Parkview Julian Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1801 Julian Avenue, Bakersfield, California 93304
- CMS Provider Number
- 055601
- Inspections on file
- 65
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Parkview Julian Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, total dependence for toileting, chronic incontinence, and a high fall risk score was not managed in accordance with the facility’s Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline. During a night shift, a CNA observed a wet brief and offered incontinence care, which the resident refused; the CNA did not notify the LVN, did not seek assistance, and did not recheck or re-offer care for nearly two hours, and the resident’s brief was not checked and changed every two hours as required. Later that shift, the CNA found the resident partially off the bed attempting to go to the bathroom, with a wet and soiled brief, and the nurse and CNA assisted the resident back to bed. Subsequent imaging identified a periprosthetic distal femur fracture, and the resident later underwent surgical repair.
A RN documented respiratory distress symptoms for a resident in error, recording observations such as difficulty breathing and sternal retractions that were meant for another individual. The DON confirmed that nursing documentation must be accurate, as per facility policy.
A resident's grievances regarding food preferences and noise were not properly addressed, as the facility failed to inform the resident of the investigation outcomes or actions taken. Documentation was incomplete, with missing signatures and notifications, and staff confirmed that required follow-up and communication did not occur, contrary to facility policy.
A resident who is fully dependent on staff for toileting hygiene reported waiting up to 40 minutes for assistance after using the call light, despite a history of UTIs. A CNA confirmed that high resident assignments sometimes delay responses to call lights, contrary to facility policy requiring prompt attention.
A resident who managed his own finances experienced repeated unapproved charges on his bank card by a family member. Despite staff awareness and documentation of the financial abuse, the incident was not reported or investigated as required by policy, and no care plan was developed to protect the resident or address his refusal of protection.
A resident with Alzheimer's disease and a high fall risk experienced a fall resulting in a right hip fracture after staff failed to follow the care plan interventions, which included placing a floor mat on the right side of the bed and ensuring the use of nonskid socks. Documentation and staff interviews confirmed that these interventions were not in place at the time of the incident, despite being clearly outlined in the care plan.
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not timely submitting required reports to the CDPH and local ombudsman for two residents involved in incidents. Additionally, the facility did not notify the attending physician or develop a care plan for a resident who experienced financial abuse, contrary to policy requirements.
A resident in a LTC facility did not receive an antibiotic as prescribed by the MD for a surgical wound infection. The Treatment Nurse entered the order incorrectly, administering Keflex every eight hours instead of four times a day. The DON confirmed the inaccuracy, and the facility's policy requires complete and accurate medication orders.
A facility failed to follow its policy on resident weight management for a resident with mild protein-calorie malnutrition, who did not have his weight taken for three months. Despite multiple meal refusals and discomfort with the hoyer lift, no alternative weight measurement methods were used, and the issue was not discussed by the Interdisciplinary Team. The Dietary Manager confirmed that the Quarterly Nutrition Review was inaccurate due to outdated weight data.
A resident was not involved in the care planning process when the facility changed the method of transferring him from his bed to the shower bed. The resident was not informed of the reason for the change, and there was no documentation of a discussion with him prior to the care plan initiation. This failure violated the resident's rights as outlined in the facility's policy.
A resident missed a necessary doctor's appointment for valley fever treatment due to the facility's failure to schedule transportation. The appointment was noted in the resident's order details, but the Social Services Department did not receive a transportation request, which is required for scheduling. The facility's policy indicates that the Social Services Department assists with transportation arrangements, but this was not executed, leading to the missed appointment.
A resident with moderate cognitive impairment was not monitored for respiratory distress after a fire in her room, despite experiencing throat and lung pain, chest pain, and difficulty breathing. The facility's care plan required alert charting and monitoring of vital signs every shift for 72 hours, but this was not documented or conducted, as confirmed by a nurse consultant.
A facility failed to log and timely process medical records requests for three residents, violating its policies on resident access to PHI and third-party disclosures. The requests were delayed by 20 to 31 days, despite a policy requiring action within five days.
The facility failed to properly inventory and secure personal items of two residents upon admission, leading to the presence of dangerous materials like lighters and cigarettes in their possession. Staff confirmed that smoking materials should be stored securely, but this was not done, resulting in a deficiency.
The facility failed to ensure that several residents had signed and dated Advance Directives (ADs) in their medical records, and did not document that other residents were informed about their right to complete an AD. This oversight involved multiple residents whose ADs were either unsigned, undated, or missing entirely, potentially impacting the honoring of their healthcare wishes.
The facility did not complete smoking assessments for several residents who smoked independently, as required by their policy. This failure involved incomplete or delayed assessments for multiple residents, posing a potential safety risk.
A facility failed to administer medications as per physician orders for a resident, with missing documentation for Normal Saline Flush and Unasyn. Key staff lacked current CPR certification, and the facility did not provide required educational programs to all staff, impacting patient care and safety. Additionally, a Maintenance Technician was unaware of policies, leading to unapproved space heaters in residents' rooms.
The facility failed to ensure a safe environment for residents, leading to several deficiencies. A resident at risk for choking was left unsupervised with sugar packets, while ten residents who smoked were not monitored, contrary to facility policy. Additionally, two residents had unauthorized space heaters, and a resident at risk for wandering had an unalarmed door, posing potential safety hazards.
The facility failed to notify the Ombudsman of hospital transfers for two residents, as required by their policy. This was confirmed through record reviews and staff interviews, revealing that no notifications were made for transfers occurring in several instances.
A cook in the facility failed to follow the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth, potentially compromising the nutritive value of meals for residents on a pureed diet. The facility's policy requires adherence to approved recipes to conserve nutritive value, which was not followed in this instance.
The facility failed to maintain sanitary food storage and preparation practices. Expired baking soda, a dented can, and unlabeled and undated food items were found in the dry storage room, freezer, and refrigerator. These deficiencies were confirmed by staff, who acknowledged non-compliance with the facility's policies.
The report highlights deficiencies in facility safety and maintenance, including a water-stained ceiling with mold, unauthorized space heaters in residents' rooms, and a non-functional alarm on a sliding glass door for a resident at risk of elopement. The Maintenance Supervisor was unaware of the water damage, and the Administrator had not approved the space heaters, while the DON confirmed the resident's elopement risk.
A facility failed to complete the informed consent process for a resident receiving Amitriptyline, a psychotherapeutic medication. During a review, it was discovered that the informed consent form lacked a signature of verification, indicating the process was incomplete. This was contrary to the facility's policy, which mandates obtaining informed consent before administering medical interventions requiring it.
The facility failed to maintain a homelike environment for a resident and two other residents. A resident's clothing was damaged due to improper laundering, resulting in bleach stains. Additionally, two residents' rooms had unpainted drywall patches, broken baseboards, and peeling wallpaper, as confirmed by a maintenance technician.
The facility failed to follow its dialysis care procedures for two residents with chest catheters. One resident lacked an order for monitoring her dialysis access site, and both residents were incorrectly assessed for bruit and thrill, which are not applicable for chest catheters. The facility's policy outlines procedures for AV shunts or fistulas, which neither resident had.
The facility failed to complete required PASRR evaluations for two residents. One resident's PASRR Level I screening indicated a positive result for SMI, but the facility did not respond to communication attempts, resulting in an incomplete assessment. Another resident's positive Level I screening required a Level II evaluation, which was not conducted. The facility did not follow its policy requiring in-depth evaluations for positive Level I screens.
A resident on IV antibiotics for osteomyelitis did not receive two doses of Unasyn due to a staffing mix-up, resulting in no registered nurse coverage for a shift. The facility's policy requires sufficient nursing staff to meet resident needs, which was not met in this case.
Two residents were served meals that did not align with their documented preferences, leading to dissatisfaction and an outburst. The facility's policy required adherence to food preferences, but both residents were served Mac and Cheese despite disliking pasta, as confirmed by the CDM.
A resident with a BIMS score of 15, indicating no cognitive impairment, was not provided coffee, their preferred beverage, throughout the day, despite their care plan indicating a need to maintain hydration. Staff, including the Dietary Supervisor and CNAs, did not accommodate the resident's requests, citing a lack of process for beverage preferences outside meal times. The facility's policy stated that resident preferences should be adhered to within reason, but this was not followed.
The facility failed to ensure the Director of Staff Development (DSD) met the required qualifications, as she had only a year and a half of nursing experience instead of the required two years. This discrepancy was confirmed by the Director of Nurses (DON) and had the potential to impact the DSD's ability to provide adequate education to the nursing staff, potentially affecting residents' health and safety.
The facility failed to follow physician's orders for two residents, leading to potential health risks. One resident received an incorrect dosage of Seroquel, while another did not receive a recommended speech therapy evaluation after a choking incident. Both the LVN and DON confirmed these discrepancies.
A facility failed to monitor behaviors for a resident prescribed Quetiapine fumarate for behavior management, leading to potential unnecessary psychotropic medication use. The Director of Nursing confirmed the absence of behavior monitoring records, and an LVN stated that behaviors should be documented in the MAR. The facility's policy required daily monitoring of target behaviors, which was not followed.
The facility failed to conduct timely care planning meetings for a resident, with the most recent care conference completed in July 2023 and subsequent required conferences in October 2023 and January 2024 not conducted. This lapse was confirmed by the Social Services Director and was against the facility's policy, potentially leading to unmet care needs.
A resident did not receive Klonopin and Seroquel as prescribed, with no documentation of administration, refusal, or holding of the medications. This was confirmed by the MDS Nurse during an interview and record review.
Failure to Follow Fall, Refusal of Treatment, and Continence Policies for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline for a resident with severe cognitive impairment and a history of falls. The resident had diagnoses including generalized muscle weakness, need for assistance with personal care, history of falling, and a prior displaced intertrochanteric fracture of the right femur with surgical intervention. The MDS documented that the resident was wheelchair-bound, totally dependent for toileting hygiene, unable to stand, walk, or transfer to the toilet, and always incontinent of bowel and bladder. The resident’s fall risk evaluation score of 17 indicated a high fall risk, and the care plan identified risk for repeated falls related to deconditioning, gait/balance problems, psychoactive drug use, generalized weakness, prior mechanical fall with right femur fracture, impulsive behavior, and episodes of crawling out of bed, with an intervention to anticipate and meet the resident’s needs. On the night in question, CNA 1 reported that during the 10 p.m. to 6:30 a.m. shift, she checked the resident at approximately 3:30 a.m. and observed that the brief’s wetness indicator had changed color, indicating the brief was wet. CNA 1 stated she offered to change the resident’s brief, but the resident refused. Despite this refusal, CNA 1 did not notify the LVN or the charge nurse as required by the facility’s Refusal of Treatment policy, did not seek assistance from another CNA to help with changing the resident, and did not return to re-offer or attempt to change the brief for the next one hour and 45 minutes. CNA 1 also stated that during that entire night shift she changed the resident only once, after the fall, and did not check and change the resident’s brief every two hours as required by the facility’s Continence Management Guideline, explaining that the resident usually refused at night. At around 5:15 a.m., CNA 1 passed by the resident’s room and saw the resident holding the bed rail with one leg bent on the floor mat; the resident stated she was trying to go to the bathroom to urinate. CNA 1 checked the resident’s brief and found it wet with bowel movement. LVN 1, who was passing medications at that time, was called to the room and observed the resident with most of her hip on the bed and her legs hanging off the bed; LVN 1 and CNA 1 assisted the resident to the ground and then back to bed, and LVN 1 documented that the resident initially had no pain or visible injury. Subsequent imaging on 12/29 showed a periprosthetic distal femur fracture of indeterminate age, and by 12/31 the resident had developed right knee swelling and pain, leading to hospital evaluation where CT imaging confirmed a periprosthetic distal femoral metaphyseal fracture, followed by surgical repair with retrograde intramedullary nailing on 1/3. The facility’s Fall Management Program policy required assisting patients with toileting as appropriate, which was not carried out in accordance with the resident’s identified needs and risk factors. These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur fracture (broken bone) requiring hospitalization and surgery.
Inaccurate Nursing Documentation for Resident Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for one resident when a Registered Nurse (RN) incorrectly recorded respiratory distress symptoms, including difficulty breathing, shallow respirations, sternal retractions, and shortness of breath while lying flat, in the resident's Nurse Advance Skilled Evaluation. During a review, the RN acknowledged that the documentation was entered in error and was actually intended for another, unidentified resident. The Director of Nursing (DON) confirmed that nursing documentation should be accurate, as outlined in the facility's policy and procedure for nursing documentation, which requires records to be concise, clear, pertinent, and accurate. This inaccuracy in documentation had the potential to result in inappropriate care for the resident, as the recorded symptoms did not reflect the resident's actual condition at the time.
Failure to Inform Resident of Grievance Outcomes
Penalty
Summary
The facility failed to follow its grievance policy and procedure for one resident who reported multiple concerns, including issues with food preferences and excessive noise from a roommate's television. The resident stated that after requesting to speak with the administrator and kitchen staff regarding these concerns, no one had come to address them. Review of the Resident Grievance/Complaint Investigation Reports showed that while the complaints were documented, there was no evidence that the resident was informed of the outcome of the investigations or any actions taken to resolve the grievances. Key sections of the reports, such as signatures, dates, and notifications to the concerned party, were left blank. Interviews with facility staff, including the DON, confirmed that grievances are routed to the Social Services Director and then to the responsible department, with the administrator ultimately responsible for ensuring investigation, resolution, and communication of outcomes to the resident. However, documentation revealed that no follow-up with the resident was recorded, and the required sign-offs were missing. The facility's policy requires that residents be informed of the findings and corrective actions in a timely manner, which was not done in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to accommodate a resident's needs by not ensuring timely response to call lights. During an interview, a resident reported having to wait up to 40 minutes after using the call light to be changed following a bowel movement. The resident, who is cognitively intact and fully dependent on staff for toileting hygiene, also reported a history of urinary tract infections since admission. Review of the resident's Minimum Data Set confirmed her dependence for toileting hygiene. A Certified Nursing Assistant (CNA) stated that she is sometimes responsible for up to 17 residents during her shift and may be delayed in responding to call lights when attending to other residents. The facility's policy requires nursing staff to answer call bells promptly and courteously. However, the observed delays in responding to the resident's call light requests indicate that this policy was not consistently followed.
Failure to Report and Investigate Financial Abuse and Develop Protective Care Plan
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not reporting and investigating the misappropriation of a resident's property to the California Department of Public Health and the local ombudsman. A resident, who was cognitively intact and managed his own finances, reported that his brother had made unapproved charges on his bank card after being given permission to use a limited amount. Despite multiple incidents of unapproved charges by the brother, staff did not report or investigate the situation, as the resident did not wish to press charges and was aware of his brother's actions. Interviews with staff, including the Behavioral Health Worker, Social Services Director, and Administrator, confirmed that the resident's brother had repeatedly used the resident's bank card without full approval. The Social Services Director and Administrator acknowledged the unapproved charges but did not initiate an investigation or report the incident, citing the resident's reluctance to take action against his brother. Documentation in the resident's social services notes indicated awareness of the financial abuse and discussions with the resident about the risks and benefits, but no formal reporting or investigation occurred as required by facility policy. Additionally, the facility did not develop or implement a care plan to protect the resident from further financial abuse, nor did it address the resident's refusal to be protected from his brother. The Director of Nursing confirmed that no care plans were created or updated in response to the financial abuse incidents. The facility's care planning policy requires comprehensive, person-centered care plans to address changes in a resident's condition or behavior, but this was not followed in this case.
Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to follow the individualized care plan for a resident with Alzheimer's disease, hemiplegia, muscle weakness, and a high risk for falls. The care plan specifically required the use of a floor mat on the right side of the bed and ensuring the resident wore nonskid socks when getting out of bed. Multiple assessments and evaluations, including the Minimum Data Set and Fall Risk Evaluation, identified the resident as severely cognitively impaired and at high risk for falls, necessitating these interventions. Despite these documented interventions, records and interviews revealed that on several occasions, including the incident in question, the required floor mat was not in place and the resident was not wearing nonskid socks. On the day of the fall, the resident was found on the floor on the right side of the bed, without a floor mat and barefoot. Staff interviews confirmed a lack of awareness of the resident's fall risk status and the specific interventions outlined in the care plan. Previous post-fall evaluations also documented instances where the floor mat was missing and appropriate footwear was not used. As a result of these failures to implement the care plan, the resident sustained a fall resulting in a right hip intertrochanteric fracture, requiring hospitalization and surgical intervention. The facility's own policy emphasized the importance of developing and following a comprehensive, person-centered care plan based on assessed needs, but this was not adhered to in the resident's case.
Failure to Report and Address Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Prohibition Program policy, resulting in several deficiencies. The Director of Nursing (DON) confirmed that the facility did not submit the SOC 341 form to the California Department of Public Health (CDPH) and the local ombudsman for two residents involved in an unwitnessed altercation. This lapse in communication led to a delay in reporting the incident. Additionally, the facility did not submit a 5-day investigation report to the local ombudsman and CDPH for another resident who was a victim of financial abuse, exceeding the required timeline. Furthermore, the facility did not notify the attending physician of the financial abuse allegation concerning the same resident, leaving the physician unaware of the situation. The facility also failed to develop a care plan to address the resident's mental or psychosocial needs following the discovery of financial abuse. These actions were contrary to the facility's policy, which mandates immediate reporting of abuse allegations and reassessment of residents to update care plans as necessary.
Failure to Administer Antibiotic as Prescribed
Penalty
Summary
The facility failed to ensure that an antibiotic order was administered as prescribed by the Medical Doctor for a resident. The resident was admitted for surgical aftercare and was prescribed Keflex to treat a surgical wound infection. The Medication Administration Record indicated that the resident received Keflex every eight hours from February 13 to February 20, contrary to the Medical Doctor's order of four times a day for ten days. During an interview, the Treatment Nurse acknowledged entering the Keflex order incorrectly and not following the Medical Doctor's orders. The Director of Nursing confirmed that the Keflex order was inaccurate. The facility's policy and procedure for physician orders require that all medication orders include the name, dosage, frequency, duration, route, and condition/diagnosis for which the treatment is ordered, which was not adhered to in this case.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the assessment and management of resident weights, specifically for one resident who did not have his weight taken for three months. This oversight was identified during a review of the resident's records, which showed that the last recorded weight was from several months prior. The resident, diagnosed with mild protein-calorie malnutrition, had multiple meal refusals documented over the course of January, which could have impacted his nutritional status. Despite these refusals and the resident's condition, no alternative methods for weight measurement were employed, and the resident's weight was not discussed by the Interdisciplinary Team during this period. Interviews with the Dietary Manager and Director of Nursing revealed that the facility's Quarterly Nutrition Review was inaccurate due to outdated weight data. The resident expressed that he refused to be weighed at times because the hoyer lift caused discomfort, yet no alternative methods were offered. The facility's policy required weights to be taken upon admission and then regularly thereafter, but this was not followed. The Director of Nursing acknowledged that alternative methods, such as measuring arm circumference, were not utilized, and the resident's refusal to be weighed was not addressed by the Interdisciplinary Team.
Resident Not Involved in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was involved in the comprehensive person-centered care planning process, resulting in a violation of the resident's rights. The resident, who had been transferred via sheet from his bed to the shower bed since January 2024, was informed by facility staff that this method of transfer would no longer be used. The resident was not given a reason for this change, and there was no documentation of a discussion with the resident regarding the change in transfer method. During interviews and record reviews, it was revealed that the facility's Administrator and Director of Nursing were unable to provide documentation of any discussion with the resident about the change in transfer method prior to the initiation of the care plan on December 21, 2024. The facility's policy on resident rights, revised in November 2017, states that residents have the right to participate in decisions and care planning and to be fully informed of their treatment. The lack of documentation and failure to involve the resident in the care planning process led to the deficiency.
Failure to Schedule Transportation for Resident's Doctor Appointment
Penalty
Summary
The facility failed to ensure that transportation was scheduled for a resident's necessary doctor's appointment, resulting in the resident missing the appointment. The resident, who was being treated for valley fever, a serious lung infection, had an appointment scheduled on December 16, 2024, as indicated in the order details dated December 4, 2024. However, the social services note from the same day indicated that transportation was not arranged, leading to the appointment being rescheduled. Interviews with the Social Services Director and the Director of Nursing revealed that the transportation request was not received by the Social Services Department, which is responsible for scheduling transportation. The Director of Nursing confirmed that the nurses are responsible for entering the order into the resident's medical record and filling out a transportation request to be given to the Social Services Director. The facility's policy on referrals to outside services states that the Social Services Department may assist in making transportation arrangements as necessary, but this process was not followed, resulting in the missed appointment.
Failure to Implement Care Plan After Fire Incident
Penalty
Summary
The facility failed to implement a care plan for a resident following a fire incident in the resident's room. The resident, who had moderate cognitive impairment, experienced throat and lung pain, chest pain, and difficulty breathing after inhaling smoke from the fire. Despite these symptoms, the facility did not monitor the resident for respiratory distress as required. The resident reported that the nurses did not monitor her after the fire, which occurred on December 21, 2024. The facility's care plan for the resident, dated December 21, 2024, indicated that the resident should be placed on alert charting to assess any changes in medical condition, with vital signs, including oxygen saturation and respiration, checked every shift for 72 hours. However, a review of the resident's medical records revealed no documentation of alert charting or monitoring of vital signs from December 21 to December 23, 2024. The nurse consultant confirmed that the required monitoring was not conducted, which was a deviation from the facility's care planning policy.
Failure to Log and Timely Process Medical Records Requests
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding resident access to protected health information (PHI) for three of four sampled residents. Specifically, the medical records requests (MRR) for these residents were not logged, which is a requirement according to the facility's policy titled 'Resident Access to PHI.' This policy mandates that the facility document the date of the request, the employee addressing the request, the date of the facility's response, the action taken, and whether a review of the facility's initial response was requested. During an interview and record review, the Medical Records (MR) staff confirmed that no log was maintained for the MRRs of the three residents, potentially leading to delays in reviewing and acting upon these requests. Additionally, the facility did not comply with its policy titled 'Third Party Disclosures of Protected Health Information,' which requires timely action on communication requests. The MRRs for the three residents were not sent to the requesting office within the required timeframe, with delays ranging from 20 to 31 days. The policy specifies that requests for PHI by a resident's attorney prior to filing a lawsuit should be addressed within five days. The failure to act upon these requests in a timely manner resulted in a violation of the residents' rights to have their MRRs processed promptly.
Failure to Inventory and Secure Residents' Personal Items
Penalty
Summary
The facility failed to ensure that personal items of two residents were properly inventoried upon admission, which led to the potential for unaccounted personal items and the presence of dangerous materials. During observations and interviews, it was found that one resident had a lighter and cigarettes on his bedside table, which he stated he was allowed to keep upon admission. A Certified Nursing Assistant confirmed the presence of these items and stated that residents should not have lighters or smoking materials in their possession, as they should be stored in a locked box with a nurse or activity staff. Another resident also had smoking materials, including a lighter, which were not properly inventoried or secured as per the facility's smoking policy. The facility's staff, including a Registered Nurse and a Licensed Vocational Nurse, confirmed that the smoking policy and procedure were explained to residents upon admission, and that a personal inventory should be completed to track residents' belongings and ensure safety. However, the inventory for one resident did not document the presence of a lighter or cigarettes, and there was no documentation of a refusal to search the resident's bag. The facility's policy indicated that all smoking materials should be stored securely, but this was not adhered to, leading to the deficiency.
Failure to Ensure Proper Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that six of the twenty sampled residents had a signed and dated Advance Directive (AD) in their medical records. During interviews and record reviews, it was found that the ADs for these residents were either unsigned or undated. Specifically, the Social Service Director (SSD) confirmed that the ADs for Residents 58, 87, 193, 22, 17, and 70 were present in their medical records but lacked necessary signatures and dates. This oversight could potentially lead to situations where the residents' healthcare wishes are not honored in emergency medical situations. Additionally, the facility did not document that five of the twenty sampled residents were informed about their right to complete an Advance Directive or had evidence of declining to complete one. The SSD confirmed that there were no ADs in the medical records of Residents 344, 4, 68, 60, and 45, nor was there documentation indicating that these residents were informed of their rights regarding ADs. The facility's policy requires that upon admission, staff should obtain a copy of a resident's AD or inform them of their right to complete one, which was not adhered to in these cases.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking assessments for residents who smoke independently on the smoking patio. Specifically, the facility did not complete smoking assessments for ten out of eleven sampled residents, which is a requirement to ensure safety while smoking. The Minimum Data Set Coordinator acknowledged that a smoking assessment should have been conducted upon re-admission for Resident 42, but it was not completed until a later date. This oversight was consistent across multiple residents, as their smoking assessments were either incomplete or not conducted in a timely manner. The facility's policy, dated February 1, 2022, mandates that all smokers be assessed for smoking safety at the time of admission and at least quarterly. However, the review of smoking assessments for several residents, including Residents 17, 24, 42, 43, 62, 78, 89, 243, and 245, revealed that the assessments were either incomplete or not conducted according to the policy. This failure to perform timely and complete smoking assessments resulted in residents not being evaluated for safety while smoking, posing a potential risk of burns or other injuries.
Medication Administration and Staff Training Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to physicians' orders for a resident, identified as Resident 82. The IV Medication Administration Record (MAR) for Resident 82 showed multiple instances where there was no documentation of the administration of Normal Saline Flush and Unasyn, a medication used to treat infection. The Director of Nursing confirmed the lack of documentation for these medications on specific dates, which could potentially lead to the worsening of the resident's infection. The facility's policy requires that medications be administered by a licensed nurse per the physician's order and documented accordingly, which was not adhered to in this case. Additionally, the facility did not ensure that three key staff members, including a Registered Nurse, the Director of Staff Development, and the Director of Nursing, had current CPR certification. The personnel files reviewed showed expired or missing CPR certifications, which is against the facility's policy that mandates all clinical staff to maintain active CPR certification. This oversight could potentially hinder the staff's ability to perform life-saving procedures during emergencies. Furthermore, the facility failed to provide the required educational programs to its staff, including 57 Certified Nursing Assistants and 27 Licensed Nurses. The Director of Staff Development was unable to provide sign-in sheets or documentation for various mandatory training topics, such as infection control, patient rights, and safety measures. This lack of training documentation suggests that not all staff received the necessary education to perform their duties effectively, which could impact patient care and safety. Additionally, the Maintenance Technician was unaware of the facility's policy regarding the use of personal space heaters, resulting in two residents having unapproved heaters in their rooms.
Deficiencies in Supervision and Safety Measures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for several residents, leading to multiple deficiencies. One resident, who was at risk for choking, was left unsupervised in the dining room and was observed putting sugar packets into her mouth and chewing on them. This resident had a severely impaired cognitive ability, as indicated by her Minimum Data Set, and her care plan specifically noted a behavior of eating non-food items, with an intervention to remove unnecessary paper items from meal trays. Additionally, the facility did not adequately supervise residents who smoked. Ten residents who smoked were not monitored with smoking materials and were allowed to smoke unsupervised, contrary to the facility's policy that required all smoking activities to be scheduled and supervised by staff. Smoking materials were found in residents' possession, and some residents were observed smoking without supervision. The facility's policy stated that all smoking materials should be locked up, and residents who could not smoke independently should be accompanied by staff, but these protocols were not followed. Furthermore, two residents had space heaters in their rooms without authorized approval, posing a potential fire hazard. The facility's policy required the administrator's approval for electrical appliances, and the administrator confirmed that no space heaters were authorized. Another resident, who was at risk for wandering and elopement, had an unlocked and unalarmed sliding glass door in her room, which could have allowed her to leave the facility unnoticed. The facility's policy required functioning alarms for residents at risk of elopement, but this was not adhered to in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of the Ombudsman during resident transfers. Specifically, the facility did not send a notice of transfer to the Ombudsman for two residents, Resident 42 and Resident 50, when they were transferred to the hospital. This oversight was identified during a review of Resident 42's medical record, which showed transfers on three separate occasions without any indication of Ombudsman notification. An interview with the Minimum Data Set Coordinator confirmed that no Ombudsman notification was done for these hospital transfers. Similarly, for Resident 50, transfer forms dated September and October indicated hospital transfers, but there were no corresponding Ombudsman notifications. This was confirmed during a review of the facility's transfer/discharge binder, where the Social Services Director acknowledged the absence of Ombudsman notifications for those months. The facility's policy, dated April 2024, clearly states that a copy of the Notice of Proposed Transfer/Discharge must be provided to the Ombudsman at the same time it is given to the resident or their representative, which was not followed in these instances.
Deviation from Pureed Food Recipe
Penalty
Summary
The facility failed to adhere to its policy and procedure for food preparation, specifically in the preparation of pureed meals. During an observation and interview, a cook was found to have deviated from the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth. This deviation occurred while preparing meals for residents on a pureed diet, potentially compromising the nutritive value of the food provided to them. The facility's policy, dated 2023, mandates that food be prepared using methods that conserve nutritive value, flavor, and appearance, and that approved recipes be followed precisely. The cook acknowledged the error during a review of the recipe, which clearly indicated the use of specific fluids to maintain the nutritional integrity of the meal. This oversight in following the recipe could lead to nutritive impairment for residents requiring a pureed diet.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to maintain food storage and preparation areas in a sanitary manner, as observed during a survey. In the dry storage room, 11 boxes of baking soda were found to be expired, and a dented can of Pork and Beans was improperly stored with regular canned goods. Additionally, a plastic bag of dry pasta noodles was found unlabeled and undated. These observations were confirmed by a staff member, who acknowledged that the items should have been properly labeled, dated, and stored according to the facility's policy and procedures. Further deficiencies were noted in the kitchen's freezer and refrigerator. An unlabeled and undated bag of hash browns was found in the freezer, and in the refrigerator, pitchers of red and brown liquids, as well as glasses of milk and juices, were also unlabeled and undated. The facility's policy requires all food items in storage areas to be labeled and dated, and all prepared foods to be covered, labeled, and dated. The staff member confirmed these items were not in compliance with the facility's policy.
Facility Safety and Maintenance Deficiencies
Penalty
Summary
The report identifies several deficiencies related to the safety and maintenance of the facility. In one instance, a water stain with black mold was observed on the ceiling above a resident's bed, indicating a potential leak. The Maintenance Supervisor acknowledged the water damage but found no documentation of staff notifying him about the issue, despite the facility's standard operating procedures highlighting the health risks associated with excessive moisture and mold. Additionally, space heaters were found in the rooms of two residents without the necessary approval from the Administrator, who stated that such appliances are not allowed due to fire risks. Furthermore, a resident identified as a wanderer and at risk for elopement had an unlocked sliding glass door with a non-functional alarm, contrary to the care plan and facility policy. The Director of Nursing confirmed the resident's risk status and the requirement for a functioning alarm to ensure safety.
Incomplete Informed Consent for Psychotherapeutic Medication
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informed consent for psychotherapeutic medication for one of the sampled residents. During an interview and record review, it was found that the informed consent for a resident receiving Amitriptyline, a medication used to treat symptoms of depression, was incomplete. The Minimum Data Set Coordinator (MDSC) confirmed that the signature of verification on the informed consent form was blank, indicating that the consent process was not completed. This oversight occurred despite the facility's policy requiring verification of informed consent prior to administering any medical intervention that necessitates such consent.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as evidenced by issues with laundry services and room maintenance. Resident 17 experienced damage to personal clothing due to improper laundering, resulting in bleach stains and the need to discard several shirts. During an interview, the laundry services staff acknowledged that clothing might not have been sorted correctly, leading to bleach damage. Additionally, the rooms of Residents 62 and 75 were found to have unaddressed maintenance issues, including unpainted drywall patches, broken baseboards, and peeling wallpaper. These conditions were observed during interviews with a maintenance technician, who confirmed that the building required significant cosmetic repairs. These deficiencies contributed to an environment that was not homelike for the affected residents.
Failure to Follow Dialysis Care Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dialysis Care' for two residents, resulting in deficiencies in monitoring and assessing dialysis access sites. Resident 69, who had a dialysis catheter on her chest, did not have an order for monitoring her dialysis access site, and the type of access was not documented in her Order Summary Report. Additionally, the staff incorrectly assessed for bruit and thrill, which are not applicable for a chest catheter, as they are typically associated with an arteriovenous (AV) shunt or fistula in the arm. Similarly, Resident 67, who also had a dialysis catheter on her chest, was subjected to inappropriate assessments for bruit and thrill, as documented in her Progress Notes. The facility's policy specifically outlines the procedure for assessing an AV shunt or fistula, which neither resident had. These actions indicate a failure to provide accurate and appropriate care for the residents' dialysis access sites, as the staff did not follow the established procedures for the type of dialysis access the residents had.
Failure to Complete PASRR Evaluations for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for Pre-Admission Screening and Resident Review (PASRR), resulting in deficiencies for two residents. For Resident 68, the PASRR Level I screening indicated a positive result for Serious Mental Illness (SMI), but the facility did not respond to multiple communication attempts within 48 hours, leading to an incomplete assessment and failure to resubmit the PASRR. This inaction prevented the necessary Level II evaluation from being conducted, as required by the facility's policy. Similarly, for Resident 69, the PASRR Level I screening also indicated a positive result, necessitating a Level II Mental Health Evaluation. However, the facility did not conduct the required Level II evaluation. The facility's policy clearly states that a positive Level I screen requires an in-depth evaluation by the state-designated authority before admission to a nursing facility, which was not followed in these cases.
Inadequate Staffing Leads to Missed Medication Doses
Penalty
Summary
The facility failed to ensure adequate staffing to meet the care plan needs of a resident, specifically in administering necessary medications. Resident 82, who was on IV antibiotics for osteomyelitis related to the right foot and ankle, did not receive two scheduled doses of Unasyn on October 27, 2024. The care plan required the administration of antibiotics as per the medical doctor's orders, but the IV Medication Administration Record (IV MAR) showed no documentation of the 6 a.m. and 12 p.m. doses being administered on that day. During an interview and record review with the Director of Nursing (DON), it was revealed that the facility experienced a scheduling mix-up and was unable to secure registered nurse coverage for the day shift on October 27, 2024. This staffing issue directly led to the missed doses of medication for Resident 82. The facility's policy on staffing, which was reviewed, mandates that sufficient nursing personnel be available to meet resident needs, but this was not adhered to in this instance.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preference' by not honoring the meal preferences of two residents, Resident 24 and Resident 43. During an observation and interview, it was noted that Resident 24 was served Mac and Cheese for lunch, despite her documented dislike for pasta. The Certified Dietary Manager (CDM) confirmed that Resident 24's Meal Tray Ticket (MTT) indicated a dislike for pasta, and acknowledged that Mac and Cheese should not have been served to her. Similarly, Resident 43 was also served Mac and Cheese, which was against his documented meal preference as indicated on his MTT. This led to an angry outburst from Resident 43. The CDM confirmed that Resident 43's MTT also indicated a dislike for pasta, and acknowledged the error in serving him Mac and Cheese. The facility's policy stated that residents' food preferences should be adhered to within reason, and substitutes for disliked foods should be provided from the appropriate food group.
Failure to Accommodate Resident Beverage Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations and follow the care plan for a resident, leading to potential dehydration and poor oral moisture and skin elasticity. The resident expressed dissatisfaction with not being able to receive coffee, their preferred beverage, throughout the day. Despite the resident's requests, staff members, including the Dietary Supervisor and Certified Nursing Assistants, did not provide coffee, citing reasons such as the kitchen being closed or not having a process to accommodate beverage preferences outside of meal times. The resident's care plan indicated a potential fluid deficit and the need to maintain hydration, yet the facility did not adhere to this plan. The Director of Nursing acknowledged that beverage provision should be based on resident choice, especially for residents with a BIMS score of 15, indicating no cognitive impairment. The facility's policy on food preferences stated that resident preferences should be adhered to within reason, but this was not followed in the case of the resident's coffee preference.
DSD Lacks Required Nursing Experience
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) met the required qualifications for the position, specifically having a minimum of two years of experience as a Licensed Nurse. During an interview and record review, it was revealed that the DSD received her Licensed Vocational Nurse (LVN) license in February 2023 and had only about a year and a half of nursing experience by the time she started working as a DSD in June 2024. This lack of experience did not meet the job qualifications outlined in the DSD's job description, which required a minimum of two years of experience as a Licensed Nurse in supervision and providing care in a long-term care facility. The Director of Nurses (DON) confirmed during an interview that the job description for the DSD position indeed required two years of nursing experience. The failure to meet this requirement had the potential to impact the DSD's ability to provide adequate education to the nursing staff, which could negatively affect the residents' health and safety. The report highlights the discrepancy between the DSD's qualifications and the job requirements, emphasizing the importance of adhering to established criteria for such critical roles within the facility.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to potential adverse health concerns. For Resident 1, the physician's order dated 4/5/24 indicated a change in the dosage of Quetiapine Fumarate (Seroquel) from 50 mg to 75 mg to be administered in the afternoon for aggression. However, upon review on 5/20/24, it was found that Resident 1 was still receiving the 50 mg dosage in the evening, with three doses missing from the medication card. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that Resident 1 was not receiving the correct dosage as per the updated physician's order. For Resident 2, a Change in Condition Evaluation (COCE) dated 5/26/24 noted symptoms of choking, with a recommendation for a speech therapy evaluation (STE). However, during a review on 6/14/24, the DON was unable to provide documentation that the STE had been completed, acknowledging that it should have been done. The facility's policy on Telephone Orders for Medication, dated 11/1/17, outlines the procedure for documenting orders, but it appears this was not followed in these instances.
Failure to Monitor Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors were monitored for one of the sampled residents, leading to the potential for unnecessary psychotropic medication administration. Resident 1 was prescribed Quetiapine fumarate, an antipsychotic medication, for behavior management. However, during a review of Resident 1's care plan, it was found that there was no documentation of behavior monitoring. The Director of Nursing confirmed the absence of behavior monitoring records and acknowledged that Resident 1's behaviors should have been monitored. Additionally, a Licensed Vocational Nurse stated that behaviors should be documented in the Medication Administration Record when residents are on psychotropic medications. The facility's policy on psychotherapeutic drug management required daily monitoring of target behaviors, charting by exception, which was not adhered to in this case.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to ensure that care planning meetings for a resident were completed in a timely manner. Specifically, the care conference for a resident admitted on an unspecified date was not conducted as required. The most recent care conference for this resident was completed on 7/13/23, but subsequent conferences that should have been held in October 2023 and January 2024 were not conducted. This lapse was confirmed during an interview and record review with the Social Services Director (SSD) on 3/6/24 at 12:40 p.m. The facility's policy and procedure (P&P) titled 'Care Planning,' dated 11/1/17, mandates that the Interdisciplinary Team (IDT) develop a comprehensive care plan within 7 days after the completion of the comprehensive admission assessment. The care plan must be periodically reviewed and revised by a team of qualified personnel after each assessment, including comprehensive and quarterly review assessments. The SSD confirmed that the care conferences were not completed as per the facility's policy, which had the potential for the resident to have unmet care needs.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to administer ordered medications for one of three sampled residents. Specifically, Resident 1 did not receive Klonopin and Seroquel as prescribed. The Klonopin, ordered to manage severe manic symptoms associated with bipolar disorder, was not documented as administered on 2/22/24 at 5 p.m. Similarly, the Seroquel, prescribed for schizoaffective disorder, was not documented as administered on 2/22/24 at 9 a.m. and 9 p.m. These omissions were confirmed by the Minimum Data Set Nurse during an interview and record review on 3/6/24 at 11:52 p.m. The facility's policy and procedure for medication administration, revised on 11/1/2017, requires that medications be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. The policy also mandates that any refusal or holding of medication be documented appropriately on the Medication Administration Record (MAR). In this case, there was no documentation indicating that the medications were administered, refused, or held, which is a deviation from the established policy. The Minimum Data Set Nurse confirmed these findings during the review.
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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