Pomona Vista Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 651 N Main St, Pomona, California 91768
- CMS Provider Number
- 055282
- Inspections on file
- 39
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Pomona Vista Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia and mild cognitive impairment became scared, shaking, and tearful after another cognitively impaired resident with psychosis and schizophrenia grabbed the resident’s arm in a hallway. Staff, including social services and nursing, witnessed or were aware of the incident and checked on the affected resident, but no progress note or SBAR was completed for that resident and the physician was not notified of the change in condition. This inaction conflicted with facility policy requiring physician notification after accidents with potential need for intervention or significant physical, mental, or psychosocial changes.
A resident with hemiplegia, hemiparesis, and mild cognitive impairment, but with capacity to make decisions, was found to have two boxes of canned soda in their bedside nightstand that did not belong to them. During an observation and interview, the resident reported feeling upset and that their private space had been violated. The SSD, IP, and DON each acknowledged that the nightstand and closet are considered the resident's private space and that items not belonging to the resident should not be stored there. Review of the facility's Resident Rights policy confirmed the resident's right to retain and use personal possessions and to a safe, clean, comfortable, and homelike environment, which was not maintained in this case.
The facility failed to report an allegation of abuse to required external agencies after one resident with significant physical impairments and mild cognitive deficits stated being scared when another resident with severe cognitive impairment and behavioral disturbances grabbed their arm in a hallway. Staff, including a PTA, CNA, SSD, LVN, DON, and the Administrator, acknowledged that the unwanted grabbing constituted an allegation of physical abuse that should have been reported to the state agency, Ombudsman, and law enforcement within two hours under the facility’s abuse policy. Despite this, the incident was not reported as required, even though documentation showed the affected resident was distressed and the other resident had been exhibiting aggressive and disruptive behaviors and was sent to an acute hospital for further evaluation.
A resident with hemiplegia, hemiparesis, and mild cognitive impairment was grabbed on the arm in a hallway by another cognitively impaired resident who was exhibiting aggressive behaviors. The affected resident became visibly distressed and later reported feeling scared, and the SSD requested a psychology consult due to the resident having a hard time with health challenges. Despite these documented events and the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes, staff, including the SSD, an LVN, and the DON, confirmed there was no care plan developed to address the resident’s physical and psychosocial response to the incident or the need for psychological support, even though a behavior care plan was created for the aggressive resident.
Two residents with severe cognitive impairment did not have comprehensive care plans addressing their specific needs—one for non-compliance with turning and repositioning, and another for PTSD. Staff observed and reported these issues, but no individualized, measurable interventions were documented or implemented, contrary to facility policy.
A resident with dementia and high risk for pressure ulcers developed a deep tissue injury after staff failed to consistently follow a turning and repositioning schedule, did not use positioning devices, and did not develop or communicate a care plan addressing the resident's frequent refusal to be repositioned. Inadequate reporting of skin changes and lack of coordinated care contributed to the deficiency.
Two residents with enteral feeding tubes did not receive care in accordance with manufacturer and facility protocols, as water flush bags were not changed within the recommended 24-hour period. Additionally, a resident who was NPO received medication via G-tube without proper clarification of the physician's order, which specified oral administration. The DON confirmed that these practices did not align with established policies.
Two residents did not receive proper respiratory care: one did not have continuous oxygen therapy as required by their care plan, and another used a nebulizer mask and tubing that were not changed weekly per facility policy. These lapses were confirmed by staff interviews and direct observation.
Two residents' medical records were found incomplete when their informed consents for psychotropic medications lacked signed dates. Both an LVN and the DON confirmed the missing dates during record review, noting the importance of dating consents to track physician approval. Facility policy required complete and accurate documentation, which was not met in these cases.
Surveyors found that staff failed to follow infection prevention and control practices, including improper storage of unlabeled personal care items in shared restrooms, use of expired medical supplies, storage of staff personal belongings with medical supplies, failure to change enteral feeding water flush bags within 24 hours for two residents, and delayed disposal of an absorbent brief left on the floor by multiple staff members. These actions were inconsistent with facility policy and staff expectations for maintaining a safe and sanitary environment.
A CNA provided an upper body bed bath to a resident with hemiplegia and hemiparesis without drawing the privacy curtain, leaving the resident exposed and visible from the hallway. The resident, who was cognitively intact and required assistance with ADLs, reported feeling uncomfortable when privacy was not maintained, contrary to facility policy requiring staff to protect resident dignity.
A resident with severe cognitive impairment and dependence on staff for toileting hygiene was observed with long fingernails and a black substance under the fingernails. The DON acknowledged the need for cleaning to prevent infection. This failure to provide necessary hygiene services was inconsistent with the facility's ADL policy.
A resident with dementia and dysphagia consistently had meal intake below the facility's goal, yet the issue was not addressed during care conferences or through updated interventions. Despite being dependent on staff for all ADLs and having impaired cognition, the resident's inadequate intake was only monitored, without further action taken to meet nutritional needs.
A resident with a history of PTSD and severe cognitive impairment did not receive trauma-informed care, as staff were unaware of the diagnosis and had not received training on PTSD. The facility lacked a care plan addressing the resident's PTSD, and the resident's specific trauma-related needs were not met, despite policy requirements for behavioral health services and staff education.
Nurse staffing data was not posted in a location accessible to residents and visitors, as required by facility policy. Staffing schedules were kept in binders on lower counters within nursing stations, not visible from the hallway, and only the DHPPD was posted by the door entrance. Staff confirmed that the actual staffing information was not made readily available to the public.
A nurse administered Quetiapine, ordered to be given by mouth, via G-tube to a resident who was NPO and dependent on enteral feeding, without clarifying the route with the physician. The resident had severe cognitive impairment and multiple medical conditions. Both the nurse and DON confirmed that the order should have been clarified before administration, as not all oral medications are safe for G-tube delivery.
A locked medicine refrigerator containing insulin pens and vaccines was repeatedly found to be outside the required temperature range, with documented temperature readings above policy limits over several months and no corrective actions taken, resulting in a deficiency related to medication storage practices.
Fifteen resident rooms were found to be below the required 80 square feet per resident in multiple-occupancy rooms, as confirmed by facility records and direct measurement. Despite this, interviews with staff and residents indicated that they felt there was sufficient space for care and movement.
The facility failed to thoroughly investigate an alleged abuse incident between two residents, as they did not interview a third resident who claimed to be a witness. Despite the facility's policy requiring interviews with all involved parties, the Administrator chose not to interview the witness, relying instead on a nurse's account. This led to an incomplete investigation, potentially omitting crucial evidence.
A resident with dementia and severe cognitive impairment exhibited wandering behavior, entering other residents' rooms and showing aggression when redirected. Despite staff awareness, the facility failed to timely develop or update a care plan to address this behavior, as required by their policy on accidents and supervision.
A facility failed to document the implementation of one-to-one supervision for a resident with severe cognitive impairment and wandering behavior. Despite claims of supervision by the DON, there was no documentation in the resident's clinical record or staffing sheets to confirm this. The Care Plan indicated supervision would start later than claimed, and Progress Notes did not reflect the supervision, violating the facility's policy on documenting interventions.
A resident with dementia and a history of aggressive behavior hit another resident on the chest in a LTC facility. Despite requiring 1:1 monitoring, the aggressive resident was able to strike the other resident, who was sitting in a wheelchair. The facility's policy to protect residents from physical harm was not effectively implemented, leading to this incident.
A resident with severe cognitive impairment reported being punched by another resident, but the facility failed to report the allegation to the appropriate authorities within the required timeframe. The Administrator did not report the incident, believing it was not possible, despite the facility's policy requiring immediate reporting of such allegations.
The facility failed to implement its infection prevention and control program as two CNAs did not perform hand hygiene according to training. CNA 1 did not wash hands after removing soiled gloves and touched the clean linen cart. CNA 2 delivered food trays to multiple residents without using ABHR or washing hands between rooms. Interviews with staff confirmed the protocol for hand hygiene, and the IPN emphasized its importance in preventing infection spread.
A resident with dementia and psychosis was inadequately supervised, leading to frequent wandering into other residents' rooms. Despite staff awareness and attempts to redirect the resident, there was no specific monitoring schedule or 1:1 supervision provided, contrary to the facility's policy on adequate supervision to prevent accidents.
A resident with dementia and behavioral issues was not given the required 1:1 supervision, leading to physical abuse of two other residents. Despite previous incidents, the facility failed to implement necessary supervision measures, resulting in repeated aggressive behavior. Staff interviews and record reviews confirmed the lack of documented supervision, violating the facility's policies on abuse prevention and adequate supervision.
A newly admitted resident with dementia physically abused two other residents due to inadequate management of their behaviors. The resident exhibited wandering and intrusive behaviors, which were not effectively addressed by the facility. Both affected residents had impaired cognition and reported incidents of being hit or tapped, leading to suspected abuse assessments. The facility's policy required an interdisciplinary team approach for dementia care, but incidents occurred before such care was implemented.
A facility failed to readmit a resident from a hospital, violating its policy. The resident, with conditions including stroke and dementia, was sent to a hospital for evaluation after an altercation. Despite the policy to hold beds for hospitalized residents, the facility declined readmission, citing safety concerns.
A resident with a history of stroke, epilepsy, and dementia was found with a head injury, but the facility failed to perform required neurological checks. Despite the facility's policy mandating such assessments, no checks were conducted, as confirmed by staff interviews, potentially risking undetected neurological issues.
The facility failed to revise and implement individualized care plans for two residents, leading to potential declines in their physical and psychosocial well-being. One resident experienced a further decline in the range of motion in both lower extremities, while another resident did not have access to necessary hearing aids. The facility's policies required care plans to be updated based on comprehensive assessments and changes in residents' conditions, but this was not done.
The facility failed to provide appropriate care for two residents by not ensuring dentures were offered before meals and not following up on dental treatment authorization for one resident, and not changing an IV Heplock catheter in accordance with policy for another resident. These deficiencies led to potential health risks, including difficulty chewing and infection.
A resident with multiple diagnoses, including severe protein-calorie malnutrition, experienced significant weight loss due to the facility's failure to accurately and consistently monitor and assess their nutritional status. Despite being on a tube feeding regimen, the resident's weight dropped from 118 lbs to 96 lbs over several months. The facility did not promptly address the weight loss, and dietary supplements and a fortified diet were delayed. Interviews with staff revealed that the facility was aware of the weight loss but failed to complete necessary documentation or adequately monitor the resident's condition.
The facility failed to maintain a medication error rate below 5%, resulting in an 11.11% error rate. Errors included an LVN crushing non-crushable medications for a resident and another LVN administering expired diltiazem to a different resident. These actions were against professional standards and facility policies, potentially reducing medication efficacy.
The facility failed to ensure that two residents were free from significant medication errors. An LVN crushed Metformin ER tablets for a resident with severe cognitive impairment, contrary to professional standards and facility policy. Another LVN administered expired Diltiazem to a resident with multiple diagnoses, failing to check the expiration date as required. These actions had the potential to cause a decline in the residents' physiological well-being.
The facility failed to ensure expired medications were not stored in the medication storage room and that licensed staff did not prepare expired medication for a resident during medication administration. An RN found expired Magnesium tablets in the storage room, and an LVN administered expired Diltiazem to a resident with heart conditions without checking the expiration date.
The facility failed to maintain proper sanitizing fluid concentration in one of the kitchen's red buckets and did not correctly label opened cartons of Almond milk and 2% low-fat milk in a refrigerator. The Dietary Services Director acknowledged the issues, which could lead to inadequate surface sanitization and the use of expired food and drinks.
The facility failed to ensure that residents and/or their responsible parties understood the Binding Arbitration Agreement (BAA) signed upon admission. Three residents or their RPs signed the BAA without proper explanation of the arbitration process, including the selection of a neutral arbitrator and a convenient venue. Staff interviews revealed inconsistencies and incorrect information provided during the explanation of the BAA.
The facility failed to follow infection prevention and control practices for five residents, including not implementing Enhanced Barrier Precautions for those with indwelling medical devices, improper hand hygiene and PPE use by staff, and improper storage of personal items in shared restrooms, potentially increasing the spread of infections.
The facility failed to assess a resident for the ability to self-administer medication, as required by policy. The resident, with multiple diagnoses and fluctuating decision-making capacity, had a nasal spray at the bedside without documented assessment or physician's order. The DON confirmed the policy requirements were not followed, potentially affecting the resident's well-being.
The facility failed to follow up with DHCS regarding the PASRR process for a resident with a Positive Level I Screening, indicating the need for a Level II Evaluation. Despite the initial screening, there was no evidence that the required evaluation was conducted, leading to potential delays in specialized services. The resident had severe cognitive impairment and multiple diagnoses, requiring significant staff assistance.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and significant weight loss. Despite physician's orders for nutritional supplements and medication, no care plan was in place to address the resident's weight loss, leading to inadequate individualized care.
A facility failed to provide a preferred activity for a resident with dementia, major depressive disorder, and hypertension. Despite the resident's MDS indicating a preference for music, the resident was observed without access to a radio, which was identified as therapeutic. Interviews revealed that while the resident participated in some activities, the specific preference for music was not consistently met.
A resident with hearing loss and multiple diagnoses, including Alzheimer's disease, did not receive their hearing aids daily, impacting their ability to hear and engage with their environment. Despite having a care plan and facility policy in place, staff failed to consistently provide the hearing aids, as confirmed by observations and interviews.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to potential risks for catheter-associated urinary tract infections. The treatment nurse did not follow proper infection control practices, and the facility staff did not consistently adhere to the facility's policy and CDC guidelines for catheter care.
The facility failed to ensure that 15 of 22 resident rooms met the minimum 80 square feet per resident requirement in multiple resident bedrooms. Despite submitting a waiver request and staff and residents indicating there was enough space for care, measurements confirmed the rooms were undersized according to regulatory standards.
Failure to Notify Physician After Resident-to-Resident Grabbing Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a change in the resident’s condition after an incident with another resident. One resident with hemiplegia and hemiparesis following a cerebral infarction, who was mildly cognitively impaired and dependent on staff for transfers and walking, reported being scared when another resident grabbed the resident’s left arm in the hallway. The resident’s admission and assessment records showed the resident had capacity to understand and make decisions, and required substantial to maximal assistance with multiple activities of daily living. The other resident involved had diagnoses including metabolic encephalopathy, psychosis, and schizophrenia, and was documented as not having capacity to understand and make decisions, with severe cognitive impairment and substantial to maximal assistance needs. On the date of the incident, this resident was documented in progress notes and an SBAR as being agitated, yelling out, throwing objects, hitting their head against the wall, and grabbing other residents, and was subsequently sent to an acute hospital for further evaluation. Staff interviews confirmed that this resident grabbed the first resident’s arm in the hallway, which scared the first resident, and that the Social Services Director witnessed the incident while nursing staff checked on the affected resident. Record review and staff interviews with the Social Services Director, an LVN, and the DON confirmed that there were no progress notes or SBAR completed for the affected resident related to the incident, and that the resident’s physician was not notified that the resident had been grabbed, was scared, and was observed shaking and tearing afterward. The Social Services Director and LVN both stated that the physician should be notified whenever a resident has a change of condition, and the DON acknowledged that the physician was not made aware of the incident or the resident’s reaction. The facility’s written policy on Notification of Changes required informing and consulting with the resident’s physician when there is an accident with potential to require physician intervention or a significant change in the resident’s physical, mental, or psychosocial condition, which did not occur in this case.
Resident Privacy and Personal Space Violated by Storage of Non-Resident Items
Penalty
Summary
The facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment by placing and leaving items that did not belong to the resident in the resident's private storage space. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and other abnormalities of gait and mobility, had been assessed as having the capacity to understand and make decisions, with only mild cognitive impairment. During an observation and interview in the resident's room, surveyors found two boxes of canned soda stored inside the resident's bedside nightstand. The resident stated that the canned soda was not theirs and reported feeling upset that someone had violated their private space. Further observations and interviews with facility staff confirmed that the nightstand was considered the resident's private space and that items not belonging to the resident should not be stored there. The Social Services Director acknowledged that the nightstand was the resident's private space and that anything not belonging to the resident should be removed. The Infection Preventionist and the Director of Nursing both stated that the facility should not leave items that do not belong to residents in their rooms, including inside nightstands and closets, and that residents have the right to use these areas for their own personal belongings. Review of the facility's Resident Rights policy indicated that residents have the right to be treated with respect and dignity, to retain and use personal possessions as space permits, and to a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Failure to Report Resident-to-Resident Physical Abuse Allegation to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the California Department of Public Health, the Ombudsman, and local law enforcement in accordance with its Abuse, Neglect, and Exploitation policy dated 12/19/2022. The policy required that all alleged violations involving abuse be reported immediately, but not later than two hours after the allegation is made, to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable. Despite this requirement, the facility did not report an incident in which one resident grabbed another resident’s arm in the hallway, which staff and leadership acknowledged should have been treated and reported as an allegation of physical abuse. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction, along with gait and mobility abnormalities, and required substantial to maximal assistance with most ADLs and was dependent on staff for transfers and walking. Resident 1’s H&P indicated capacity to understand and make decisions, and the MDS showed mild cognitive impairment. Progress notes dated the day after the incident documented that the Social Services Director (SSD) requested a psychology consultation because Resident 1 was having a hard time due to health challenges. During interview, Resident 1 stated being scared when another resident grabbed their left arm in the hallway. Resident 4, who grabbed Resident 1’s arm, had diagnoses including metabolic encephalopathy, psychosis, and schizophrenia, with the H&P indicating a lack of capacity to understand and make decisions and the MDS showing severe cognitive impairment and need for substantial/maximal assistance with multiple ADLs. On the day of the incident, documentation and interviews indicated Resident 4 was agitated, yelling, throwing objects, grabbing others, and hitting their head against the wall, and was sent to an acute hospital for further evaluation. Multiple staff, including a PTA, CNA, SSD, LVN, DON, and the Administrator, confirmed that Resident 4 grabbed Resident 1’s arm, that this scared Resident 1, and that such unwanted grabbing should be reported as an allegation of physical abuse within two hours; the DON and Administrator acknowledged the facility did not report this incident to the required external agencies as mandated by policy.
Failure to Develop Person-Centered Care Plan After Resident-to-Resident Incident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan with measurable objectives and timeframes to address a resident’s physical and psychosocial needs following an incident with another resident and a subsequent request for psychological support. One resident, admitted with hemiplegia and hemiparesis following a cerebral infarction and documented abnormalities of gait and mobility, had a history and physical indicating capacity to understand and make decisions and an MDS showing mild cognitive impairment and dependence on staff for multiple ADLs, including transfers and walking. On one occasion, this resident was grabbed on the left arm in the hallway by another resident, after which the resident was observed to be shaking and tearing and later reported feeling scared. Record review showed that the Social Services Director requested a psychology consultation for this resident the day after the incident because the resident was having a hard time due to health challenges. However, there was no corresponding care plan developed to address the resident’s psychosocial response to being grabbed or the identified need for psychological consultation. Interviews with the Social Services Director and an LVN confirmed that they were unable to locate any care plan interventions related to the resident’s shaking, tearing, fear after the hallway incident, or the requested psychology consultation. The Director of Nursing also confirmed that no care plan had been created to monitor the resident’s psychosocial well-being in relation to these events. In contrast, the other resident involved in the incident had a documented care plan initiated on the same date as the behavioral episode. This second resident, admitted with metabolic encephalopathy, psychosis, and schizophrenia, had an H&P indicating lack of capacity to make decisions and an MDS showing severe cognitive impairment and need for substantial/maximal assistance with multiple ADLs. Progress notes and an SBAR form documented that this resident was agitated, yelling out, throwing objects, hitting their head against the wall, and grabbing others, including the first resident. A care plan was developed for this resident’s behavioral/psychotic episode, but no corresponding care plan was created for the first resident’s psychosocial needs after being grabbed, despite facility policy requiring a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident’s medical, mental, and psychosocial needs.
Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in unmet individualized needs. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and psychosis, staff observed and reported consistent refusal and fear when being turned and repositioned. Despite these observations and reports to nursing staff, there was no care plan developed to address the resident's non-compliance with turning and repositioning, nor were interventions created to manage the resident's fear and refusal. For another resident with severe cognitive impairment and a diagnosis of PTSD, the facility did not create a care plan to address the PTSD diagnosis. The Director of Staff Development was unaware of the PTSD diagnosis, and there was no individualized, person-centered care plan in place to guide staff in managing the resident's mental health needs, triggers, or appropriate communication techniques. The absence of a care plan meant that staff were not aligned in their approach to care for this resident, and strategies for managing PTSD-related behaviors were not documented or implemented. The facility's policies and procedures require the development of comprehensive, person-centered care plans that address all identified medical, nursing, mental, and psychosocial needs, including trauma-informed care for residents with a history of trauma. In both cases, the facility did not follow its own policies, resulting in a lack of documented, measurable objectives and interventions for the residents' specific needs.
Failure to Prevent and Manage Pressure Injury Due to Inadequate Care Planning and Communication
Penalty
Summary
The facility failed to provide adequate nursing care and services to prevent the development of a pressure injury for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including dementia, hyperlipidemia, and psychosis, was assessed as being at risk for pressure ulcers and required maximal assistance with mobility and personal care. Despite this, staff did not consistently follow a turning and repositioning schedule, and there was no individualized care plan addressing the resident's frequent refusal to be turned or repositioned. Observations revealed that staff encountered resistance from the resident during turning and repositioning, with the resident often holding onto siderails and appearing scared. Staff interviews confirmed that the resident regularly refused repositioning, and that this behavior was not effectively communicated or addressed through care planning. There was no documentation of a care plan to manage the resident's non-compliance, and staff did not consistently use positioning devices such as pillows to offload pressure from bony prominences. Additionally, staff did not always verbally report changes in the resident's skin condition, leading to delays in assessment and intervention. The lack of a coordinated approach and clear communication among staff contributed to the development of a deep tissue injury (DTI) on the resident's right malleolus. Facility policies required individualized interventions and care plan modifications in response to resident risk factors and non-compliance, but these were not implemented. The failure to develop and communicate a care plan for the resident's resistance to turning, inconsistent use of repositioning aids, and inadequate reporting of skin changes directly led to the deficiency.
Failure to Follow Enteral Feeding Tube Protocols and Medication Order Clarification
Penalty
Summary
The facility failed to provide appropriate care for two residents with enteral feeding tubes by not adhering to manufacturer and facility protocols regarding the timely replacement of water flush bags. For both residents, observations revealed that the water flush bags used for tube feeding were not changed within the recommended 24-hour period. Specifically, one resident's water flush bag was dated four days prior to the observation, and the other resident's bag was dated five days prior. The Director of Nursing confirmed that the water flush bags should be changed every 24 hours, as per facility policy and manufacturer guidelines. Additionally, there was a failure to clarify a physician's order regarding medication administration for one resident who was documented as NPO (nothing by mouth) but was receiving medications via a gastrostomy tube. The physician's order specified that the medication was to be given orally, yet the medication was administered through the G-tube without clarification from the physician. The DON acknowledged that the route of administration should have been verified and clarified with the physician to ensure safe medication administration. Both residents involved had significant medical histories, including conditions such as encephalopathy, protein-calorie malnutrition, dysphagia, dementia, hemiplegia, and respiratory failure. At the time of the deficiencies, one resident was dependent on staff for all activities of daily living and lacked decision-making capacity, while the other had severely impaired cognition. The facility's own policies and the manufacturer's instructions were not followed in these instances, leading to the identified deficiencies.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. For one resident with a history of acute respiratory failure and COPD, the care plan required continuous oxygen administration at 4 liters per minute via nasal cannula. However, during multiple observations, the resident's oxygen was found to be off and the nasal cannula was not properly positioned, contrary to the care plan instructions. The resident was dependent on staff for personal hygiene and mobility, and had moderate cognitive deficits, making self-management of oxygen therapy unlikely. For another resident with hemiplegia, hemiparesis following a stroke, and respiratory failure with hypoxia, the nebulizer mask and tubing were not changed in accordance with the facility's policy, which required weekly changes. The equipment was observed to be dated from several weeks prior, and staff confirmed that the mask and tubing were overdue for replacement. The facility's policy specified that nebulizer tubing and delivery devices should be changed weekly or as needed, and failure to do so could affect the delivery of medication.
Incomplete Medical Records Due to Undated Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the completeness of medical records for two residents. For one resident admitted with diagnoses including lack of coordination, major depressive disorder, and heart failure, and another resident admitted with hemiplegia/hemiparesis and unspecified dementia, their informed consents for psychotropic medications were found to be missing signed dates. Review of their Minimum Data Set assessments indicated one resident had intact cognition and the other had mild cognitive impairment at the time of the deficiency. During interviews and concurrent record reviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that the informed consents were incomplete due to missing dates. The Director of Nursing stated that dating the consents was important to identify when the physician approved the administration of psychotropic medications. The facility's policy required documentation to be accurate, relevant, and complete, but the undated informed consents did not meet this standard.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for all sampled residents, as evidenced by multiple observed deficiencies. Personal toiletries and resident care items were found unlabeled and improperly stored inside shared restrooms accessible by multiple residents, rather than being labeled and kept at the bedside or in closets as required for infection control. Staff interviews confirmed that these items should have been individually labeled and stored away from communal areas to prevent cross-contamination. Additionally, medical supplies in the medication storage room were found to be expired, and staff personal belongings were improperly stored alongside medical supplies, both of which were acknowledged by staff as violations of infection control protocols. Further deficiencies were observed in the management of enteral feeding supplies. For two residents receiving tube feedings, the water flush bags were not changed within the required 24-hour timeframe, as confirmed by both the infection preventionist and the DON. Observations showed that the bags remained in use beyond the recommended period, increasing the risk of contamination. Facility policy and staff interviews indicated that timely replacement of these bags is essential to prevent bacterial growth and maintain a sanitary environment for residents receiving enteral nutrition. Environmental cleanliness was also compromised when an absorbent brief was observed on the floor near a resident's bed and was not promptly disposed of by multiple staff members who entered the room. Despite several staff noticing the brief, it remained on the floor until a CNA eventually discarded it. Staff interviews confirmed that such items should be immediately removed to maintain a sanitary environment, and the presence of the brief on the floor was recognized as an infection control issue. The facility's infection prevention and control policy requires all staff to maintain cleanliness and address environmental hazards, which was not followed in this instance.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) provided an upper body bed bath to a resident in a three-bed room without drawing the privacy curtain. The resident's upper body was left exposed while the door to the room remained open, making the resident visible from the hallway, which had frequent foot traffic from staff, visitors, and other residents. The CNA later acknowledged forgetting to pull the privacy curtain during the provision of personal care. The resident involved had diagnoses including hemiplegia, hemiparesis affecting the right dominant side, gout, and a history of repeated falls. The resident's cognitive function was intact, and he required supervision or touching assistance with activities of daily living and mobility. The resident reported feeling exposed and uncomfortable when staff forgot to pull the privacy curtain, expressing a preference for privacy during personal care. Facility policy required staff to maintain resident privacy and dignity during care.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
A deficiency was identified when a resident, admitted with dementia and Alzheimer's disease and assessed as severely cognitively impaired, was observed to have long fingernails with a black substance under the left fingernails. The resident's Minimum Data Set indicated dependence on staff for toileting hygiene and required setup assistance with eating, but no impairment in upper extremity range of motion. During an observation with the DON, it was noted that the resident's fingernails needed cleaning, as the black substance could be a source of infection. Review of the facility's policy on Activities of Daily Living (ADLs) stated that residents unable to carry out ADLs should receive necessary services to maintain good grooming and personal hygiene. The facility failed to provide adequate hygiene for this resident, as evidenced by the unclean fingernails, which was inconsistent with the facility's own policy and procedures for maintaining residents' ADLs.
Failure to Address Inadequate Meal Intake for Resident with Dementia and Dysphagia
Penalty
Summary
Resident 43, who was admitted with diagnoses including dementia and dysphagia, was found to have meal intake consistently below the established goal of 75-100% during a review of meal intake records for April 2025. The resident was assessed as having moderately impaired cognition and was dependent on staff for all activities of daily living. Despite these needs, the interdisciplinary care conference notes did not address the resident's inadequate meal intake, and the dietary assessment plan only indicated monitoring of intake without further intervention. Observations and interviews confirmed that the resident's meal intake remained below the desired goal for most meals, with only two exceptions during the reviewed period. The DON acknowledged that the majority of meal intakes did not meet the goal and that the issue was not addressed during the IDT meeting. The facility's policy required identification, implementation, monitoring, and modification of interventions to maintain nutritional status, but these steps were not documented or carried out for this resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had a history of severe trauma related to military service, was admitted with multiple diagnoses including PTSD, hypertension, and peripheral vascular disease. The resident's assessment indicated severe cognitive impairment and a need for substantial assistance with activities of daily living and mobility. Despite these needs, there was no evidence that the facility addressed the resident's PTSD in their care planning or daily care. Interviews with facility staff, including a CNA, LVN, Director of Staff Development, and the Director of Nursing, revealed a lack of awareness and training regarding PTSD. Staff members were either unaware of the resident's PTSD diagnosis or lacked knowledge about PTSD symptoms, triggers, and appropriate interventions. The Director of Staff Development and the Director of Nursing both confirmed that staff had not received in-service training specific to PTSD, and there was no care plan developed with PTSD interventions for the resident. A family member expressed concern that the facility had not addressed the resident's PTSD symptoms and was unsure if staff were even aware of the diagnosis. Review of the facility's policy indicated that behavioral health services, including trauma-informed care and staff education on PTSD, were required. However, these policies were not implemented for the resident in question, resulting in inadequate attention to the resident's trauma-related needs.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted in a prominent and readily accessible location at both the North and South nursing stations. Observations revealed that the staffing schedules were kept in binders on lower counters within the nursing stations, which were not visible from the hallway and therefore not accessible to residents or visitors. Interviews with staff confirmed that the posted information, such as the Census and Direct Care Service Hours Per Patient Day (DHPPD), was only available on the wall by the door entrance, and the actual staffing schedules were not posted in a location accessible to the public. A review of the facility's policy indicated that nurse staffing information should be posted daily in a readable format and be readily available to residents and visitors at any time. The policy also required that the posted information be updated to reflect actual staffing, including absences due to call-outs or illness. Despite this, the facility's practice did not align with its policy, as the required information was not posted in a manner accessible to residents and visitors.
Failure to Clarify Medication Route for NPO Resident
Penalty
Summary
A deficiency occurred when a nurse administered Quetiapine, ordered to be given by mouth, via a gastrostomy tube (G-tube) to a resident who was documented as NPO (nothing by mouth) and receiving all medications through a G-tube. The nurse did not clarify the route of administration with the physician before giving the medication through the G-tube, despite the order specifying oral administration. The facility's policy required verification of physician orders for medication and enteral tube flush amounts, but this step was not followed for the Quetiapine order. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living and mobility, and had multiple diagnoses including encephalopathy, diabetes mellitus, and dysphagia. The medication administration was observed by surveyors, and both the nurse and the Director of Nursing acknowledged during interviews that not all oral medications are safe to administer via G-tube without physician clarification, as this could affect medication safety and effectiveness. The failure to clarify the medication route resulted in a significant medication error.
Failure to Maintain Proper Medication Refrigerator Temperature Controls
Penalty
Summary
The facility failed to maintain proper temperature controls for a locked medicine refrigerator used to store medications and biologicals, including insulin pens and vaccines. During an observation with the Registered Nurse Supervisor, the refrigerator was found to be at 43.5°F, and a review of the Refrigerator Temperature Log revealed multiple instances over several months where the temperature exceeded the facility's policy range of 36-46°F. Despite these out-of-range readings, no actions were documented as being taken to address the temperature deviations. The facility's policy and procedure required all medications to be stored according to manufacturer recommendations and within specified temperature ranges to ensure their integrity. The Registered Nurse Supervisor acknowledged the importance of maintaining the correct temperature for medication effectiveness and safety. The repeated failure to maintain the refrigerator within the required temperature range, as documented in the logs, directly led to the deficiency.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that 15 out of 22 resident rooms met the minimum requirement of 80 square feet per resident in multiple-resident bedrooms. According to the facility's own analysis and a waiver request letter, the affected rooms measured 147 square feet and were configured as either two- or three-bed rooms, resulting in less than the required space per resident. Observations confirmed the room sizes, and the facility's policy also acknowledged the minimum space requirements, stating that variances should only be maintained if they do not adversely affect residents' health and safety. Interviews with staff and residents indicated that, despite the rooms not meeting the regulatory size requirements, both staff and residents felt there was enough space to provide care and move around comfortably. The deficiency was identified through a combination of record review, direct measurement, and interviews, which established that the facility was not in compliance with the required room size standards for multiple-resident bedrooms.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged abuse incident between two residents on January 18, 2025, as per their Policy and Procedure on Abuse, Neglect, and Exploitation. The investigation was incomplete because the facility did not obtain a statement from a third resident who identified herself as a witness to the incident. This oversight potentially omitted crucial evidence regarding the alleged abuse. The facility's policy requires identifying and interviewing all involved persons, including witnesses, but this was not adhered to in this case. Resident 1, who has moderately impaired cognition and requires assistance for daily activities, was allegedly involved in an incident with Resident 2, who has severely impaired cognition and requires substantial assistance. Resident 3, who has intact cognition, claimed to have witnessed the interaction between Residents 1 and 2 without staff intervention. Despite this, the Administrator decided not to interview Resident 3, relying solely on the Registered Nurse Supervisor's account, who stated that no abuse was witnessed. This decision led to an incomplete investigation, as the facility did not follow its own procedures for handling allegations of abuse.
Failure to Address Wandering Behavior in Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan in a timely manner to address the wandering behavior of a resident diagnosed with metabolic encephalopathy and dementia. The resident exhibited goal-directed wandering behavior, as noted in the Elopement Risk assessment, and had severe cognitive impairment requiring substantial assistance for daily activities. Despite these assessments, the care plan to address the resident's risk for elopement and wandering was not created upon admission, nor was it updated when the resident began wandering into other residents' rooms and displaying aggression when redirected by staff. Interviews with other residents and family members revealed that the resident's wandering behavior was known to the staff, yet it remained unaddressed, leading to safety concerns for both the wandering resident and others. The Director of Nursing acknowledged that a care plan should have been created or updated to reflect the resident's behavior and the interventions being implemented, such as close monitoring. The facility's policy on accidents and supervision emphasized the need for documenting interventions in care plans, which was not adhered to in this case.
Failure to Document One-to-One Supervision for Resident
Penalty
Summary
The facility failed to accurately document the implementation of close monitoring and one-to-one supervision for a resident with severe cognitive impairment and a history of wandering behavior. The resident, who was admitted with diagnoses including metabolic encephalopathy and dementia, required substantial assistance for daily activities. Despite the Director of Nursing stating that a sitter was provided for one-to-one monitoring on a specific date due to wandering behavior, there was no documentation in the resident's clinical record or the facility's Nursing Staffing Assignment and Sign-In Sheet to confirm that this supervision was provided. The resident's Care Plan for elopement risk and wandering indicated that one-to-one supervision would be rendered by staff, but this was documented to start a week after the stated date of supervision. Additionally, the facility's Progress Notes for the date in question did not reflect that a sitter or one-to-one monitoring was provided. This lack of documentation and inconsistency with the facility's Policy and Procedure on accidents and supervision, which requires communication and documentation of interventions, highlights the deficiency in maintaining accurate medical records for the resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to remain free from physical abuse when Resident 3 hit Resident 2 on the chest. Resident 2, who was admitted with diagnoses including hemiplegia and a history of cerebral infarction, was sitting in his wheelchair next to his room when Resident 3 attempted to enter the room. Resident 3, who was admitted with dementia and Alzheimer's disease, became upset when trying to push Resident 2's wheelchair and swung his hand, hitting Resident 2 on the chest. Resident 3 had a history of aggressive behavior, as noted in his care plan, and required 1:1 monitoring due to his confusion and tendency to wander. On the day of the incident, Resident 3 exhibited physical aggression and agitation, which was documented in his SBAR communication form. Despite the presence of staff, including an Activities Assistant and a CNA, the incident occurred quickly, and Resident 3's aggressive behavior was not prevented. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from physical harm, including hitting and punching. However, the incident involving Resident 3 and Resident 2 indicates a failure to implement these policies effectively, resulting in a breach of Resident 2's right to safety and protection from physical abuse.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health, the Ombudsman, and local law enforcement within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, who reported being punched in the face by another resident. The resident's responsible party informed a nurse at the facility about the incident, but the specific nurse was not identified. The facility's policy and procedure, titled 'Abuse, Neglect and Exploitation,' mandates immediate reporting of such allegations, but this was not adhered to. The facility's Administrator was informed of the incident but chose not to report it, determining that it was not possible for the incident to have occurred. The Director of Nursing was also informed by the resident that another individual attempted to pat the resident on the arm, leading to a physical response from the resident. Despite these reports, the facility did not follow its policy to report the alleged abuse to the appropriate authorities, resulting in a delay in notification and the potential for further abuse to the resident.
Failure to Implement Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program, as evidenced by the actions of two Certified Nursing Assistants (CNAs) who did not perform hand hygiene in accordance with the training provided by the Infection Prevention Nurse (IPN). During an observation, CNA 1 was seen removing soiled gloves after providing care to a resident but did not wash hands or use alcohol-based hand rub (ABHR) before touching the clean linen cart. In an interview, CNA 1 acknowledged the failure to perform hand hygiene after removing gloves, which is a critical step in preventing the spread of infection. Similarly, CNA 2 was observed delivering food trays to multiple residents without performing hand hygiene between rooms. CNA 2 touched various surfaces, including tables, privacy curtains, and a wheelchair, without using ABHR or washing hands. When interviewed, CNA 2 admitted forgetting to use hand sanitizer when entering and exiting residents' rooms, despite being aware of the requirement to do so. Interviews with other staff members, including Licensed Vocational Nurses (LVNs) and the Director of Staff Development (DSD), confirmed that the facility's protocol required hand hygiene after removing gloves and when entering and exiting resident rooms. The IPN reiterated the importance of hand hygiene in preventing infection spread. A review of the hand hygiene in-service handout indicated that hand hygiene should be performed before and after resident contact, after glove removal, and when touching shared equipment or resident surroundings.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, identified as Resident 8, who was at risk for wandering and elopement. Resident 8, who had diagnoses including unspecified psychosis and dementia with behavioral disturbances, was observed wandering into other residents' rooms. The care plan for Resident 8 indicated the need for visual supervision at all times, but interviews with staff revealed that there was no specific monitoring or supervision schedule in place for this resident. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Certified Nurse Assistants (CNAs), and the Director of Staff Development (DSD), confirmed that Resident 8 frequently wandered around the facility and into other residents' rooms. Staff members were aware of this behavior and attempted to redirect Resident 8, but there was no 1:1 sitter provided for direct supervision. The facility's policy on accidents and supervision required adequate supervision to prevent accidents, but this was not effectively implemented for Resident 8. Resident 8's wandering behavior was also noted by other residents and staff, including the Business Office Manager and the Social Services Director, who reported that Resident 8 would enter other residents' rooms and use their bathrooms. Some residents and their families had complained about this behavior. Despite the awareness of Resident 8's wandering and the potential for resident-to-resident altercations, the facility did not consider 1:1 supervision, which was necessary to ensure the safety and protection of all residents involved.
Failure to Provide Required Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident 3, who had a history of dementia and behavioral issues, was not provided with the required 1:1 supervision as outlined in their care plan. This lack of supervision led to Resident 3 hitting Resident 2, following a previous incident where Resident 3 had hit Resident 1. The facility's failure to implement the necessary supervision measures allowed Resident 3 to continue exhibiting aggressive behavior towards other residents. Resident 1, who was admitted with multiple diagnoses including dementia and severe cognitive impairment, was first hit by Resident 3. Despite this incident, the facility did not assign 1:1 supervision to Resident 3, as confirmed by staff interviews and record reviews. Resident 2, who also had dementia and cognitive impairment, was subsequently hit by Resident 3. The facility's policy required increased supervision to protect residents from harm, but this was not adequately implemented. Interviews with staff, including CNAs and the Director of Nursing, revealed that there was no documented evidence of 1:1 supervision being provided to Resident 3. The facility's policies on abuse prevention and adequate supervision were not followed, leading to repeated incidents of physical abuse by Resident 3. The lack of immediate and appropriate intervention to prevent further incidents highlights the deficiency in the facility's care and supervision practices.
Failure to Manage Dementia-Related Behaviors Leads to Resident Abuse
Penalty
Summary
The facility failed to ensure that a newly admitted resident with dementia, identified as Resident 3, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency resulted in Resident 3 physically abusing two other residents, identified as Resident 1 and Resident 2. Resident 3, who had a history of dementia and unspecified psychosis, exhibited behaviors such as wandering and intruding on the privacy of others, which were not adequately managed by the facility. Resident 1, who was admitted with diagnoses including spinal stenosis and unspecified dementia, was reported to have been hit on the arm by Resident 3. Resident 1 had severely impaired cognition and lacked the capacity to understand and make decisions. Similarly, Resident 2, who had muscle weakness and dementia with behavioral disturbances, was also physically abused by Resident 3. Resident 2 had moderately impaired cognition and fluctuating decision-making capacity. Both residents reported incidents of being tapped or hit by Resident 3, leading to suspected abuse assessments in their care plans. The facility's policy on dementia care required an interdisciplinary team approach to assess, develop, and implement care plans for residents with dementia. However, the Director of Nursing acknowledged that the incidents of physical abuse occurred before the interdisciplinary team could provide better care. The facility's failure to differentiate the assessment and care provided to residents with dementia from those without contributed to the deficiency, as Resident 3's behaviors were not effectively managed, leading to the physical abuse of other residents.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident back from a General Acute Care Hospital (GACH) as per its policy and procedure titled 'Readmission to Facility.' The resident, who had been initially admitted to the facility and later readmitted with diagnoses including cerebral infarction, epilepsy, and dementia, was sent to GACH for further evaluation and treatment following a physical altercation and psychosis. Despite the facility's policy to initiate a bed-hold and permit residents to return after hospitalization, there was no bed-hold documented for this resident. Interviews revealed that the facility declined to accept the resident back after the hospital attempted to transfer them back. The Director of Business Development confirmed that the facility decided not to readmit the resident, and the Administrator stated it was not safe to do so. This decision was contrary to the facility's policy, which protects residents' rights to readmission regardless of payment source.
Failure to Perform Neurological Checks After Resident's Head Injury
Penalty
Summary
The facility failed to perform neurological checks on a resident after a change in condition, as required by their policy and procedure for head injuries. The resident, who had a history of cerebral infarction, epilepsy, and dementia, was found with a lump and redness on the forehead and a scratch on the nose. Despite these findings, no neurological checks were conducted, which was a deviation from the facility's policy. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed that neurological checks should have been performed to assess for any changes in the resident's mental status or physical functioning. The facility's policy required such assessments following a known or suspected head injury, but this was not adhered to in this case, potentially placing the resident at risk for undetected neurological issues.
Failure to Revise and Implement Individualized Care Plans
Penalty
Summary
The facility failed to revise and implement individualized care plans for two residents, leading to potential declines in their physical and psychosocial well-being. Resident 47, who had multiple diagnoses including type 2 diabetes mellitus, Parkinson's disease, generalized muscle weakness, spinal stenosis, and peripheral vascular disease, experienced a further decline in the range of motion (ROM) in both lower extremities. Despite this decline being documented in a Joint Mobility Assessment (JMA) on 3/5/2024, the care plan was not updated to address this change. The Physical Therapist noted that splinting could have been recommended to prevent further decline, but no such intervention was added to the care plan. The Director of Nursing confirmed that the decline should have been addressed by notifying the physician and revising the care plan accordingly. Resident 19, who had diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and Alzheimer's disease, required hearing aids due to significant hearing loss. Despite this need being documented in multiple assessments and the resident's property list, the care plan did not include interventions to ensure the resident wore the hearing aids. Observations and interviews revealed that the resident frequently did not have access to the hearing aids, significantly impairing their ability to hear and communicate. The facility's policy required care plans to be updated with new or modified interventions upon a change in status, but this was not done for Resident 19. The facility's policies and procedures emphasized the importance of revising care plans based on comprehensive assessments and changes in residents' conditions. However, these policies were not followed in the cases of Residents 47 and 19. The failure to update and implement appropriate care plans for these residents resulted in a lack of necessary care and services, potentially leading to further physical and psychosocial decline.
Failure to Provide Appropriate Care and Services
Penalty
Summary
The facility failed to provide appropriate care and services for two residents, leading to potential health risks. For Resident 19, the facility did not ensure that dentures were offered before each meal and failed to follow up with the dentist in a timely manner to obtain the status of dental treatment authorization. This resulted in Resident 19 experiencing difficulty chewing food, as observed when the resident placed zucchini rind from her mouth onto her food tray. The resident's dentures did not fit properly due to bone loss, and although the staff was aware, they did not consistently offer the dentures or follow up on the treatment authorization request, causing delays in necessary dental care. For Resident 41, the facility did not adhere to its policy and procedure for intravenous (IV) therapy. The resident had an IV Heplock catheter that was not changed in accordance with the facility's policy, which required IV sites to be changed every 72 hours. The catheter, dated 3/31/24, was observed on 4/15/24, indicating it had been in place for more than the recommended duration. The staff, including the Licensed Vocational Nurse (LVN) and Director of Nursing (DON), acknowledged the oversight and the importance of changing IV sites to prevent complications such as infection. Both deficiencies highlight the facility's failure to follow established protocols and provide necessary care, potentially compromising the residents' health and well-being. The lack of timely follow-up and adherence to care procedures underscores the need for improved oversight and documentation to ensure residents receive appropriate and timely care.
Failure to Monitor and Address Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure the nutritional status and progressive weight loss of a resident (Resident 5) was accurately and consistently monitored and assessed as needed. Resident 5, who had multiple diagnoses including type 2 diabetes mellitus, hemiplegia, hemiparesis, and severe protein-calorie malnutrition, was readmitted to the facility with a nasogastric tube for nutritional intake. Despite being on a tube feeding regimen, Resident 5 experienced significant weight loss over several months, which was not promptly addressed by the facility's staff. The resident's weight dropped from 118 lbs on 10/19/23 to 96 lbs on 3/5/24, indicating a progressive decline that was not adequately monitored or acted upon in a timely manner. The facility's care plan for Resident 5 included interventions to report signs and symptoms of dehydration, such as weight loss, but these interventions were not effectively implemented. The resident's weight loss was not addressed during the Interdisciplinary Care Conference in December 2023, and there were no documented dietary progress notes from 10/17/23 through 11/2023. The Registered Dietician (RD) did not conduct a nutritional assessment between 10/18/23 and 1/17/24, despite the resident's significant weight loss. Additionally, dietary supplements were not ordered until 3/14/24, and a fortified diet was not ordered until 12/6/23, indicating a delay in addressing the resident's nutritional needs. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), revealed that the facility was aware of Resident 5's weight loss but failed to complete a change of condition (COC) documentation or adequately monitor the resident's weight trends. The facility's policies and procedures for assisted nutrition and hydration, weight monitoring, and notification of changes were not followed, resulting in the resident's significant weight loss and decline in health. The DON acknowledged that the resident's weight loss was significant and should have been monitored more closely to prevent further decline.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5% during medication administration for two of five sampled residents. The medication error rate was found to be 11.11% due to three medication errors out of 27 opportunities observed. For Resident 4, a Licensed Vocational Nurse (LVN) crushed and prepared Metformin Extended Release (ER) and famotidine without verifying if they were crushable, which is against professional standards of practice. The nurse realized the error before administration, noting that crushing Metformin ER could cause a rapid drop in blood sugar and crushing famotidine could decrease its efficacy. The Director of Nursing (DON) confirmed that crushing these medications could result in less effective treatment for Resident 4's conditions, including diabetes and GERD. For Resident 10, another LVN failed to check the expiration date of diltiazem before administration. The medication, which was used to treat high blood pressure and chest pain, had expired. The LVN acknowledged that administering expired medication could cause nausea, vomiting, and reduced efficacy. The DON reiterated the importance of checking expiration dates to ensure resident safety and medication effectiveness. The facility's policy and procedure on medication administration emphasized the need to administer medications as ordered and in accordance with professional standards, including checking expiration dates and not crushing medications that should not be crushed. These failures had the potential to result in decreased medication efficacy for the residents involved. Resident 4 had severe cognitive impairment and was dependent on staff for self-care, while Resident 10 had fluctuating cognitive capacity and multiple heart-related diagnoses. The errors were identified during medication pass observations and interviews with the involved staff and the DON, highlighting lapses in following the facility's medication administration policies and procedures.
Failure to Ensure Residents are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 4, a Licensed Vocational Nurse (LVN) crushed Metformin Extended Release (ER) tablets, which are not meant to be crushed, due to the resident's difficulty swallowing. This action was contrary to professional standards of practice and the facility's policy, which explicitly states that medications with 'Do not crush' instructions should not be crushed. The Director of Nursing (DON) confirmed that crushing Metformin ER could result in less effective medication and poorer control of the resident's blood sugar levels. The resident had severe cognitive impairment and was dependent on staff for self-care activities, making the proper administration of medication crucial for their well-being. For Resident 10, another LVN failed to check the expiration date of Diltiazem before administering it. The medication had expired, and the LVN did not follow the facility's policy, which requires checking expiration dates as part of the medication administration process. The DON confirmed that administering expired medications could cause harm and would not be effective. Resident 10 had multiple diagnoses, including hypertensive heart disease and coronary artery disease, and was dependent on the proper administration of medications to manage these conditions. These failures in medication administration had the potential to cause a decline in the physiological well-being of both residents. The facility's policies and procedures were not followed, leading to significant medication errors that could have been avoided with proper adherence to professional standards and protocols.
Expired Medications Found in Storage and Administered to Resident
Penalty
Summary
The facility failed to ensure that expired medications were not stored in the medication storage room and that licensed staff did not prepare expired medication for a resident during medication administration. During an observation, it was found that a cabinet labeled 'House Supply Meds' contained multiple unopened medications, including a bottle of Magnesium tablets that had expired. The Registered Nurse (RN) acknowledged that the expired medication should not have been kept in the storage room, as it could potentially result in adverse side effects if administered to residents. The facility's policy and procedure (P&P) indicated that all medications should be stored according to the manufacturer's recommendations and routinely inspected for expired medications by the consultant pharmacist. Additionally, during a medication pass observation, a Licensed Vocational Nurse (LVN) prepared and administered an expired Diltiazem medication to a resident with a history of hypertensive heart disease, heart failure, and coronary artery disease. The LVN did not check the expiration date on the Diltiazem bottle, which had expired on 4/6/24, and proceeded to administer the medication. The LVN later acknowledged the importance of checking expiration dates to ensure resident safety and prevent potential harm, such as nausea and vomiting, from administering expired medications. The Director of Nursing (DON) confirmed that checking for expiration dates is a crucial step in the medication administration process to ensure the efficacy and safety of the medications. The facility's P&P on Medication Administration emphasized that medications should be administered by licensed nurses in accordance with professional standards of practice, including identifying expiration dates and notifying the nurse manager if a medication is expired.
Improper Sanitizing Fluid Concentration and Incorrect Labeling of Milk
Penalty
Summary
The facility failed to ensure that one of two red buckets used for sanitizing contact surfaces in the kitchen had adequate concentration levels of sanitizing fluid. During an observation and interview, it was found that Red Bucket 1 had a concentration of 200 parts per million (ppm), whereas the required concentration should be between 50 to 100 ppm. The Dietary Services Director (DSD 2) acknowledged the discrepancy and stated that the red buckets were supposed to be changed every two hours or as needed to maintain proper sanitization levels. This failure could lead to inadequate sanitization of surfaces, potentially causing foodborne illnesses due to bacteria transfer. Additionally, the facility did not correctly label opened cartons of Almond milk and 2% low-fat milk in one of the kitchen refrigerators. The Almond milk and 2% low-fat milk were found with use-by dates that had already passed. DSD 2 admitted that it was their responsibility to check the dates daily and that they had missed the expired dates. According to the facility's Refrigerated Storage Quick Reference Guide, opened liquid whole or low-fat milk should be used within one week. The improper labeling and storage of these milk cartons could result in the use of expired food and drinks, posing a risk to resident safety and health.
Failure to Ensure Understanding of Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties (RPs) understood the Binding Arbitration Agreement (BAA) signed upon admission. This deficiency was identified for three residents: Resident 53, Resident 12, and Resident 24. Resident 53, who had fluctuating capacity to understand and make decisions, signed the BAA without recalling any staff explanation about the arbitration process. Resident 12, who had no cognitive impairment, also signed the BAA but reported that the form was not explained to them. Resident 24, who had severe cognitive impairment, had their RP sign the BAA, but the RP stated that no staff explained that signing the BAA was optional or provided details about the arbitration process. Interviews with the Admissions Assistant (AA 1) and the Administrator revealed inconsistencies in the explanation of the BAA to residents and their RPs. AA 1 stated that she was responsible for explaining the BAA and obtaining signatures, but her explanation included incorrect information about the selection of the arbitrator and venue. The Administrator was also uncertain about the process for selecting a neutral arbitrator and a convenient venue. This lack of proper explanation and understanding of the BAA process by the staff contributed to the residents and their RPs not being fully informed. The facility's policy and procedure on Binding Arbitration Agreements, dated 12/19/2022, required that the BAA be explained in a manner that the resident and/or RP would understand and acknowledge. The policy also stated that the BAA must not be a condition for admission or continued care and must provide for the selection of a neutral arbitrator and a convenient venue. The facility's failure to adhere to these policies resulted in residents and their RPs signing the BAA without a clear understanding of its implications and the arbitration process.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection prevention and control practices for five sampled residents, leading to potential increased spread of infection. Resident 12, who had an indwelling urinary catheter (IUC), did not have Enhanced Barrier Precautions (EBP) implemented timely. During an observation, a treatment nurse did not wear a gown while providing IUC care and failed to follow proper infection control practices, such as not disinfecting reusable items touched with contaminated gloves. The facility's Infection Preventionist Nurse confirmed that EBP should have been implemented for residents with indwelling medical devices like Resident 12 and Resident 159, who also had an IUC but lacked EBP signage by their door. Additionally, a Licensed Vocational Nurse (LVN) did not perform hand hygiene or wear proper Personal Protective Equipment (PPE) while obtaining the blood pressure of Resident 3, who was on isolation precautions. The LVN acknowledged the importance of these practices to prevent disease transmission but failed to adhere to them. Furthermore, in a shared restroom used by Residents 15 and 57, toiletries were found unlabeled and improperly stored, which could lead to contamination and infection. The Infection Preventionist stated that personal items should not be kept in shared restrooms to prevent cross-contamination. The facility's policies and procedures on Enhanced Barrier Precautions, Personal Protective Equipment, and infection control were not followed, as evidenced by the observations and interviews. The deficiencies included not implementing EBP for residents with indwelling medical devices, improper hand hygiene and PPE use by staff, and improper storage of personal items in shared restrooms. These failures had the potential to increase the spread of infections throughout the facility.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct an assessment to determine if self-administration of medications was clinically appropriate for Resident 53, as required by the facility's policy and procedure. Resident 53, who was admitted with multiple diagnoses including chronic pulmonary edema, heart failure, and hypertension, had fluctuating capacity to understand and make decisions according to the History and Physical dated 1/22/24. However, the Minimum Data Set dated 1/25/24 indicated no cognitive impairment. During an observation on 4/15/2024, a nasal spray was found at Resident 53's bedside, which the resident stated was brought in by their daughter and known to the nurses. Licensed Vocational Nurse 3 confirmed there was no documented assessment for Resident 53's ability to self-administer the medication safely. The Director of Nursing confirmed that the facility's policy required an assessment by the interdisciplinary team to determine if self-administration was appropriate, followed by obtaining a physician's order and updating the resident's care plan. The policy also required all resident belongings to be inspected and any unauthorized medications to be reported and stored securely. The facility's failure to follow these procedures had the potential to negatively affect Resident 53's physical well-being due to possible drug-to-drug interactions and unforeseen adverse effects.
Failure to Follow Up on PASRR Process for Resident
Penalty
Summary
The facility failed to follow up with the Department of Health Care Services (DHCS) regarding the PASRR process for Resident 24, who had a Positive Level I Screening indicating the need for a Level II Evaluation. Despite the initial screening on 1/22/24, there was no evidence that the required Level II Evaluation was conducted. The Admissions Coordinator (AC 1) acknowledged the oversight and stated that the responsibility for obtaining PASRR forms from the hospital and referring cases to the Director of Nursing (DON) and licensed nurses was not fulfilled in this instance. The DON confirmed that the lack of a timely Level II Evaluation could result in incorrect treatments and delays in specialized services for the resident. Resident 24 was initially admitted to the facility on 11/5/22 with multiple diagnoses, including Alzheimer's disease, anxiety disorder, major depressive disorder, respiratory failure, and atrial fibrillation, all with onset dates of 1/21/24. The resident's Minimum Data Set (MDS) dated 2/1/24 indicated severe cognitive impairment and dependency on staff for self-care and mobility. The facility's policy required coordination with the PASRR program to ensure appropriate care and services, but this was not adhered to, as evidenced by the failure to complete the Level II Evaluation within the stipulated 40 calendar days of admission.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive plan of care for Resident 22, who was admitted with diagnoses including metabolic encephalopathy, peripheral vascular disease, and unspecified dementia. The resident was severely impaired in cognitive skills and required substantial assistance with daily activities. Despite significant weight loss and a physician's order for nutritional supplements and medication for depression, no weight loss care plan was found in the resident's clinical record. This lack of a care plan was confirmed during an interview with the Director of Nursing, who acknowledged the importance of addressing the resident's weight loss to prevent further nutritional problems. Observations and interviews revealed that Resident 22 had difficulty eating, often clenching her teeth and consuming only a small portion of her meals. The Registered Dietitian noted that the facility had been trying to increase the resident's weight for some time, but the resident had lost 18 pounds. The facility's policy required the development of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not done for Resident 22, resulting in the resident not receiving individualized care to address her weight loss and nutritional needs.
Failure to Provide Preferred Activity for Resident
Penalty
Summary
The facility failed to provide a preferred activity for a resident, as indicated in the resident's Minimum Data Set (MDS) dated 6/14/23. The MDS showed that the resident liked listening to music, which was somewhat important to them. Despite this, the resident was observed without access to music, specifically a radio that had been donated for their use. The resident was seen resting their head on a handrail near the conference room, indicating a lack of engagement in their preferred activity. Interviews with the Activities Director and Activity Aide revealed that while the resident participated in some activities and required encouragement, the specific preference for music was not consistently met. The resident, who was admitted to the facility on 6/8/21, had diagnoses including dementia, major depressive disorder, and hypertension. The care plan indicated a need for social and sensory stimulation, with a goal for the resident to maintain involvement in cognitive and social activities. However, the lack of music in the resident's room, despite it being identified as a therapeutic and preferred activity, highlights a failure to adhere to the care plan and the facility's policy to support residents' activity choices based on their comprehensive assessment and preferences.
Failure to Provide Hearing Aids Daily
Penalty
Summary
The facility failed to ensure that hearing aids were made available daily for a resident who was hard of hearing. The resident, who had diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and Alzheimer's disease, was readmitted to the facility and had a documented history of hearing loss. Despite having hearing aids with a charger, the resident reported that staff did not consistently provide the hearing aids in the morning, which significantly impacted the resident's ability to hear. Observations and interviews confirmed that the resident was often without hearing aids and had difficulty hearing, which affected their ability to engage with their environment, such as watching television. The resident's care plan indicated that they were hard of hearing when not in a quiet setting, and the facility's policy stated that assistive devices should be consistently provided and monitored by nursing staff. However, the resident and a Certified Nurse Assistant (CNA) reported that the hearing aids were not regularly given to the resident, and the normal protocol for handling hearing aids was not followed. This failure to provide the necessary assistive device daily resulted in the resident experiencing significant hearing difficulties, as confirmed by multiple observations and interviews with the resident and staff.
Failure to Provide Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter (IUC) in accordance with the facility's policy and professional standards of practice. The resident, who had multiple diagnoses including type 2 diabetes mellitus, history of stroke, chronic kidney disease, and obstructive and reflux uropathy, required partial/moderate assistance with daily activities and had no cognitive impairments. The physician's orders for the IUC maintenance included daily cleansing with normal saline or soap and water, and changing the catheter for blockage, leaking, or excessive sedimentation. However, the facility did not consistently follow these orders, leading to potential risks for catheter-associated urinary tract infections (CAUTI). During an observation, the treatment nurse (TXN 1) failed to maintain proper infection control practices while providing IUC care. TXN 1 did not pour the normal saline into the medication cup before entering the resident's room and touched the saline bottle with contaminated gloves after handling the resident's catheter. Additionally, the nurse did not disinfect the saline bottle after use, which could lead to cross-contamination. The resident's urinary collection bag was observed to contain slightly cloudy urine with sediments, indicating possible infection or improper catheter maintenance. Interviews with the facility staff, including the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON), revealed that the facility's protocol required licensed nurses to perform IUC care and assist CNAs during resident showers to ensure proper catheter care. However, the CNAs were not trained to perform IUC care, and there was a lack of consistent adherence to the facility's policy and CDC guidelines for infection control. This failure to follow proper procedures and maintain hygiene standards increased the resident's risk for CAUTI and other complications related to catheter use.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to ensure that 15 of 22 resident rooms met the minimum 80 square feet per resident requirement in multiple resident bedrooms. Specifically, rooms 3, 4, 5, 6, 7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24 were found to have a floor area of 147 square feet, which is insufficient for the designated number of residents. The facility had submitted a Request for Room Size Waiver Letter, indicating that these rooms did not meet the required space but claimed that residents' health and safety were not adversely affected. Measurements taken during an observation confirmed the inadequate room sizes, and interviews with staff and residents revealed that they felt there was enough space to provide care, despite the deficiency in square footage. The facility's policy and procedure, dated 12/19/2022, stated that resident bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident bedrooms. However, the facility did not comply with this policy for the specified rooms. Interviews with a Certified Nursing Assistant and two residents indicated that they believed there was sufficient space for care activities, but the measurements did not meet regulatory requirements. The facility had requested variances from the survey agency according to resident needs and preferences, but the deficiency remained unaddressed at the time of the survey.
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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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