Riverside Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8781 Lakeview Avenue, Riverside, California 92509
- CMS Provider Number
- 555330
- Inspections on file
- 114
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 93 (2 serious)
Citation history
Health deficiencies cited at Riverside Postacute Care during CMS and state inspections, most recent first.
A resident with decision-making capacity and multiple chronic conditions was assessed and approved to self-administer only a specific bowel care medication, yet surveyors observed numerous additional OTC and supplement medications stored at the bedside and taken as needed by the resident without documentation. Nursing staff and the DON reported that residents are not permitted to keep or self-administer medications without physician orders and inclusion on a self-administration assessment, and that self-administered doses must be reported for MAR documentation. The DON confirmed that the medications found at the bedside were not ordered, not included on the self-administration assessment, and were not being tracked, contrary to the facility’s self-administration policy requiring IDT review, secure storage, and clear documentation processes.
A resident with significant neurologic and cognitive impairments, who was dependent on staff for mobility and incontinence care, activated the call light for a brief change and waited 31 minutes before staff responded. During this period, other staff entered the room but did not address the illuminated call light. The assigned CNA was on a meal break, while the TN and a housekeeper later confirmed that all staff are responsible for answering call lights, which facility policy states should be addressed and, if possible, completed within five minutes.
The facility failed to notify four residents and/or their responsible parties when their primary payor was changed from Medi-Cal IEHP to private pay, contrary to resident rights and the facility’s pay source conversion policy. Electronic census records showed that all four residents were converted to private pay effective the same date, but interviews with cognitively intact and moderately impaired residents revealed they were unaware they were paying privately or what the costs were, and a responsible party reported receiving no notification of the change. The BOM, ADM, and DOF gave conflicting accounts of responsibility and communication processes, with the BOM stating she was not informed of the corporate-initiated changes, the ADM stating the BOM should notify residents and report changes in meetings, and the DOF stating that facility leadership should explain and document payor changes, while also acknowledging the decision to convert these residents to private pay was made at the facility level without documented Medi-Cal direction.
A resident with a history of TIA and vascular dementia, documented as self-responsible and able to make decisions, authorized the LTCO in writing to obtain copies of the resident’s financial records, including trust account reports, representative payee documents, and a financial summary of coverage and share of cost. The LTCO emailed this request and the signed consent to the BOM, who stated she normally provides such financial information promptly and is expected to respond within 24 hours and fulfill requests by the next business day. Despite this, the BOM did not provide the requested records, and 12 days elapsed without fulfillment of the request, resulting in a failure to provide timely access to the resident’s financial records as required.
Two residents with significant cognitive impairment were not protected from abuse. In one case, a dependent resident with dementia and severe cognitive deficits was left unsupervised on a smoking patio, where a cognitively intact resident was witnessed by a CNA touching the resident’s breast and attempting to raise the resident’s shirt while the resident said "no." In the other case, a resident with traumatic brain injury, Parkinson’s disease, psychosis, and no decision-making capacity was heard screaming while a CNA stood over the resident and repeatedly told the resident to "shut up," as reported by another cognitively intact resident to an LVN. These events occurred despite facility policies stating residents must be free from sexual and verbal abuse and treated with respect and dignity.
Surveyors found that two residents who smoked were keeping cigarettes and lighters at their bedsides, despite staff statements and facility policy that residents were not allowed to have smoking materials and that only activities staff should control them. One resident, with nicotine dependence and decision-making capacity, was documented as a non-smoker and had no current smoking assessment reflecting his actual smoking status, yet was allowed to smoke without a valid assessment or supervision. Another resident, with COPD, diabetes, major depressive disorder, and fluctuating decision-making capacity, had a care plan requiring supervised smoking with all smoking materials kept in a smoking cart, but was observed with both cigarettes and a lighter in her nightstand. The DON confirmed that assessments and practices did not align with facility policy, which allowed independent smokers to keep cigarettes but prohibited residents from keeping lighters.
Staff failed to follow the facility’s hydration process and policy requiring NOC shift CNAs to replace and refill bedside water pitchers daily, resulting in two residents being observed on consecutive days with teal water pitchers only one-quarter full and not refilled. Both residents, who had conditions including DM, CKD, hypotension, lung CA, and a moderate cognitive deficit, reported that their pitchers had not been refilled for at least two days, despite care plans directing staff to encourage fluids, in-between snacks and fluids, and good nutrition and hydration to support skin health. A CNA acknowledged that the NOC shift appeared not to have refilled the pitchers, and the ADM stated that this failure could place residents at risk for dehydration.
An LVN entered the room of a COVID-19 positive resident posted with contact and droplet precaution signage wearing only a surgical mask, gown, and gloves to check blood sugar, despite facility policy and CDC guidance requiring an N95 respirator and eye protection for care in a COVID isolation area. The LVN acknowledged that an N95 and face shield should have been used, and both the IP nurse and DON confirmed that proper PPE for this situation included gown, gloves, N95 respirator, and face shield, in accordance with the facility’s written COVID-19 infection prevention and control policy.
A CNA placed a towel over a non-verbal, dependent resident's mouth during care while the resident was coughing, as the CNA was not wearing a mask. Another CNA witnessed and intervened, removing the towel. The resident was unharmed, and facility leadership confirmed this action violated abuse prevention policy.
A facility failed to report an allegation of physical abuse involving a resident with fluctuating decision-making capacity to CDPH within the required two-hour timeframe. A CNA witnessed another CNA place a towel over a resident's head and mouth but delayed reporting the incident, resulting in a two-day gap before authorities were notified, contrary to facility policy and federal requirements.
A resident with end stage renal disease and significant mobility limitations was transported to dialysis appointments via Uber instead of a wheelchair van, resulting in unsafe transfers, missed or delayed dialysis, and actual injury including a chest-wall hematoma and possible rib fractures. Staff and the resident reported the transportation was inappropriate and uncomfortable, and the facility did not conduct an interdisciplinary assessment of transportation needs prior to arranging Uber rides.
A resident with mobility limitations and recent foot surgery was transported to dialysis appointments in a standard vehicle instead of a wheelchair-accessible van after the facility changed transportation providers without updating the care plan or involving the resident and family. The care plan lacked interventions for safe transport, and the change led to missed treatments, hospitalization, and injury.
A resident with a history of playing loud music and verbally abusing others was not effectively managed, despite ongoing complaints and documentation of the behavior. Staff failed to implement or update care plans or interventions, resulting in another resident feeling threatened and verbally abused. The responsible resident was cognitively intact and refused offered interventions, but no further actions were taken to address the situation.
A resident with diabetes and peripheral vascular disease developed a new skin avulsion on the left second toe after podiatric treatment. The wound was not consistently evaluated or monitored as a change of condition, and required documentation and shift-to-shift monitoring were not completed, resulting in a deficiency in care.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident was re-admitted with open wounds and peripheral vascular disease, but did not receive wound treatment for three days due to the absence of physician orders and lack of documentation. Staff interviews confirmed that the admitting RN did not obtain or clarify treatment orders, and the facility's policy requiring prompt notification and treatment for skin breakdown was not followed.
A CNA was witnessed by two staff members roughly pushing a cognitively impaired resident multiple times to prevent the resident from getting up from bed. The resident, who had severe cognitive impairment and multiple mental health diagnoses, was found with redness and swelling on the face after the incident. Facility policy prohibits any form of abuse or rough handling.
A resident at high risk for pressure injuries was re-admitted with a blister on the right elbow that was not assessed, documented, or treated by nursing staff. The lack of assessment and intervention allowed the blister to worsen, resulting in a Stage 4 pressure injury with exposed bone, contrary to facility policy and standard nursing protocols.
A resident with dementia and moderate cognitive impairment reported being physically abused by a CNA. Although the administrator was notified, the required report to CDPH was not made within the mandated two-hour timeframe, as confirmed by staff interviews and documentation review.
A resident with a G-tube for dysphagia experienced a clogged tube, and an LVN attempted to clear the blockage using forceful and inappropriate techniques, including milking the tube and applying A&D ointment, which resulted in a tear in the tubing. Facility policy required gentle flushing with warm water and physician notification if unsuccessful, but these procedures were not followed, leading to the resident being sent to the hospital for tube replacement.
Two residents with intact decision-making capacity were transferred to a hospital for acute medical conditions without receiving written notice of the facility's bed hold policy at the time of transfer. Nursing staff did not complete the required bed hold consent forms, and interviews revealed confusion about the policy requirements, despite facility policy mandating written notification upon transfer.
The facility did not consistently offer or provide enough bedtime snacks to all residents, as confirmed by resident reports, staff interviews, and direct observation. A resident with diabetes was not provided with appropriate sugar-free snack options, and staff indicated that the available snacks were insufficient to meet resident needs, with shortages of preferred items like fruit and no snacks left for those who missed the initial distribution.
Trash, used gloves, and food residuals were found on the ground around the dumpsters and gate area outside the kitchen. Both the FNS Director and RD confirmed that the area should be kept clean to prevent pest attraction and infection control issues, in accordance with facility policy.
Multiple residents reported long waits for assistance with ADLs, call lights, and medication, while staff interviews confirmed significant staffing shortages, especially on night shifts. CNAs were assigned high numbers of residents, often exceeding recommended ratios, and were unable to complete care tasks efficiently. Facility records showed that required CNA care hours were not consistently met, leading to delays in care, residents being left in soiled conditions, and overall negative impacts on resident well-being.
Multiple residents experienced discomfort due to cold room temperatures, with several rooms recorded below the recommended range and staff also reporting feeling cold during night shifts. In addition, residents' personal clothing was not washed or distributed in a timely manner due to broken laundry equipment and insufficient laundry staff, leading to missing belongings and piles of unfolded clothes. The facility lacked proper documentation of equipment checks and did not have a policy for laundry services.
Surveyors identified multiple deficiencies in medication labeling and storage, including IV bags without beyond use dates, expired and discontinued medications stored with active stock, and insulin vials and pens lacking open dates or kept beyond recommended periods. Staff interviews confirmed that these practices did not follow facility policy or manufacturer instructions.
Surveyors found that dietary staff did not follow proper food safety and sanitation procedures, including incorrect use of Quat sanitizer, improper cleaning of meal carts, and lack of knowledge on thermometer calibration and required submersion times for kitchenware. These failures affected all residents receiving food from the kitchen.
Multiple failures occurred in food service, including not adding required margarine to fortified diets, lack of labeling to distinguish diet Jello for CCHO diets, and improper portioning of salad, meat, and cheese in meals. These actions resulted in residents not receiving meals as prescribed by their diet orders and facility policies.
Multiple residents reported that meals were frequently served cold, bland, and lacking variety, with some noting that hot foods were only warm and cold foods, such as ice cream, were sometimes melted. A test tray evaluation confirmed that food items were below required serving temperatures and that pureed foods did not have the correct texture. The Food and Nutrition Service Director and Registered Dietitian acknowledged these issues, which were not in line with facility policies for meal service and food preparation.
Several residents requiring pureed diets and nectar thick liquids were served food and beverages that did not meet prescribed texture and consistency requirements. Pureed meat was not smooth, thickened milk was lumpy or improperly mixed, and inappropriate items such as Jello and regular shakes were provided to residents with swallowing difficulties, contrary to physician orders and facility policy.
Surveyors identified multiple failures in food safety and sanitation, including dust accumulation in kitchen areas, unrestrained facial hair among staff, improper storage of open and expired food items, unsanitary kitchen equipment, and staff lacking knowledge of proper cleaning and sanitizing procedures. These deficiencies created conditions that could lead to food contamination and risk of foodborne illness for all residents receiving meals from the facility.
The facility did not have a written QAPI plan in place to address ongoing systemic issues with CNA staffing, dietary, and laundry services. Despite having a QAPI committee, the program did not identify or correct these deficiencies, resulting in multiple residents not receiving appropriate services in these areas.
Surveyors observed multiple infection control failures, including a resident's IV tubing coming into contact with food during a meal, laundry staff not monitoring or knowing required washer and dryer temperatures, and improper handling of clean linen—such as returning linen touched by a resident to an uncovered cart and using a floor-contaminated cover on clean linen. These actions did not follow facility policies or infection prevention standards.
Surveyors observed multiple pests, including bugs, a spider, and a house fly, in the kitchen's dry storage and food preparation areas. Staff interviews confirmed that pests should not be present due to the risk of cross contamination, and facility policies require ongoing pest control. Despite these requirements, pests were found in the kitchen.
Multiple deficiencies were identified in medication handling and administration, including improper disposal of a non-scheduled medication by an LPN, leaving medications unattended at a resident's bedside, and discrepancies in controlled medication documentation for two residents. Additionally, a resident did not receive scheduled narcotic pain medication due to pharmacy supply issues and lack of an emergency kit, resulting in missed doses and incomplete documentation.
Two residents were not served their meals at the same time as others at their tables, resulting in prolonged waiting and distress. Staff interviews revealed a lack of an organized meal delivery system, leading to confusion and delays. Both residents, who were cognitively intact and had relevant medical conditions, expressed discomfort and dissatisfaction with the experience, and facility policies regarding resident dignity and rights were not followed.
The facility did not obtain or renew informed consents for psychotropic medications as required by policy for two residents, resulting in administration of medications such as Melatonin, Diphenhydramine, and Depakote without proper documentation of consent. The DON confirmed the absence of current informed consents in the medical records, despite ongoing administration and policy requirements for biannual renewal.
A resident with a history of amputation, respiratory failure, and blindness reported her left leg prosthesis missing after a room change and did not receive feedback or follow-up from staff despite notifying multiple facility personnel. Staff interviews confirmed the loss was reported and some actions were taken, but the facility did not document or resolve the grievance as required by policy.
A resident with complex medical needs did not receive medications as ordered, including antihypertensives and insulin, on multiple occasions. Documentation was incomplete or missing for vital signs and blood sugar checks required before administration. Facility policy and physician orders were not consistently followed, as confirmed by the DON.
The Consultant Pharmacist did not identify or report duplicate medication orders for two residents, resulting in both receiving higher-than-intended doses of Vitamin D and Omeprazole, respectively. Additionally, a resident on routine opioid therapy did not have a bowel regimen in place, and this omission was not flagged by the pharmacist. The DON confirmed these issues, which were not detected during the monthly medication review as required by facility policy.
Two residents received duplicate doses of the same medications due to unreviewed and unclarified duplicate orders. One resident was administered double doses of Vitamin D, while another received up to four doses of Omeprazole daily. Nursing staff did not identify or clarify the duplicate orders, resulting in excessive medication administration.
A medication pass observation revealed that an LVN made four medication errors while administering medications to a resident, resulting in a 13.79% error rate. Errors included not administering scheduled azelastine nasal spray, giving an as-needed fluticasone nasal spray instead, administering a lower dose of Vitamin D3 than ordered, and omitting cyanocobalamin. The LVN confirmed the errors and lack of medication availability, and the DON stated that staff are expected to verify medications against the MAR and physician orders.
A resident with epilepsy did not receive a scheduled dose of phenobarbital, and there was no documentation or physician notification regarding the missed dose. The omission was confirmed by review of the MAR, CDR, and interviews with the DON and LVN, with the resident also reporting a history of seizures when medication was missed.
A resident with severe cognitive impairment and malnutrition experienced oral pain and a visible gum bump. Although a nurse notified the PCP and a dental consult was ordered, the resident was not seen by the facility dentist nor referred externally, leaving the dental issue unaddressed as required by facility policy.
The facility did not ensure the Food and Nutrition Services Director, a Certified Dietary Manager, completed the required six hours of in-service training on California dietary service regulations before starting full-time duties as dietetic services supervisor. This was confirmed through interviews and review of job qualifications.
Condensation ice buildup was found on the fans and a box of food inside a kitchen reach-in freezer. The FNS Director confirmed the freezer had not been working properly for about two weeks, and the EPD identified a defrost timer issue related to daylight saving time changes. No maintenance request had been submitted by dietary staff, despite the malfunction.
A resident was unable to access her personal funds in a timely manner due to a delay in check signing by the corporate office, despite having a trust account with the facility. The Business Office Manager Assistant confirmed the delay, and the Administrator was unaware of the issue until later. The facility's policy required funds to be available to residents, but this was not adhered to, resulting in the resident being upset.
Two residents did not receive physician-ordered treatments for their skin conditions due to staffing issues and lack of communication at the facility. Resident 2, who was alert, reported missing treatments for tinea corporis, while Resident 5, with cognitive impairment, had lapses in wound care. The facility struggled with treatment nurse coverage, and charge nurses were expected to fill in, but documentation was lacking, and responsibilities were unclear.
A resident's call light was found non-functional during unannounced visits, with both the resident and an LVN confirming the issue. The resident, with end-stage renal disease and moderate cognitive impairment, was at risk due to the malfunction. The DON acknowledged the responsibility of staff to ensure call lights are operational, as per facility policy.
A broken floor tile in a resident room posed a safety risk to two residents, one of whom is legally blind. The tile was located by the restroom door and was identified during unannounced visits. The Maintenance Director and Administrator were informed of the issue, but it had not been addressed promptly, despite the facility's policy requiring regular inspection and maintenance of resident rooms.
Failure to Follow Self-Administration of Medication Policy for Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for self-administration of medications for one resident. The resident was admitted with multiple serious conditions, including acute and chronic respiratory failure, lumbar radiculopathy, chronic pain syndrome, acetonuria, and was receiving palliative care. A History and Physical indicated the resident had capacity to make decisions. A Quarterly Risk Assessment for Self-Administration of Medications dated February 3, 2026, documented that the resident requested to self-administer medications, that nursing recommended the resident could self-administer, and specifically listed only docusate sodium 100 mg as a bowel care medication to be self-administered as needed. During observation, surveyors found multiple medications stored at the resident’s bedside in two zippered cosmetic bags, including acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, docusate sodium 250 mg, potassium 99 mg, and Hair Skin and Nails vitamins. The resident stated she kept these medications at the bedside and took them as needed, reporting daily use of docusate sodium 250 mg for constipation and as-needed use of the other medications, including ZzzQuil Pure Zzzs Melatonin Gummies for sleep. The resident also stated she was not required to keep a record of, or inform nursing staff about, the medications she took. Interviews with LVNs, the RN, and the DON showed inconsistency between facility practice and the self-administration policy. Multiple nurses stated residents were not allowed to keep medications at the bedside or self-administer unless there was a physician’s order and a completed self-administration assessment, and that residents who self-administer must inform nursing so doses can be documented on the MAR. The DON confirmed there was a self-administration assessment for the resident but acknowledged that the medications found at the bedside were not on the assessment and not ordered by the physician, and confirmed that acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, potassium 99 mg, and Hair Skin and Nails vitamins were not included on the Quarterly Risk Assessment. The facility’s written policy required IDT evaluation of appropriateness, safe and secure storage, determination and instruction regarding documentation responsibility, and removal of any unauthorized bedside medications, which was not followed in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was answered in a timely manner, resulting in a 31‑minute delay in response to a request for incontinence care. The resident involved had multiple significant diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis affecting the right dominant side, muscle wasting and atrophy, major depressive disorder, bilateral ankle contractures, vascular dementia, epilepsy, bilateral foot drop, and schizophrenia. The resident reported using the call light when needing a brief change or assistance and stated he was unable to get out of bed without help. He also stated that call light response times were very slow and varied depending on which staff were working. During observation at the bedside, the resident pressed the call light at 11:06 a.m., illuminating the light in the room and above the doorway. While the call light remained on, a staff member entered the room and assisted the roommate, and a housekeeper entered the room but did not address the active call light. The call light was not answered until 11:37 a.m., when the Treatment Nurse entered and responded, confirming that a 31‑minute wait was unacceptable and that all staff were responsible for answering call lights. The CNA assigned to the resident stated she had been on lunch break during this time and that all staff were responsible for answering call lights, which should be answered within five minutes. The housekeeper stated she cleans resident rooms and can answer call lights. The facility’s “Answering the Call Light” policy indicated that staff should ensure timely responses, notify appropriate staff if another person is needed, and complete tasks within five minutes if possible.
Failure to Notify Residents and Families of Conversion From Medi-Cal to Private Pay
Penalty
Summary
The deficiency involves the facility’s failure to notify four residents and/or their responsible parties of changes in their primary payor status from Medi-Cal IEHP to private pay, as required by resident rights and the facility’s own policy. Record review showed that each of the four residents had Medi-Cal IEHP as the primary payor prior to January 1, 2026, and that their primary payor was changed to private pay effective January 1, 2026, in the PointClickCare (PCC) census records. The facility’s policy titled “Pay Source Conversion” states that Social Services is responsible for notifying the family of non-coverage and anticipated payment, and that the resident and/or responsible party must be informed of their financial obligations when there is a conversion from one primary pay source to another. Resident 2 was admitted with a history of transient ischemic attack and was documented as self-responsible, with an MDS indicating intact cognition. Resident 3 was admitted with dementia, also documented as self-responsible, and had an MDS indicating intact cognition. Resident 4 was admitted with dementia, had a responsible family member, and an MDS showing she was rarely/never understood with moderately impaired cognition. Resident 5 was admitted with metabolic encephalopathy and had an MDS indicating moderately impaired cognition. Despite these documented conditions and responsible party designations, interviews with Residents 2, 3, and 5 revealed that they were unaware they were currently paying privately for their stays, did not know the cost, and reported that no one had discussed these financial changes with them. Resident 4 was non-responsive at the time of attempted interview, and later her responsible party reported not receiving any notification of the payor change or information about the cost. Interviews with staff confirmed that required notifications were not provided. The Business Office Manager (BOM) stated that her department is responsible for notifying residents and responsible parties of payor changes via a notice of insurance change letter, but reported that the Director of Finance (DOF) at the corporate office initiated the payor changes on December 31, 2025, without informing her. The Accounts Receivable Director stated that the BOM, Administrator (ADM), or Social Services Director (SSD) should inform residents about becoming private pay. The Social Service Assistant stated that the BOM is responsible for payor changes and that she had never dealt with payor changes. The ADM stated the BOM is supposed to give notice of payor status changes to residents and report such changes in stand-up meetings, but he was not aware of the corporate-initiated changes and the BOM did not report any payor changes. The DOF stated that BOM, SSD, and sometimes ADM should explain payor changes and document their actions, and later clarified that no written Medi-Cal recommendation was received and that the decision to change the four residents to private pay was made at the facility level. These actions and inactions resulted in residents and responsible parties not being notified of the change from Medi-Cal to private pay and their resulting financial obligations.
Failure to Timely Provide Resident Financial Records Requested by Ombudsman
Penalty
Summary
The facility failed to provide copies of financial records within the required timeframe after a request was made on behalf of a resident by the Long-Term Care Ombudsman (LTCO). The resident involved was admitted with a history of transient ischemic attack and vascular dementia and was documented as self-responsible, with a Minimum Data Set indicating capacity to understand and make decisions. The LTCO emailed the Business Office Manager (BOM) requesting the resident’s trust account report, any representative payee documents from the last 12 months, and a financial summary of coverage and share of cost, and included a consent form signed by the resident authorizing release of this information. During an interview, the BOM stated that she typically provides requested financial information to residents or responsible parties within 10–15 minutes and that, for non-responsible parties, she obtains resident consent via a signed form. She acknowledged receiving the LTCO’s email request and consent form and stated that she is expected to respond to financial record requests within 24 hours and fulfill them by the next business day. The BOM further acknowledged that she should have responded and fulfilled this request by the next business day but had not done so, and that 12 days had elapsed since the request was made. The facility’s policy allowed up to 30 days for providing copies of personal or medical records but also recognized the right of the LTCO to examine resident records in accordance with state law. The failure to provide the requested financial records within two business days constituted a violation of the resident’s and the resident’s representative’s rights.
Failure to Prevent Sexual and Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual abuse by another resident and verbal abuse by staff. In the first incident, a cognitively impaired resident with dementia, Alzheimer’s disease, major depressive disorder, and a BIMS score of 3 was involved. This resident had been assessed as lacking capacity to make decisions and was dependent on others for domestic tasks and safety awareness. On the date of the incident, the resident was on the smoking patio without staff supervision during a 4 p.m. smoke break. A CNA reported hearing this resident saying "no, no, no" and then observed a male resident touching the resident’s breast with one hand while attempting to raise the resident’s shirt with the other hand. The CNA noted that there were no other residents present and no staff supervising the smoking patio at that time. The male resident involved was cognitively intact, with a BIMS score of 15 and documented capacity to make decisions. In a subsequent interview, he stated that the cognitively impaired resident had held and kissed his hand and that he did not touch her breast or shirt, although a psychiatric note later documented that he stated he felt invited and began fondling her. The facility’s five-day follow-up report stated that staff witnessed the aggressor touching the victim’s breast and that evidence suggested the allegation of sexual abuse occurred. The DON acknowledged that the dependent resident required supervision and should not have been outside on the smoke patio without supervision. The second incident involved verbal abuse of another cognitively impaired resident with traumatic brain injury, Parkinson’s disease, psychosis, no decision-making capacity, and a BIMS score of 0, indicating the resident was rarely or never understood. Early in the morning, another resident with normal cognition reported to an LVN that he had seen a CNA hovering over this impaired resident and heard the CNA tell the resident to "shut up" while the resident was crying or screaming. The witness later described hearing screams that were not the resident’s normal screams, then observing the CNA standing over the resident and repeatedly saying "shut up" before leaving the room and going to the linen cabinet. The incident was documented in an SBAR as alleged verbal abuse, and an interdisciplinary post-event note recorded that the alleged perpetrator was sent home and the resident was assessed with no injury. The administrator stated that residents should be in a safe environment at all times and free from verbal abuse. Facility policies on Abuse Prevention and Resident Rights stated that residents have the right to be free from sexual and verbal abuse and to be treated with kindness, respect, and dignity.
Failure to Control Resident Smoking Materials and Maintain Accurate Smoking Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to resident smoking and smoking materials. During observation and interview, one resident was found sitting in bed with a sitter present and stated he was a smoker who kept his cigarettes and lighter in his jacket by the bedside. He produced a pack of cigarettes and a lighter from his jacket pocket and stated he only smoked on the smoking patio. Another resident, observed alert and oriented in a wheelchair at bedside, stated she was a smoker and kept her smoking materials in her nightstand drawer. She removed a lighter and a pack of cigarettes from the top nightstand drawer and also stated she only smoked on the smoking patio. When interviewed, the LVN stated residents were not allowed to have smoking materials and that only activities staff were supposed to have residents’ smoking materials. During this interview, the first resident again produced his cigarettes and lighter, and the LVN confirmed he should not have smoking materials with him. Record review for this resident showed a readmission with diagnoses including end stage renal disease, nicotine dependence, and an above-knee amputation, and a history and physical indicating he had capacity to make decisions. However, his smoking assessment documented him as a non-smoker and did not reflect his current smoking status as a smoker. There was no documented smoking assessment reflecting his current status until the concurrent observation and interview on the survey date, confirming he had been allowed to smoke without a valid smoking assessment and without supervision. For the second resident, record review showed admission diagnoses including COPD, diabetes mellitus, and major depressive disorder, with a history and physical indicating fluctuating capacity to understand and make decisions. Her quarterly smoking assessment documented that she was a smoker, a safe smoker, and independent. Her care plan stated she smoked cigarettes and was independent, with a goal that she would smoke safely with supervision, and interventions specifying that activity staff would keep all smoking materials in the smoking cart at all times, give one cigarette and light it for her, and supervise all residents. The DON stated that facility process required smoking assessments on admission and quarterly, that independent smokers could keep cigarettes but not lighters, and that residents were not allowed to have lighters. The DON acknowledged that the first resident’s assessment did not reflect his current smoking status and that he should not be smoking without an assessment or supervision, and that the second resident, although assessed as an independent safe smoker, should not have had a lighter at bedside under facility policy.
Failure to Provide Fresh Bedside Water and Hydration per Policy
Penalty
Summary
The facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily for two residents, resulting in water pitchers remaining only one-quarter full over multiple days. On two consecutive mornings, one resident was observed alert and oriented in a wheelchair with a teal bedside water pitcher that was one-quarter full; the resident reported that CNAs usually refilled his water but that it had not been done that morning, and later stated the pitcher had not been refilled either the previous day or that day. A CNA later confirmed, in the resident’s presence, that the NOC shift appeared not to have refilled this resident’s water pitcher for two days. This resident’s records showed diagnoses including diabetes mellitus, chronic kidney disease, and hypotension, and care plans directing staff to encourage fluids during the day to promote prompted voiding, assist and encourage in-between fluids and snacks due to risk for protein malnutrition, and encourage hydration related to hyperglycemia and skin integrity. Another resident was observed on two consecutive days with a teal water pitcher on the nightstand that was one-quarter full, first while alert, oriented, dressed, and eating lunch, and later with the water level unchanged from the prior day. This resident stated that CNAs usually refilled her water pitcher but that it had not been filled that day, and later reported it had not been filled the previous day or that day. In a subsequent observation with a CNA present, the CNA stated that the NOC shift is responsible for filling all residents’ water pitchers daily before the end of shift and acknowledged that it appeared the NOC shift did not refill this resident’s pitcher. This resident’s records indicated diagnoses including chronic kidney disease and lung cancer, a BIMS score of 11 indicating a moderate problem with thinking, and a care plan intervention to encourage good nutrition and hydration to promote healthier skin. The Administrator stated that the facility’s process is for NOC shift CNAs to replace and refill residents’ water pitchers with fresh water daily toward the end of each shift and acknowledged that failure to refill pitchers could place a resident at risk for dehydration. The facility’s policy on Resident Hydration and Prevention of Dehydration stated that nurses’ aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
Failure to Use Required PPE for COVID-19 Isolation Resident
Penalty
Summary
The deficiency involves a failure to implement appropriate infection prevention and control practices for a resident with confirmed COVID-19. On January 8, 2026, signage posted outside the resident’s room clearly indicated both contact and droplet precautions, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must put on gloves and a gown before room entry. The droplet precaution sign further required that eyes, nose, and mouth be fully covered before entering. The resident’s admission record, dated January 9, 2026, documented a diagnosis of COVID-19. The facility’s written policy on Infection Prevention and Control for COVID-19 Infection, dated June 2023, required all staff to wear fit-tested NIOSH-approved N95 respirators in any indoor space where there are residents in isolation, and specified that eye protection is required when caring for residents in the COVID isolation area. Despite these posted precautions and written policies, on January 8, 2026, at 12:25 p.m., an LVN preparing to check the COVID-positive resident’s blood sugar level was observed donning only a surgical mask, gown, and gloves before entering the room. During a concurrent interview, the LVN acknowledged that the contact and droplet precaution signs were posted to be followed to avoid transmitting bacteria and confirmed that the resident had COVID-19. The LVN further stated she was wearing a surgical mask, gown, and gloves when she entered the room and acknowledged she should have worn an N95 mask and a face shield. In subsequent interviews, the Infection Preventionist Nurse and the Director of Nursing both stated that the LVN should have worn the proper PPE—gown, gloves, N95 respirator, and face shield—before entering the isolation room. CDC Infection Control Guidance for SARS-CoV-2, cited in the report, recommends that healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection use an NIOSH-approved N95 or higher-level respirator, gown, gloves, and eye protection.
Resident's Mouth Covered with Towel by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) placed a towel over the mouth of a resident who was non-verbal, dependent for activities of daily living, and had severely impaired decision-making capacity due to a cerebral infarction. The incident occurred while the CNA was providing care and the resident began coughing. The CNA, not wearing a mask at the time, covered the resident's mouth with a towel for at least one minute, reportedly to protect herself from the resident's cough. Another CNA witnessed the event, removed the towel, and advised the CNA that such actions were inappropriate. The resident was assessed following the incident and was found to have no injuries and was calm and in no distress. Interviews with staff and facility leadership confirmed that placing a towel over a resident's mouth is not acceptable practice and is contrary to the facility's abuse prevention policy, which prohibits physical abuse. The facility's policy emphasizes residents' rights to be free from abuse, including physical abuse.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. The incident involved a Certified Nursing Assistant (CNA) placing a towel over the resident's head and mouth and telling the resident to be quiet. Another CNA witnessed the event but did not immediately report it to a supervisor, instead choosing to wait and report it directly to the Director of Staff Development (DSD) two days later. The facility's policy and federal requirements mandate immediate reporting of such allegations, but the CNA misunderstood the reporting timeframe and delayed notification. The resident involved had a history of cerebral infarction and fluctuating decision-making capacity. Following the incident, the resident was assessed and found to have no injuries or distress, and the physician was notified. Interviews with facility staff confirmed that the expectation was for immediate reporting of abuse allegations, but the delay resulted in the incident not being reported to CDPH until two days after it occurred. Documentation showed that the CNA had previously acknowledged understanding the mandatory reporting requirements.
Failure to Provide Safe and Appropriate Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with her comprehensive assessment and professional standards of practice by not conducting a comprehensive interdisciplinary assessment of her transportation needs for dialysis appointments. The resident, who had end stage renal disease, type 2 diabetes, and a recent amputation of two toes, required substantial to maximal assistance with transfers and was dependent on a wheelchair for mobility. Despite these needs, the facility arranged for her to be transported to dialysis appointments via Uber, which required unsafe and uncomfortable transfers from her wheelchair to a standard vehicle three times a week. Documentation and interviews revealed that the resident missed or experienced delays in dialysis appointments due to transportation issues, including the facility's failure to pay for appropriate wheelchair van services and the subsequent use of Uber. The resident expressed discomfort and fear regarding the Uber transportation, stating that the cars were difficult to enter and exit, and that she was transferred by staff in a manner that was physically challenging and unsafe. Staff, including CNAs and nurses, reported difficulties in transferring the resident and acknowledged that Uber was not an appropriate mode of transportation for her condition. The facility's own rehabilitation department was not consulted to assess the resident's transportation needs prior to the decision to use Uber. As a result of these actions and inactions, the resident sustained actual harm, including a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures after being transported in a standard vehicle. The unsafe transportation practice continued even after the injury, with the resident being exposed to further risk of harm. The facility's failure to provide safe and appropriate transportation, as well as the lack of interdisciplinary assessment and communication, directly led to the resident's injuries and missed or delayed dialysis treatments.
Removal Plan
- Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health transportation.
- Resident 1 was assessed by PT to determine whether Resident 1 can tolerate the car or wheelchair van transportation.
- The Care Plan was updated to reflect current transportation information for dialysis.
- A new contract for wheelchair transport was drawn up by the ADM.
- An ad hoc QAPI Committee meeting was held to discuss changes in contracted dialysis transportation services.
- Inservice training was conducted by DON and/or DSD with licensed staff regarding use of contracted dialysis transportation.
Failure to Update Care Plan for Dialysis Transportation Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan to address the transportation needs of a resident who required dialysis. After the resident's transportation method was changed from a wheelchair-accessible van to a standard vehicle (Uber), there was no interdisciplinary assessment or update to the care plan to reflect this significant change. The change in transportation was made without discussion or involvement of the resident or her family, and there was no documentation of their participation in the care planning process. The care plan did not include interventions for transportation to dialysis, transfer assistance, or mobility safety, and was not revised after the transportation method changed or after the resident sustained an injury. The resident had a history of foot surgery and was not supposed to put pressure on her feet, requiring a lifted van for safe wheelchair transfer. Despite this, the facility arranged for transportation via Uber, which did not accommodate her functional limitations. The decision to switch transportation providers was made by the corporate office due to payment issues, and the staff responsible for social services and case management did not communicate this change to the resident or her family. As a result, the resident was transported in an inappropriate vehicle, leading to missed dialysis treatments, hospitalization, and physical injury.
Failure to Prevent Resident-to-Resident Verbal Abuse and Address Ongoing Disruptive Behavior
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in the affected resident feeling threatened. Specifically, one resident repeatedly played loud music in his room, which disturbed others. When another resident requested that the music be turned down, the first resident responded with verbal threats and derogatory language. This behavior was ongoing for months, as noted in interviews and progress notes, and was not effectively addressed by staff. The resident responsible for the loud music and verbal abuse was cognitively intact and had a diagnosis of bipolar disorder, but refused interventions such as headphones when offered. Despite multiple complaints and documentation of the disruptive behavior, the facility did not implement or update care plans or interventions to address the ongoing issue. Staff interviews revealed that the only action taken in response to a previous grievance was to move a different resident out of the room, rather than addressing the root cause. The Director of Nursing and other staff acknowledged that the behavior should have been care planned and that interventions were lacking, which contributed to the escalation of the situation and the resulting verbal abuse.
Failure to Monitor and Document New Wound Following Podiatric Procedure
Penalty
Summary
The facility failed to complete appropriate monitoring and documentation for a resident who experienced a new skin avulsion on the left second toe following podiatric treatment. The resident, who had diagnoses of diabetes mellitus and peripheral vascular disease, was noted to have a new wound on August 18, 2025, as documented in the skin check. However, subsequent skilled evaluations on August 19 and August 21, 2025, did not identify any skin issues, indicating inconsistent evaluation of the wound. The Treatment Nurse confirmed that the skin avulsion was a new finding and should have been treated as a change of condition, requiring documentation and ongoing monitoring to track the wound's progress. Interviews with facility staff, including the DON, revealed that the wound was not monitored every shift for three days as required by facility policy for a change of condition. The facility's policy states that significant changes in a resident's condition require interdisciplinary review and thorough documentation. The lack of consistent monitoring and documentation for the resident's new wound resulted in a deficiency related to the facility's failure to provide care and treatment according to orders, resident preferences, and goals.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Timely Wound Treatment Upon Admission
Penalty
Summary
The facility failed to provide wound treatment for a resident's left lower extremity open wound for three days following admission. Upon review, the resident was re-admitted with diagnoses including a non-pressure ulcer of the left foot and ankle and peripheral vascular disease. Hospital discharge documents and progress notes indicated the presence of open wounds on the resident's left lower and posterior leg and left foot. The skilled nursing facility's admission assessment also documented a skin breakdown on the left lower leg, and a Braden Skin Risk Assessment classified the resident as mild risk for pressure ulcers. However, there was no physician's order for wound treatment from the date of admission through the following three days, and the Treatment Administration Record showed no documentation of wound care being provided during this period. Interviews with facility staff revealed that the admitting RN did not obtain or clarify treatment orders for the resident's wounds, nor was the wound described in the medical records. The Quality Assurance Nurse and Assistant Director of Nursing confirmed that the expected process was for the admitting nurse to conduct a full body assessment, notify the physician, and secure treatment orders, with follow-up and shift endorsement if clarification was needed. The facility's policy required licensed nurses to notify the practitioner for any skin breakdown requiring treatment upon admission, but this was not followed, resulting in a lack of timely wound care for the resident.
Failure to Prevent Physical Abuse of a Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA 1) was observed by two other staff members to have roughly pushed a resident with severe cognitive impairment multiple times to prevent the resident from getting up from bed. The resident, who had diagnoses including psychosis, anxiety, Parkinson's disease, schizoaffective disorder, depression, and a cognitive communication deficit, was noted to have a BIMS score of 1, indicating severe cognitive impairment. The care plan for this resident included interventions to interact in a peaceful manner due to a history of anxiety and wandering. On the evening of the incident, two CNAs witnessed CNA 1 push the resident down by the shoulders, causing the resident to fall back onto the bed. Both CNAs reported seeing redness and swelling on the resident's face, and one heard slapping noises, though did not see slapping. The resident was heard yelling for help and to stop. The Registered Nurse assessed the resident and confirmed redness and swelling on the left cheek. Facility policy prohibits any form of abuse or rough handling of residents.
Failure to Assess and Treat Blister Led to Stage 4 Pressure Injury
Penalty
Summary
The facility failed to properly assess and treat a blister on the right elbow of a resident who was re-admitted with a history of chronic wounds and high risk for pressure injuries, as indicated by a Braden Scale score of 12. Upon re-admission, the resident's right elbow was wrapped with a bandage, and a blister the size of a ping-pong ball was present, but this was not documented, assessed, or reported to the physician. No treatment order was obtained for the blister at that time, and the presence of the bandage was not investigated further by the admitting nurse. Subsequent interviews and record reviews revealed that the licensed nurses did not perform or document a head-to-toe skin assessment upon re-admission, as required by facility policy. The wound was not unwrapped or measured, and the physician was not notified. The lack of assessment and documentation meant that no care plan or treatment was initiated for the blister, despite the resident's high risk for skin breakdown and pressure injuries. As a result of these failures, the blister on the resident's right elbow worsened and progressed to a Stage 4 pressure injury, with full-thickness skin loss and exposed bone. Staff interviews confirmed that the expected protocol was not followed, and the facility's own policies required immediate assessment, documentation, and intervention for any skin issues identified upon admission or re-admission.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident with dementia and moderate cognitive impairment was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident reported being punched by a Certified Nurse Assistant (CNA) on the evening of March 5, 2025. Documentation shows that the administrator was notified of the allegation, but there was no evidence that CDPH was notified immediately or within two hours as required by both regulation and the facility's own policy. Interviews with staff confirmed that the required report to CDPH was not made. The Registered Nurse (RN) involved stated she did not fax or call the report to CDPH and could not recall the reason for this omission. The administrator acknowledged that CDPH should have been notified no later than two hours after the facility became aware of the allegation. The facility's policy clearly outlines the requirement for immediate reporting of abuse allegations to the appropriate authorities.
Improper G-Tube Unclogging Procedure Results in Tube Damage
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow proper procedures for unclogging a resident's gastrostomy (G-) tube. The resident, who had dysphagia and a G-tube for feeding, experienced a clogged tube as indicated by an alarm on the G-tube pump. The nurse attempted to flush the tube with warm water, which was unsuccessful, and then applied A&D ointment and used a milking technique to try to clear the blockage. During this process, a bubble formed and burst in the tubing, resulting in a tear. The nurse then clamped the tube and notified the RN, who assessed the situation and arranged for the resident to be sent to the hospital for a replacement tube. Interviews with other nursing staff and review of facility policy revealed that the correct procedure for addressing a clogged G-tube is to flush with warm water using a gentle back-and-forth motion, without using force, massaging the tube, or applying ointments. If the clog cannot be cleared, staff are to notify the physician and follow further orders. The nurse's actions deviated from these procedures, as force and inappropriate techniques were used, leading to damage of the G-tube and necessitating hospital transfer for the resident.
Failure to Provide Written Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to two residents who were transferred to a general acute care hospital. In both cases, the residents had intact decision-making capacity and were transferred for acute medical issues—one for bacterial pneumonia and the other for chest pain. Upon review, there was no documented evidence that either resident received a written notice of the bed hold policy at the time of their transfer, as required by facility policy. Interviews with nursing staff revealed a lack of understanding regarding the requirement to complete the bed hold consent form upon transfer, with one nurse believing that discussing the policy at admission or including it in the physician's order was sufficient. The Assistant Director of Nursing and the Administrator both confirmed that the expectation was for nurses to notify residents and their families of the bed hold policy and to complete the necessary documentation at the time of transfer. Facility policy specified that written information about the bed hold option should be provided upon admission and at the time of transfer to a hospital. The absence of this documentation for both residents indicated a failure to follow established procedures for informing residents of their rights regarding bed holds during hospitalizations.
Failure to Provide Sufficient and Appropriate Bedtime Snacks
Penalty
Summary
The facility failed to ensure that bedtime snacks were routinely offered and were sufficient for all residents who received food from the kitchen. During a confidential resident council meeting, half of the residents present reported that bedtime snacks were not offered or were insufficient. One resident with diabetes specifically stated that sugar-free or diabetic-appropriate evening snacks were not available to her. Observations in the kitchen revealed a limited supply of snacks, including a small number of sandwiches, crackers, fruits, and desserts, which were distributed by activity staff in the evening. Interviews with activity staff confirmed that the quantity of snacks provided was not enough to meet resident demand, with many residents requesting more than one snack and a particular shortage of fruit. Staff also reported that there were no snacks left for residents who missed the initial distribution time. The registered dietician noted that the lack of adequate bedtime snacks could negatively impact residents' sense of comfort and satisfaction. A review of the facility's own policy indicated that nourishing bedtime snacks should be routinely offered to all residents unless contraindicated.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed trash, used gloves, and food residuals on the ground surrounding the dumpsters and gate area outside the back kitchen. These findings were made during a concurrent observation and interview with the Food and Nutrition Services Director, who acknowledged that the area needed to be kept clean to prevent bacterial growth and pest attraction, and identified the situation as an infection control issue. A subsequent interview with the Registered Dietician confirmed that the area should be kept clean and that the presence of trash, used gloves, and food residuals could attract pests and create an infection control problem. Review of the facility's policy indicated that garbage and trash cans must be inspected daily to ensure no debris is on the ground or surrounding area, and that the trash collection area must be kept clean to prevent it from becoming a feeding ground for vermin and rodents.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident complaints and staff interviews. Several residents reported long wait times for assistance with activities of daily living (ADLs), such as toileting, bathing, and receiving medications. Residents described waiting 20 to 30 minutes or more for call lights to be answered, being left in soiled conditions, and experiencing delays in receiving food and pain medication. These issues were corroborated by resident council meeting minutes, which documented ongoing concerns about untimely responses to call lights and lack of teamwork among CNAs. Staff interviews further confirmed the staffing shortages, particularly on the night shift, where CNAs were responsible for as many as 23 to 32 residents each, and sometimes up to 52 residents. CNAs reported being unable to complete their assignments efficiently, being pulled away from resident care for other tasks, and working frequent double shifts due to lack of coverage. The Assistant Director of Staff Development and the DON acknowledged that the facility was not consistently meeting the required Nursing Hours Per Patient Day (NHPPD), with documented shortfalls on several days. The DON also confirmed awareness of residents being left in urine and stool and stated that the facility had not been safely or sufficiently staffed in recent months. Record reviews showed that the facility's actual CNA direct care hours per patient day fell below the required minimum on multiple occasions, and staff assignment sheets indicated that CNAs were regularly assigned more residents than recommended. Facility policies required prompt response to call lights and sufficient staffing to meet resident needs, but these standards were not met. The deficiency resulted in negative resident experiences, including frustration, anger, and compromised quality of care, as directly stated in the report.
Failure to Maintain Comfortable Temperatures and Timely Laundry Services
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents by not ensuring comfortable temperature levels in multiple resident rooms and by not providing timely laundry services. Several residents reported feeling cold, especially at night, and were observed using multiple blankets and additional clothing to keep warm. Temperature readings taken in various rooms were found to be below the normal range of 71 to 81 degrees Fahrenheit, with some rooms as low as 67.3 degrees Fahrenheit. Staff members, including LVNs and CNAs, also reported feeling cold during nighttime shifts and noted that residents frequently requested extra blankets. The Maintenance Director was using an incorrect temperature range for monitoring and only checked a few rooms daily, with logs showing temperatures consistently below the recommended range. Additionally, the facility did not maintain proper documentation of weekly checks on laundry equipment, and there was insufficient laundry staff to ensure residents' personal clothing was washed and distributed in a timely manner. One resident reported missing clothing and attributed it to a broken washing machine, which had led to a backlog of laundry and misplaced belongings. Observations confirmed that some laundry equipment was not operational for extended periods, and piles of residents' clothing remained unfolded and undistributed for days. The Housekeeping and Laundry Supervisor confirmed ongoing issues with laundry equipment and staffing, and the Maintenance Director did not keep regular logs of equipment checks, only documenting issues when they occurred. A review of facility records and interviews with staff revealed that previous corrective actions regarding laundry services had not been sustained, as equipment remained out of service and additional staff were not consistently scheduled. The Administrator confirmed the lack of weekly documentation for laundry equipment checks and acknowledged the absence of a policy and procedure related to laundry services. These failures resulted in residents not receiving their personal belongings in a timely manner and experiencing discomfort due to inadequate room temperatures.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in accordance with its policies, procedures, and manufacturer instructions. Surveyors observed that IV Mini-bag plus containers were removed from or stored in opened manufacturer's overwraps without being marked with beyond use dates, and these were found in multiple medication carts. Additionally, a medication card for fenofibrate was found with the expiration date cut off, and the nurse administering it did not verify the expiration date prior to administration. Insulin vials and pens were also found without open dates or stored beyond their recommended use period, and staff were unable to confirm when these medications were removed from refrigeration or first opened. Expired medications were found stored in various medication and treatment carts, including an opened package of sterile wound dressing and an expired box of omeprazole tablets. Staff interviews confirmed that these items should have been discarded after opening or upon expiration, but they remained accessible in the carts. The facility's policies require immediate removal and disposal of outdated, contaminated, or deteriorated medications, but these procedures were not followed. A discontinued medication was also found stored alongside active medications in a medication cart. Staff acknowledged that discontinued medications should be removed and destroyed if not eligible for return to the pharmacy. The presence of these expired, improperly labeled, and discontinued medications in accessible storage areas demonstrated a failure to adhere to established protocols for medication management, as confirmed by staff interviews and policy reviews.
Dietary Staff Lacked Knowledge and Adherence to Food Safety and Sanitation Procedures
Penalty
Summary
The facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services, as evidenced by multiple observed deficiencies in food safety practices. Food service workers did not follow the manufacturer's guidelines for testing the Quaternary (Quat) sanitizer, with staff dipping test strips for incorrect durations and being unable to accurately read or state the required sanitizer concentration. Several dietary aides and cooks demonstrated a lack of knowledge regarding the correct concentration range for the sanitizer, with most staff incorrectly stating the acceptable parts per million (ppm) range, despite clear manufacturer instructions and posted guidelines. Further deficiencies were observed in cleaning and sanitizing procedures. Some dietary aides were unable to demonstrate the proper steps for cleaning dirty meal carts, with one aide using only sanitizer and omitting the required wash and rinse steps. Staff also showed a lack of understanding regarding the calibration of food thermometers, with incorrect target temperatures cited during demonstrations. Additionally, dietary aides were unable to state or demonstrate the correct submersion time for kitchenware in the sanitizer sink, as required by posted manufacturer guidelines. These failures were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The deficiencies had the potential to affect all 153 residents who received food from the kitchen, as improper sanitation and food safety practices could compromise the effectiveness of infection control measures in the dietary department.
Failure to Follow Prescribed Diets and Portion Control in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served according to prescribed recipes and diet orders, as observed during multiple meal services. During a lunch meal, several residents with physician orders for a fortified diet did not receive the required margarine on their vegetables, as specified in the facility's Fortified Menu Plan and confirmed by both a Certified Nurse Aide and the Registered Dietitian. The absence of margarine meant these residents did not receive the additional calories intended to support their nutritional status. Additionally, food service workers did not have a system to distinguish between diet and regular Jello for residents on a Controlled Carbohydrate Diet (CCHO). Multiple residents on CCHO diets were served red Jello that was not labeled as diet, and the dietary aide could not differentiate between the two types without labeling. The Registered Dietitian confirmed that CCHO diet residents should receive diet Jello per the menu plan, and the lack of labeling created a risk of serving the incorrect product. Further deficiencies were observed in portion control and recipe adherence. The wrong scoop size was used to serve both salad and meat portions, resulting in residents receiving either less or more than the planned serving sizes. In another instance, a diet aide prepared cheese quesadillas without measuring the amount of shredded cheese, and was unable to locate the recipe. These actions were inconsistent with the facility's policies and procedures, which require standardized recipes and portion control to meet residents' nutritional needs.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, was palatable, and offered variety according to residents' preferences and facility policy. Multiple residents reported that their food was frequently served cold or not at the correct temperature, with some stating that hot foods were only warm and cold foods, such as ice cream, were sometimes melted. Several residents also described the food as bland, lacking taste, and repetitive, with one resident specifically noting that breakfast was always served cold. During a test tray evaluation, food items for both regular and pureed diets were found to be below the facility's required serving temperatures, and the pureed beef teriyaki did not have the correct texture, with visible beef fibers remaining. The Food and Nutrition Service Director acknowledged these issues, including overcooked vegetables and tough meat, and admitted that the mashed potatoes tasted unpleasant. The Registered Dietitian confirmed that serving cold and unpalatable food could lead to decreased meal intake, which may result in residents not receiving proper nutrition. Facility policies reviewed indicated that meals should be served at specific temperatures and prepared to conserve flavor, appearance, and nutritive value, with staff required to sample food for satisfactory flavor and consistency. However, observations and interviews demonstrated that these procedures were not consistently followed, resulting in food that did not meet the established standards for temperature, palatability, and variety.
Failure to Provide Proper Food and Liquid Consistencies for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to provide food and liquids in the appropriate texture and consistency as ordered for residents with special dietary needs. During dinner service, 13 residents on pureed diets were served pureed meat that was not smooth, with visible meat fibers still intact. The Food and Nutrition Services Director confirmed that the pureed beef did not meet the required smooth, mashed potato-like texture, and stated that the food should have been blended longer to achieve the correct consistency. Facility documentation confirmed that these residents had physician orders for pureed diets, and the facility's own guidelines specified that pureed foods should be smooth and moist. Additionally, a resident with a physician order for nectar thick liquids was served milk with undissolved thickener at the bottom of the cup and a regular shake instead of a nectar thick shake. Both the LVN and CNA acknowledged that the milk was not properly mixed and that the resident received the incorrect shake consistency. The Registered Dietitian confirmed that the resident should have received a nectar thick shake and that improperly thickened liquids could discourage fluid intake. Another resident with an order for nectar thick liquids was observed receiving Jello and milk with a pudding-like consistency. The LVN stated that Jello was not appropriate for this resident, as it could melt and become a thin liquid, and that the pudding consistency milk could discourage the resident from drinking. The Registered Dietitian also confirmed that Jello should not be served to residents on nectar thick liquids and that incorrect consistencies could negatively impact fluid intake. Facility policies and procedures required that diet orders be followed and that thickened liquids be prepared to the prescribed consistency.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. Surveyors observed dust accumulation in multiple areas of the kitchen, including the dry storage room and back door frame, which was confirmed by the Food and Nutrition Services Director (FNS) and Registered Dietitian (RD) as a potential source of cross contamination. Staff members, including a Dietary Aide and the Engineering Plant Director, were observed working in food preparation areas with unrestrained facial hair, contrary to facility policy and professional standards. Additionally, open bags of frozen vegetables were found exposed to air in the walk-in freezer, and the refrigerator gasket had black grime buildup, both of which were acknowledged by staff as risks for cross contamination. Further deficiencies included improper storage and handling of food and kitchenware. Three baking pans of pizza were stored near a sanitizer bucket with an air gap, and wilted produce was found in the walk-in refrigerator. The cabinet used to store kitchenware had chipped wood, and two hot waterspouts had calcium buildup. Unsanitary practices were also observed, such as ice bags placed on the floor of the facility lobby, a dirty rag on a clean coffee cart, and eight expired boxes of English muffins in the dry storage pantry. Staff interviews confirmed a lack of knowledge regarding proper cleaning and sanitizing procedures, including the correct use and testing of Quaternary (Quat) sanitizer, the appropriate concentration for sanitizing solutions, and the correct steps for cleaning meal carts and calibrating food thermometers. The survey also revealed that staff were unable to demonstrate or articulate the required procedures for submerging kitchenware in sanitizer, as per manufacturer guidelines. These failures were corroborated by interviews with the FNS and RD, who confirmed that the observed practices did not align with facility policies or professional standards. The cumulative effect of these deficiencies had the potential to result in the contamination of food and food contact surfaces, posing a risk of foodborne illness to all residents receiving food from the kitchen, all of whom were medically compromised.
Failure to Implement QAPI Plan for Staffing, Dietary, and Laundry Deficiencies
Penalty
Summary
The facility failed to maintain a written Quality Assurance Performance Improvement (QAPI) plan to address systemic process issues related to CNA staffing, dietary, and laundry services. During the recertification survey, surveyors identified ongoing deficiencies in these areas, as referenced under F725 (nursing staff), F804 (food services), and F584 (laundry services). An interview and record review with the Administrator revealed that, although a QAPI committee was in place with representation from key facility leadership and departments, the committee did not have a program that identified, corrected, or improved the issues affecting CNA staffing, dietary, and laundry services. As a result of these failures, multiple residents did not receive appropriate services in the areas of CNA staffing, dietary, and laundry. The lack of a comprehensive and data-driven QAPI plan meant that the facility did not systematically address or monitor these deficiencies, which affected the quality of care and services provided to residents. The facility's own policy required the QAPI committee to develop, implement, and monitor corrective actions for identified quality issues, but this process was not followed for the cited areas.
Infection Control Failures in IV Care, Laundry Practices, and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several observed instances. During a lunch meal service, a resident with an intravenous (IV) access had loose IV tubing without an end cap, which was observed touching the food on her plate. The nurse responsible for taping the IV tubing confirmed that the tubing should have been secured to prevent contamination, and the Infection Preventionist agreed that the tubing should have been taped and possibly netted to avoid contact with food, as per facility policy. In the laundry department, staff were unable to state or monitor the required washer and dryer temperatures necessary for effective disinfection of linens and clothing. Laundry staff reported that they did not check temperatures, were unaware of the required standards, and did not keep logs of temperature checks. The Maintenance Director used an infrared gun to check equipment temperatures but did not document the results. The Infection Preventionist stated that staff should be aware of and track these temperatures to prevent the spread of infectious microorganisms, as supported by equipment manuals and federal guidelines. Additionally, improper handling of clean linen was observed. A staff member placed linen that had been touched by a resident back into an uncovered clean linen cart and later covered clean linen with a cover that had been in contact with the floor. The staff member acknowledged these actions were incorrect, and the Infection Preventionist confirmed that such practices could lead to contamination of clean linens. Facility policy requires clean linen to be loaded onto a covered cart and transported appropriately, which was not followed in these instances.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the observation of four bugs, one spider, and one house fly in food storage and preparation areas. During a walkthrough of the dry storage room, four brown bugs with wings and a spider were seen on the ceiling, and the Food and Nutrition Services Director acknowledged that pests should not be present in the kitchen due to the risk of cross contamination of stored foods. Additionally, a house fly was observed landing on a window near the steamtable, further indicating the presence of pests in food service areas. Interviews with facility staff, including the Food and Nutrition Services Director and the Registered Dietician, confirmed that the kitchen is expected to be free of pests to prevent cross contamination and infection control issues. A review of the facility's pest control policy and procedures indicated that the facility is required to maintain an ongoing pest control program to keep the premises free of insects, rodents, and other pests, specifically noting the importance of fly and vermin control in the Food & Nutrition Services Department. Despite these policies, the presence of pests in the kitchen was directly observed.
Deficiencies in Medication Handling, Administration, and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of four residents, as evidenced by multiple deficiencies in medication handling, administration, and documentation. In one instance, a licensed nurse discarded a non-scheduled medication (Ipratropium/Albuterol inhalation solution) into a regular trash bin after dropping it on the floor, rather than using the designated medication disposal bin and documenting the destruction as required by facility policy. The nurse later acknowledged this error during an interview, and the Director of Nursing confirmed the expectation for proper disposal and documentation. During medication administration, the same nurse left several medications unattended on a resident's bedside table while leaving the room to obtain supplies. This included pills, a liquid oral solution, and an inhalation solution. The nurse admitted that medications should not be left unattended, as this could result in them being taken by the wrong person or discarded by the resident. The DON reiterated that medications should always remain with the nurse until administration is complete, in accordance with facility policy. A review of controlled medication records for two residents revealed discrepancies between the narcotic count sheets and the electronic Medication Administration Records (eMAR). Medications were signed out on the count sheets but not documented as administered on the eMAR, resulting in unaccounted doses of Norco and Tramadol. Additionally, another resident did not receive scheduled doses of Norco due to the medication being out of stock and pending pharmacy delivery, as documented in progress notes and confirmed by inventory records. The facility did not have an emergency kit for hospice residents, and the pharmacy supplied only limited quantities of the medication, leading to missed doses. The DON verified these findings and acknowledged the lack of specific pain management policies for hospice residents.
Failure to Serve Meals Concurrently Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that meals were served to all residents at the same time, resulting in two residents not receiving their meals concurrently with others at their tables. On March 17, 2025, one resident was observed sitting in a wheelchair at a dining table with three other residents. While the other residents received their meals, this resident was left waiting and had to ask staff about his food. He remained without his meal for nearly an hour, only receiving it after the others had finished eating. Staff interviews revealed there was no organized system for meal service, leading to confusion and delays in serving certain residents. Another resident experienced similar issues on two occasions. On March 17, 2025, he was observed waiting for his lunch while others at his table were already eating. The following day, he waited approximately 20 minutes for his dinner tray while another resident at his table had already been served. This resident expressed unhappiness and frustration at being left out. Staff, including a CNA and an RN, acknowledged the lack of organization in meal delivery and recognized the negative impact on residents' dignity and well-being. Both residents involved were cognitively intact, with one having a history of diabetes mellitus and the other with diagnoses including depression, diabetes mellitus, and malnutrition. Facility policy reviews confirmed that residents' rights to dignity and equal treatment were not upheld during these incidents, as staff failed to provide meals in a manner that respected their self-esteem and individuality.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents prior to the initiation and administration of psychotropic medications for two residents, as required by its own policy and procedure. For one resident with diagnoses including insomnia, depression, anxiety, dementia, and seizure, medical records showed that Melatonin and Diphenhydramine were administered at bedtime since early September 2024 without any documented informed consent. The Director of Nursing (DON) confirmed during record review that no informed consents were present in the electronic medical records for these medications. For another resident with diagnoses of psychotic disorder with delusions, anxiety, and dementia, Depakote was ordered and administered for labile mood, but the last documented informed consent for this medication was from September 2023. The DON verified that no updated informed consent had been obtained for Depakote since that time, despite the facility's policy requiring renewal every six months. The facility's policy specifies that informed consent must be obtained in writing prior to administration of psychoactive medications and renewed biannually, but this process was not followed for the residents in question.
Failure to Address Resident Grievance Regarding Missing Prosthesis
Penalty
Summary
The facility failed to address a resident's grievance regarding a missing left below-the-knee prosthetic leg. The resident, who had a history of respiratory failure with hypoxia, left leg amputation, and blindness in both eyes, reported the prosthesis missing after a room change approximately seven months prior. The resident stated she notified the charge nurse, administrator, DON, and Social Service Assistant but did not receive any feedback or follow-up. The resident expressed distress over the loss, stating she could no longer get out of bed or walk with her walker, and felt herself getting weaker due to lack of use of the prosthesis. Interviews with facility staff confirmed the prosthesis was reported missing and that searches and insurance contacts were made, but there was no documentation or evidence of prompt resolution or communication with the resident regarding the status of her grievance. The facility's policy required investigation, reporting, and documentation of lost items, as well as safeguarding and replacement of resident property, but these procedures were not followed in this case.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to administer medications according to physician orders for one resident with multiple diagnoses, including hypertensive heart disease, diabetes mellitus, and bradycardia. Review of the resident's records showed that clonidine, hydralazine, and Lantus were not administered as ordered on several occasions. Specifically, clonidine was missed on multiple dates and times, and was sometimes signed as administered without documented blood pressure and pulse readings. Hydralazine was not given as ordered, with some doses missed or administered without proper documentation of vital signs, and in some cases, given when the resident's blood pressure or pulse was below the parameters set by the physician. Lantus was also not administered as ordered on several dates, and there was no documented evidence that blood sugar was checked prior to administration during the review period. During an interview and record review, the DON confirmed that medications should be administered and documented according to physician orders, including recording vital signs and blood sugar checks as required. Facility policy requires that all medications administered be documented on the MAR, including reasons for withholding or not administering medications, and that the person administering the medication sign the record. The review found multiple instances where these requirements were not met, resulting in a failure to provide care and treatment according to orders and established protocols.
Failure to Identify and Report Medication Therapy Irregularities During Monthly Pharmacist Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication therapy irregularities during the monthly Medication Regimen Review (MRR) for three residents. For one resident with a history of myocardial infarction, duplicate Vitamin D orders with the same strength, frequency, and indication were present, resulting in the resident receiving double the intended dose daily for nearly a month. The CP did not identify or report this duplication during the MRR, and the Director of Nursing (DON) confirmed the error upon review. Another resident with a diagnosis of malnutrition was found to have duplicate orders for Omeprazole 20 mg, both with the same strength, frequency, and indication. This led to the resident receiving four doses daily instead of the intended two, as documented in the Medication Administration Record (MAR) over a month-long period. The DON verified the duplication and inappropriate administration, and the CP acknowledged missing this irregularity during the MRR. A third resident, admitted with multiple chronic conditions including chronic pain syndrome and Alzheimer's disease, was on a routine opioid regimen (Percocet) without a corresponding bowel management plan, despite the known risk of opioid-induced constipation. The absence of a bowel regimen was not identified or addressed by the CP during the MRR, and the DON confirmed that no such regimen had been ordered since the initiation of opioid therapy. Facility policies required monitoring for adverse consequences of medications, including constipation from opioids, and mandated the CP to identify such irregularities.
Failure to Prevent Duplicate Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by allowing duplicate medication orders to be administered without review or clarification. For one resident, two separate orders for Vitamin D at the same strength, frequency, and indication were active, resulting in the resident receiving double the intended dose each day over a period of several weeks. The duplicate orders were not identified or clarified by nursing staff, and both were administered as scheduled. Another resident had two active orders for Omeprazole 20 mg, both prescribed for similar gastrointestinal indications and scheduled at overlapping times. This led to the resident receiving up to four doses of Omeprazole daily, rather than the intended two. The DON confirmed that the duplicate orders were not clarified with the physician, and nursing staff continued to administer the medication according to both orders. The facility's policy required nurses to check for correct dosage schedules and clarify any questionable orders with the pharmacy or prescriber prior to administration, but this was not followed in these cases.
Medication Error Rate Exceeds Acceptable Threshold During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a cumulative error rate of 13.79%. During the observation, a licensed vocational nurse (LVN) administered medications to a resident and made four errors out of 29 opportunities. Specifically, the LVN did not administer the scheduled azelastine nasal spray and instead gave an as-needed fluticasone nasal spray. Additionally, the LVN administered a lower dose of Vitamin D3 (2000 IU) instead of the prescribed 5000 IU, and failed to administer cyanocobalamin (Vitamin B12) as ordered. These errors were confirmed through review of the resident's medical records and the Medication Administration Record (MAR), which showed missing documentation for the omitted medications and incorrect documentation for the administered medications. During interviews, the LVN acknowledged the errors, stating that the correct medications were not available in the medication cart and would need to be reordered. The Director of Nursing (DON) confirmed that the expectation was for nurses to check the MAR and medication labels against physician orders before administration. Facility policy required medications to be administered according to written orders and for the MAR to be reviewed at the end of each medication pass to ensure all necessary doses were given and documented.
Failure to Administer and Document Seizure Medication
Penalty
Summary
A significant medication error occurred when a resident with a diagnosis of epilepsy did not receive a prescribed dose of phenobarbital, a medication used to control seizures. The resident's physician had ordered phenobarbital 32.4 mg, seven tablets by mouth at bedtime, but review of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for March showed that the dose was not administered on March 11, and there was no documentation in the MAR or nursing progress notes explaining the omission or indicating that the physician was notified. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) confirmed the absence of documentation and were unaware of the missed dose until it was brought to their attention during the survey. The facility's policy requires that all medication administrations and omissions be documented, and that the physician be notified if a dose is missed. The resident reported a history of experiencing seizures when not receiving phenobarbital and stated that he had previously informed staff to reorder his medication. The Consultant Pharmacist confirmed that missing a dose of phenobarbital could result in a seizure and that any missing administration should be reported immediately. The facility's failure to administer and document the prescribed medication, as well as to notify the physician and document the reason for the omission, resulted in the resident not being free from significant medication errors.
Failure to Provide Timely Dental Consultation
Penalty
Summary
The facility failed to ensure that a dental consultation was provided for a resident who was experiencing oral pain and had a visible bump on her lower gum. The resident, who had severe cognitive impairment and a diagnosis of protein-calorie malnutrition, reported pain when touching the affected area and discomfort while eating. Documentation showed that on March 4, a nurse observed the bump and notified the primary care physician, who then ordered a dental consult. The resident's care plan was updated to coordinate dental care as ordered. Despite these actions, the resident was not seen by the facility dentist during the dentist's visit, nor was an outside dental appointment arranged. Staff interviews confirmed that the dental consult was not completed, and the resident was not included on the list for the facility dentist. The facility's policy required social services to coordinate such referrals, but this was not carried out, resulting in the resident's dental needs remaining unaddressed.
Dietary Supervisor Lacked Required In-Service Training Prior to Full-Time Duties
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Director, who is a Certified Dietary Manager, completed the required six hours of in-service training specific to California dietary service requirements as outlined in Title 22 of the California Code of Regulations before assuming full-time duties as the dietetic services supervisor. During an interview, the Food and Nutrition Services Director stated she was unaware of the requirement to complete this training prior to starting her role. The Registered Dietitian confirmed knowledge of the requirement but was not aware that the Director had not completed the necessary training hours. A review of the facility's job description indicated that the Food and Nutrition Services Director must meet state and federal regulatory qualifications. State regulations require that if a registered dietitian is not employed full-time, a full-time dietetic services supervisor must have completed at least six hours of in-service training on California dietary service requirements before assuming the position. The lack of this required training by the supervisor was identified through interviews and record review.
Failure to Maintain Kitchen Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition when condensation ice buildup was observed on the two fans inside the reach-in freezer, along with a puddle of ice on a box of cut corn on the second shelf. The Food and Nutrition Services Director acknowledged that the freezer was not functioning properly and that condensation ice buildup had occurred intermittently over the past two weeks. The Engineering Plant Director explained that the defrost timer had been affected by the daylight saving time change, leading to temperature fluctuations, condensation, and ice formation, which could impact food quality. No verbal or written work order had been submitted by the dietary department regarding the malfunction. Facility policy requires all equipment to be maintained in good repair.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to provide timely access to personal funds for Resident 2, who had a trust account with the facility. On February 14, 2025, Resident 2 reported that she requested funds from her account on February 13, 2025, but had not received the money. The Business Office Manager Assistant (BOMA) confirmed that Resident 2 requested money either on February 12 or 13, 2025, but the facility had no available funds due to a delay in check signing by the corporate office. The BOMA acknowledged that the facility should have funds available at all times but had no control over the situation. The Administrator (ADM) stated that residents should receive their requested funds on the same business day and was unaware of the issue until later. The facility's policy indicated that residents should have access to their trust account funds if available. Despite the policy, Resident 2 did not receive the requested funds promptly, leading to her being upset. The ADM later stated that the BOMA should have informed her immediately about the lack of available funds to take corrective action.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
The facility failed to administer physician-ordered treatments to two residents, leading to potential worsening of their skin conditions. Resident 2, who was alert and conversant, reported not receiving treatment for her tinea corporis for five days. Her Treatment Administration Record (TAR) showed multiple blanks for prescribed treatments, including Ketoconazole cream and Derma-Smoothe/FS Body Oil, on specific dates in February 2025. Interviews with staff revealed that treatments were missed due to staffing issues, such as the absence of a Treatment Nurse (TN) and reassignments of Licensed Vocational Nurses (LVNs) to other duties. Resident 5, who had cognitive impairment, also experienced lapses in treatment for a wound on her left leg. Her TAR indicated missed applications of Betadine Solution and Nystatin-Triamcinolone Ointment on several occasions. Interviews with Certified Nurse Assistants (CNAs) and LVNs highlighted a lack of communication and unclear responsibilities regarding treatment administration when the TN was unavailable. Staff members were unsure if treatments were provided, and the Director of Nursing (DON) confirmed the absence of documentation for these treatments. The DON acknowledged the facility's struggle with maintaining treatment nurse coverage and stated that charge nurses were expected to administer treatments in the absence of a TN. However, the facility lacked a policy mandating that treatments be provided as ordered by the physician. The DON admitted that without proper treatment, the residents' skin conditions could deteriorate, but there was no evidence that treatments were administered to Residents 2 and 5 as required.
Non-Functioning Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light system was functioning for one of its residents, identified as Resident 1. During unannounced visits on February 14, 19, and 20, 2025, it was observed that the call light in Resident 1's room was plugged into the wall but did not activate when pressed. On February 19, 2025, Resident 1, who was sitting in bed and eating dinner, confirmed that the call light was not working, expressing concern that nobody would know if he needed help. Licensed Vocational Nurse (LVN) 1 also confirmed that the call light was not functioning and acknowledged that it was the responsibility of the charge nurse to ensure it was operational. Resident 1 was admitted to the facility with diagnoses including end-stage renal disease and had moderate cognitive impairment, requiring assistance with daily tasks. His care plan, initiated on December 17, 2024, indicated that he was at risk for falls due to confusion and required prompt response to requests for assistance. The Director of Nursing (DON) stated that all direct care staff and department heads were responsible for ensuring call lights were functioning, and acknowledged that Resident 1's call light should have been operational. The facility's policy required staff to promptly report defective call lights and notify maintenance of any malfunctions.
Broken Floor Tile Poses Safety Risk to Residents
Penalty
Summary
The facility failed to ensure a safe environment for two residents, as a broken floor tile was observed in their room. The damaged tile, located by the restroom door, measured approximately three inches long and two inches wide, with black debris present around the area. This issue was identified during unannounced visits on February 14, 19, and 20, 2025. Resident 3, who uses a wheelchair and has chronic obstructive pulmonary disease, was aware of the broken tile but unsure of how long it had been damaged. Resident 4, who is legally blind and has diabetes mellitus, frequently uses the restroom, increasing the risk of tripping over the broken tile. During the observations, the Licensed Vocational Nurse (LVN) and the Maintenance Director (MTD) acknowledged the broken tile. The MTD became aware of the issue on February 19, 2025, and attempted to procure materials to fix it. The Administrator (ADM) was informed of the broken tile on February 19, 2025, and stated that it was the responsibility of all staff to report such hazards. The facility's policy requires regular inspection and maintenance of resident rooms to ensure safety, but this was not adhered to, resulting in a potential tripping hazard for the residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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