closed waste dumpsters. During an initial tour, one of four dumpsters was found with its lid open, and another was propped open by garbage, preventing it from closing fully. These observations were verified by the Maintenance Director through photographs. Additionally, organic waste was not being collected as required by state mandate SB1383, with regular trash found in an organic waste barrel. The Administrator and DSS confirmed that the facility was not collecting organic waste, and the kitchen was also not participating in organic waste collection. Furthermore, the facility did not comply with the Mandatory Commercial Recycling Regulation, as it was not collecting recyclable trash. Observations revealed trash bags and cardboard boxes stored improperly on the ground and on hand carts, with the Maintenance Director acknowledging that the dumpsters were full. These actions and inactions led to the potential for unsafe sanitary conditions and the harboring of pests and rodents, as the refuse was not stored in a manner that made it inaccessible to insects and rodents.
Inaccurate Medical Records and Entrapment Risk Assessments
Penalty
Summary
The facility failed to maintain accurate medical records for eight residents, leading to potential risks in their care. For Resident 72, the medical records inaccurately documented the resident as being on a ventilator, despite the ventilator orders being discontinued months prior. This discrepancy was confirmed through interviews with the LVN, RT, and DON, who all verified that Resident 72 was not on a ventilator, highlighting a significant lapse in accurate documentation. Additionally, the facility did not accurately assess the risk of entrapment for residents using side rails. Residents 9, 40, 45, 47, 51, 52, 89, and 99 had their side rail assessments marked inaccurately, with all seven zones being checked despite not all zones being applicable due to the absence of split bed rails. This was confirmed through interviews with various nursing staff, including RN 2 and the MDS RN, who acknowledged the inaccuracies in the assessments. The inaccurate documentation and assessments posed a risk to the residents, as their medical records did not reflect their actual care needs and conditions. The facility's failure to adhere to its policies and procedures for charting and documentation, as well as bed safety and side rail assessments, could lead to residents not receiving the necessary care and services, as their medical records were not accurate.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. In the laundry room, used mugs and a utensil were found on a clean sink, and personal belongings were stored on clean linen shelves, which is against the facility's policy. The Maintenance Director confirmed these items should not be in clean areas. Additionally, the facility did not properly maintain its decorative water feature or keep logs as required by the water management program. The Maintenance Director admitted to not testing the water fountain or maintaining logs for HVAC and water systems. The facility's infection surveillance was also found to be inaccurate. The Infection Preventionist (IP) incorrectly reported infections for four residents as meeting McGeer's criteria when they did not. This misreporting was acknowledged by the IP during a review of the facility's monthly infection surveillance report. Furthermore, an LVN failed to maintain infection control practices by using enteral tubing that had been on the floor for a resident's GT feeding, which the LVN admitted should have been discarded and replaced. Hand hygiene practices were not followed by an LVN during medication administration, as observed in Resident 6's room. The LVN confirmed the oversight and acknowledged the importance of hand hygiene in preventing contamination. Additionally, unlabeled basins were found in shared restrooms, which were not stored properly, as verified by CNAs and the DON. These deficiencies in infection control practices were confirmed by the Administrator and DON during an interview with the Regional Director of Operations present.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to the inappropriate use of antibiotics for several residents. The facility's policy required the Infection Preventionist (IP) or designee to review all antibiotic utilization and notify the physician if the use was inconsistent with appropriate guidelines. However, this process was not followed for Resident 1, who was treated with Levaquin for a urinary tract infection (UTI) that did not meet McGeer's criteria for a true infection. Despite urine culture results indicating no clinical significance, the resident completed a five-day course of antibiotics without the physician being notified to reassess the necessity of the treatment. Similarly, Residents 28, 77, 88, and 98 were treated with antibiotics for respiratory tract infections that did not meet McGeer's criteria. The facility's documentation failed to show the required constitutional criteria for these infections, yet the residents were administered antibiotics such as cefepime, Zosyn, and ciprofloxacin. The IP confirmed that these residents' conditions were incorrectly identified as meeting the criteria for true infections, and the physicians were not informed to reevaluate the need for antibiotic treatment. These failures in the facility's antibiotic stewardship program resulted in the potential for unnecessary antibiotic exposure among residents. The IP acknowledged the discrepancies in identifying true infections and the lack of communication with physicians regarding the reevaluation of antibiotic use. This oversight could lead to inappropriate treatment and increased risk of antibiotic resistance, although the report does not explicitly state these potential consequences.
Failure to Maintain Clean and Safe Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a clean and safe operating condition, as observed during a survey. The ice machine in the kitchen was not cleaned according to the manufacturer's guidelines. The Maintenance Director stated that the ice machine was cleaned once a month using a cleaner, but upon inspection, black residue was found in the ice machine chute. This indicates that the cleaning process was not thorough or effective, potentially exposing residents to unsafe practices. Additionally, the walk-in refrigerator floor was found to be in poor condition, with worn paint exposing the cement floor surface. The Maintenance Director confirmed that there was no communication log between the Dietary and Maintenance departments regarding the condition of the refrigerator floor, and he was unaware of its state. This lack of communication and awareness contributed to the failure to maintain the refrigerator floor in a cleanable and sanitary condition. Furthermore, one of the microwaves used to heat residents' food was observed to be dirty with excess food debris. An RN verified the condition of the microwave and stated uncertainty about who was responsible for cleaning it. This lack of clarity regarding cleaning responsibilities contributed to the microwave not being maintained in a clean condition, posing a risk of foodborne illnesses to residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that three out of four dumpsters for garbage and refuse were properly covered. During an observation on August 8, 2024, at 1220 hours, it was noted that three dumpsters were filled above the maximum loading level and were not properly covered, located near the facility's parking area. Additionally, two of the dumpster lids were observed to be bent and irregular. Later, at 1500 hours, an observation of trash disposal was conducted alongside an interview with an LVN. The LVN confirmed that three dumpsters were overflowing, the lids were not properly closed, and two dumpsters had bent lids. This situation posed a risk of attracting pests and rodents that could carry diseases.
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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