Riviera Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pico Rivera, California.
- Location
- 8203 Telegraph Rd, Pico Rivera, California 90660
- CMS Provider Number
- 055045
- Inspections on file
- 46
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Riviera Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of craniotomy and severe cognitive impairment was not consistently wearing a physician-ordered cranial helmet, as observed and confirmed by staff who were unable to locate the helmet or determine how long it had been missing. The resident's care plan and orders required the helmet to be worn at all times except during showers, but this was not followed, and the resident experienced wound dehiscence and infection requiring antibiotics and wound care. Staff interviews also revealed lapses in communication and follow-up with the physician regarding the resident's care.
A facility failed to maintain a safe environment and provide adequate supervision, leading to a resident's fall and fracture. An LVN left a resident unsupervised, resulting in a fall, while an Activity Staff member failed to verify supervision. Additionally, fall prevention measures were not implemented, including the absence of fall mats and risk indicators. A Morse Fall Scale assessment was not conducted after another resident's fall, increasing the risk of further incidents.
A resident in an LTC facility refused wound care, but the facility failed to notify the primary care physician, breaching professional standards. The resident, who required assistance for daily activities and had specific wound care orders, refused treatment on a specific date. Despite facility policy requiring notification of the physician in such cases, this was not done, risking delayed healing and complications.
The facility failed to implement its isolation precautions policy for two residents. A CNA was observed feeding a resident with candida auris without wearing a gown, and another CNA entered and exited a room of a resident with an ESBL infection without PPE, carrying a used gown outside. Both actions were against the facility's policy requiring PPE for contact isolation.
The facility failed to maintain sanitary food handling practices, as a Dietary Aide did not change gloves between handling food and nonfood items, and an ice scooper was left uncovered in a hallway. The Dietary Supervisor confirmed that these practices were against infection control policies, potentially leading to cross-contamination and foodborne illnesses.
The facility failed to implement and develop person-centered care plans for several residents, leading to deficiencies in care. A resident at high risk for falls did not have floor mats placed as ordered, increasing the risk of injury. Another resident with pressure ulcers was left soiled for extended periods, contrary to the care plan. Additionally, care plans for specific medications were not developed for three residents, hindering proper monitoring and treatment. Staff acknowledged these oversights, emphasizing the importance of care plans for effective resident care.
The facility failed to implement proper interventions for pressure ulcer prevention and care for nine residents. Several residents had low-air-loss mattress settings that did not match their weights, potentially worsening their pressure ulcers. Additionally, a resident was left soiled for hours, and another was not repositioned as required, leading to skin damage. These deficiencies were acknowledged by staff, highlighting a lack of adherence to care plans and physician orders.
The facility failed to implement enhanced barrier precautions (EBP) for four residents with severe pressure ulcers, increasing the risk of MDRO spread. Observations revealed a lack of appropriate signage and PPE, despite facility policy and CDC guidance requiring EBP for residents with wounds. Staff interviews confirmed reliance on signage to determine EBP needs, which was absent for these residents.
The facility failed to obtain informed consent for psychotropic medications and bed side rails for three residents. A resident with depression and dementia received medications without consent documentation. Another resident with schizophrenia and anxiety received medications and bed rails without proper staff verification. A third resident with anxiety and depression was given lorazepam without a physician's signature on the consent form. Staff interviews confirmed the deficiency, and the facility's policy was not followed.
A facility failed to protect a resident's confidential information by not removing their name from a GT feeding bottle before disposal. The resident, with multiple medical conditions and impaired cognitive skills, had their personal information exposed, violating HIPAA requirements. An LVN confirmed the oversight, acknowledging the need to remove or obscure the name to maintain confidentiality.
A resident experienced unplanned weight loss over several months, dropping from 260 to 252 pounds, without the care plan being revised to address this issue. The facility also failed to involve the RD in the care planning process, despite policy requirements for multidisciplinary input. The resident's care plan included interventions like encouraging increased oral intake but was not updated despite continued weight loss.
A resident with severe cognitive impairment and chronic conditions was administered Norco by an LVN, who failed to document the administration on the MAR and Pain Assessment Flowsheet. This discrepancy was discovered during a review of the resident's medication records, revealing a risk of double dosing. The DON confirmed that proper documentation was required to prevent such risks, as outlined in the facility's medication administration policy.
The facility failed to provide communication boards for three residents who did not speak English, as required by their care plans. This deficiency was identified through observations and interviews, revealing that the absence of language boards hindered effective communication and potentially delayed care. The residents involved had various medical conditions and required assistance with daily activities, highlighting the importance of proper communication tools.
The facility failed to ensure that dependent residents were regularly taken out of bed, affecting three residents. Observations showed that these residents were consistently found lying in bed over several days. Their medical records indicated cognitive impairments and dependency on staff for ADLs. Interviews with staff revealed that while residents were allowed to choose when to get out of bed, it was important for their socialization and health. The deficiency could negatively impact the residents' well-being and psychosocial status.
A resident with severe cognitive impairment and a high risk of falls did not have floor mats placed on both sides of their bed as required by physician orders. Observations showed only one mat on the right side, and staff confirmed the absence of a mat on the left side, contrary to the facility's fall prevention policies.
A resident on a no added salt diet experienced unplanned weight loss due to the facility's failure to provide salt alternatives and refer the resident to a Registered Dietician (RD) as ordered. The resident complained of unappetizing meals, leading to decreased intake. Despite documented weight loss, the care plan was not revised, and the RD was not involved until months later. Interviews revealed the Dietary Supervisor did not order salt alternatives from a more expensive vendor, and the facility's policy for multidisciplinary care planning was not followed.
The facility failed to display 'No Smoking/ Oxygen in Use' signs for two residents using oxygen, posing a potential fire hazard. Despite the facility's policy requiring such signage, observations revealed its absence in the rooms of residents with significant medical conditions, including dementia and COPD. Staff interviews confirmed the oversight and acknowledged the associated risks.
A facility failed to accurately document the administration of Norco for a resident, leading to a discrepancy between the Medication Count Sheet and the actual number of tablets. The LVN admitted to not recording a dose after administration, which was confirmed by the DON. The facility's policy requires accurate documentation to prevent drug diversion.
A resident on a no added salt (NAS) diet experienced unplanned weight loss and dissatisfaction with meals due to the facility's failure to provide salt alternatives. The resident, with heart failure and hypertension, used high-sodium hot sauce packets for flavor, unaware of their sodium content. The Dietary Supervisor did not order salt alternatives from a more expensive vendor, and the LVN failed to check for high-sodium condiments, contributing to the deficiency.
A resident on a no added salt (NAS) diet was provided Tapatio brand hot sauce packets without physician notification or orders, despite having heart failure, stroke, and hypertension. The dietary supervisor admitted the resident received the packets due to preference, and the resident was unaware of the high sodium content. The facility's policy required a care plan to address dietary dissatisfaction, which was not implemented.
The facility failed to ensure that three residents understood the binding arbitration agreements they signed upon admission. Despite having intact cognitive skills, the residents were not adequately informed about the nature of the arbitration agreement, which waived their right to resolve disputes in court. Interviews revealed that the residents did not receive clear explanations from the facility staff, highlighting a deficiency in communication and understanding.
The facility was found to have overcrowded resident rooms, with one room accommodating five residents and another four, exceeding the regulatory limit. A waiver was submitted for these rooms, which were used for higher acuity residents, but the Administrator acknowledged the risk of decreased space and potential discomfort for residents.
The facility failed to provide the required minimum square footage per resident in 31 rooms, with measurements falling short of federal regulations. Despite space for movement and necessary equipment, the rooms did not meet the 80 sq. ft. per resident requirement. A room variance waiver was submitted, acknowledging the space constraints but asserting no adverse effects on residents' health and safety.
A resident was not readmitted to a facility after hospitalization despite being deemed appropriate to return. The resident, initially admitted with cellulitis and a pressure ulcer, refused some care, leading to a hospital transfer. The facility's IDT decided against readmission, citing the resident's refusal of care, despite available beds and the facility's capability to provide necessary care.
A facility failed to conduct pain assessments every shift for a resident with severe cognitive impairment and multiple health issues, as ordered by the physician. The resident's MAR showed a missed pain assessment during a specific shift, confirmed by both an LVN and the DON. The facility's policy required consistent pain assessment, highlighting a lapse in adherence to the protocol.
A resident with multiple medical conditions, including a previous fracture and functional quadriplegia, was injured when a CNA attempted to reposition her alone without adjusting the low air loss mattress settings. This led to the resident sliding near the edge of the bed and sustaining a fracture that required hospitalization. The care plan specified a two-person assist and proper mattress adjustments, which were not followed.
Failure to Ensure Resident Wore Cranial Helmet as Ordered
Penalty
Summary
The facility failed to ensure that a resident who had undergone a craniotomy consistently wore a cranial helmet as ordered by the physician. Observations revealed that the resident was not wearing the helmet on multiple occasions, and both a CNA and an LVN were unable to locate the helmet or determine how long it had been missing. The resident's care plan and physician orders specified that the helmet should be worn at all times except during showers, but staff interviews confirmed that this was not being followed. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had a history of behaviors such as removing the helmet and picking at the surgical site. Record reviews indicated that the resident had a surgical incision with staples on the head and had experienced episodes of wound dehiscence and infection, requiring antibiotics and wound care. Staff interviews further revealed a lack of communication and follow-up with the resident's physician regarding the care plan and orders. The failure to ensure the resident wore the cranial helmet as ordered placed the resident at risk for further injury and delayed healing, as directly noted in the report.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for two residents, leading to significant deficiencies in care. A Licensed Vocational Nurse (LVN) left a resident unattended and unsupervised at a nurse's station, despite the resident being at high risk for falls. The resident subsequently fell and sustained a displaced subcapital left femoral neck fracture, requiring surgical intervention. The LVN admitted to not ensuring another staff member was supervising the resident, which could have prevented the fall. Additionally, an Activity Staff member left the same resident at a nurse's station without verifying that a charge nurse was present to supervise. This lack of verification and communication contributed to the resident being left unsupervised, increasing the risk of falls. The facility's policy required staff to inform the charge nurse whenever a resident was transferred to a supervised area, which was not followed in this instance. The facility also failed to implement necessary fall prevention measures for both residents. One resident did not have bilateral fall mats at her bedside as ordered by the physician, and neither resident had fall risk indicators outside their rooms or on their mobility aids, as required by their care plans. Furthermore, a Morse Fall Scale assessment was not conducted following the second resident's fall, which is a critical step in assessing and mitigating fall risks. These deficiencies placed both residents at risk for further falls and injuries.
Failure to Notify Physician of Resident's Wound Care Refusal
Penalty
Summary
The facility failed to notify the primary care physician when a resident refused wound care, which is a breach of professional standards of quality. The resident, who was cognitively intact and dependent on assistance for activities of daily living, had been admitted with diagnoses related to orthopedic aftercare following a surgical amputation. The Treatment Administration Record (TAR) for January 2025 indicated specific wound care orders for various parts of the resident's body, including the left below-knee amputation site and other areas requiring monitoring and treatment. On January 5, 2025, the resident refused all wound care, but the physician was not informed of this refusal, as confirmed by a Licensed Vocational Nurse and the Director of Nursing. The facility's policy required documentation of the practitioner's notification and response in cases of treatment refusal, which was not adhered to in this instance. This oversight placed the resident's wounds at risk for delayed healing and potential complications, as noted in the report.
Failure to Implement Isolation Precautions
Penalty
Summary
The facility failed to implement its policy and procedure for isolation and transmission-based precautions for two residents. For Resident 3, a CNA was observed feeding the resident without wearing a gown, despite a contact isolation sign outside the room indicating the need for PPE. The resident was on contact isolation due to a diagnosis of candida auris, a serious fungal infection. The CNA acknowledged the oversight, and the LVN confirmed that the CNA should have been wearing a gown and gloves to prevent the transmission of organisms. For Resident 4, another CNA entered and exited the resident's room without wearing any PPE, despite a contact isolation sign indicating the requirement. The resident was on contact isolation due to an ESBL infection in the urine. The CNA was observed leaving the room with a used isolation gown in hand, which should have been discarded inside the room. The LVN confirmed that the gown should not have been taken out of the room as it was contaminated. The facility's policy indicated that gloves and disposable gowns should be used upon entering a contact precaution room, and contaminated gowns should not contact potentially contaminated surfaces or items in the resident's room.
Deficient Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation practices in the kitchen, as observed during a survey. A Dietary Aide (DA 1) did not change gloves between handling food items and nonfood items, such as touching a doorknob and receiving a menu slip from nursing staff. Despite being trained to change gloves after touching nonfood items, DA 1 continued to handle resident food trays and drinks without removing the gloves, which was against the facility's infection control policy. The Dietary Supervisor confirmed that staff were instructed to change gloves to prevent cross-contamination and foodborne illnesses. Additionally, the facility did not provide a closed container for the ice scooper, which was left uncovered and exposed to air in the hallway. A resident in a wheelchair was observed touching the scooper while using the table to propel himself. The Dietary Supervisor acknowledged that the kitchen staff were responsible for ensuring the scooper was covered to prevent contamination. The facility's policy indicated that proper glove use and covering of utensils were essential to prevent foodborne illnesses.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans and interventions for several residents, leading to deficiencies in care. For Resident 72, the facility did not implement the physician's order to place floor mats on both sides of the bed, which was crucial due to the resident's high risk of falls. Despite the care plan indicating the need for fall interventions, observations revealed that only one floor mat was consistently placed on the right side of the bed, contrary to the physician's orders. This oversight was confirmed by both a CNA and an RN, who acknowledged the discrepancy and the potential risk of injury to the resident. Resident 39 experienced a significant lapse in care as the facility failed to maintain cleanliness and timely incontinence care, as outlined in the care plan. The resident, who had multiple pressure ulcers, reported being left soiled for extended periods during the night shift, which was corroborated by the resident's roommate and the treatment nurse. The treatment nurse emphasized the importance of timely perineal care to prevent the worsening of pressure ulcers, and the RN confirmed that the care plan was not followed, which could hinder the healing process and increase the risk of infection. Additionally, the facility did not develop care plans for the use of specific medications for Residents 92, 65, and 130, which are essential for monitoring potential adverse reactions and ensuring proper treatment. Resident 92's care plan did not address the use of Plavix, lorazepam, and morphine sulphate, while Resident 65's care plan lacked details on Eliquis and tramadol. Similarly, Resident 130's care plan did not include escitalopram, lorazepam, Risperdal, and Valproic Acid. The MDS Coordinator and the DON both acknowledged the absence of these care plans, highlighting the importance of having them to monitor for side effects and ensure the medications' effectiveness in treating the residents' conditions.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper interventions to prevent the formation and worsening of pressure ulcers for nine residents. Several residents were observed with low-air-loss mattress (LALM) settings that did not correspond to their actual body weights, which could negatively impact their existing pressure ulcers. For instance, Resident 24's LALM was set for 50 lbs, while their actual weight was 161 lbs, and the physician's order was not clarified. Similarly, Resident 72's LALM was set for a range of 600 to 1000 lbs, despite their weight being 137 lbs. These incorrect settings were acknowledged by the treatment nurse, who stated that the settings could adversely affect the residents' wounds. In addition to incorrect LALM settings, the facility failed to maintain adequate hygiene and repositioning protocols for residents with pressure ulcers. Resident 39 was left soiled for extended periods, up to five and a half hours, which was against the care plan that required cleaning after each episode of incontinence. This neglect was confirmed by both the resident and their roommate, who reported that staff did not respond to call lights during the night shift. The treatment nurse and a registered nurse emphasized the importance of timely cleaning to prevent worsening of pressure injuries and infections. Furthermore, Resident 92 was not repositioned every two hours as required by their care plan, which led to the development of moisture-associated skin damage on their sacrum. Observations showed that Resident 92 remained in the same position for several hours, contrary to the physician's order and care plan interventions. The registered nurse confirmed that failure to reposition residents with limited mobility could lead to pressure injuries and increased risk of infection.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents, increasing the potential for the spread of multidrug-resistant organisms (MDROs). Resident 72, who was admitted with severe cognitive impairment and a Stage IV pressure ulcer, did not have signage indicating the need for EBP, despite the presence of a roommate who required such precautions. Observations over two days confirmed the absence of appropriate signage and EBP implementation for Resident 72. Resident 24, admitted with quadriplegia and a Stage III pressure ulcer, also lacked signage and personal protective equipment (PPE) outside their room. Multiple observations confirmed the absence of EBP signage and PPE, even when a phlebotomist was present, indicating a failure to follow necessary precautions. Interviews with staff revealed a reliance on signage to determine EBP requirements, which was not present for Resident 24. Residents 62 and 39, both with severe pressure ulcers and other significant health issues, similarly lacked EBP signage and implementation. Observations showed that signage only indicated EBP for their roommates, not for the residents themselves. The Infection Preventionist Nurse confirmed that the facility's policy required EBP for residents with wounds, as per CDC guidance, but this was not being followed, posing a risk for MDRO spread.
Failure to Obtain Informed Consent for Medications and Bed Rails
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications and using bed side rails for three residents. Resident 9, who was diagnosed with depression and dementia, lacked the capacity to make decisions. Despite this, the facility administered mirtazapine and memantine without obtaining informed consent from the responsible party. The medical records did not contain any documentation of informed consent for these medications. Resident 68, diagnosed with schizophrenia and anxiety disorder, had moderately impaired cognitive skills but was capable of making decisions. The facility administered Ativan and Zyprexa without proper verification of informed consent, as the consent forms lacked the facility staff's signature. Additionally, the informed consent for the use of bilateral upper bed side rails was also missing the necessary staff signature. Resident 121, with severe cognitive impairment due to anxiety and depression, was administered lorazepam without a physician's signature on the informed consent form. Interviews with facility staff, including an LVN and the ADON, confirmed that informed consent was incomplete and that medication or treatment should not have been initiated without all required signatures. The facility's policy required informed consent to be obtained and verified before administering psychotropic medications or using side rails, but this was not adhered to in these cases.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from a gastrostomy tube (GT) feeding bottle before disposing of it in the trash. During an observation, a GT feeding bottle with the resident's name was found in the trash can in the resident's room. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the resident's name should have been removed or blackened out before disposal to comply with the Health Insurance Portability and Accountability Act (HIPAA) requirements. The resident involved, identified as Resident 100, had multiple medical conditions, including diabetes mellitus, dysphagia, chronic obstructive pulmonary disease, and hypertension. The resident was also noted to have severely impaired cognitive skills and was dependent on others for self-care and mobility. The facility's policy on maintaining the dignity and confidentiality of clinical information was not adhered to, as evidenced by the failure to protect the resident's personal information on the discarded GT feeding bottle.
Failure to Revise Care Plan and Involve RD in Weight Loss Management
Penalty
Summary
The facility failed to revise the care plan for a resident who did not meet the goal of maintaining her body weight without additional weight loss. The resident, who had diagnoses of heart failure and stroke, was admitted to the facility and had no cognitive impairment, allowing her to eat independently. Despite a care plan goal to maintain her weight, the resident experienced unplanned weight loss over several months, dropping from 260 pounds to 252 pounds. The care plan, dated September 8, 2024, included interventions such as encouraging increased oral food intake but was not revised despite continued weight loss. Additionally, the facility did not involve the Registered Dietician (RD) in the care planning process for the resident's weight loss. The RD was not consulted until November 14, 2024, despite the facility's policy requiring multidisciplinary input, including from the RD, for care planning related to weight loss. The policy also required monitoring and reassessment, which were not adequately addressed, as the care plan was not updated to reflect the resident's ongoing weight loss and potential causes, such as poor oral intake.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly documented the administration of Norco, a medication used to treat moderate to severe pain, for a resident. The LVN did not sign the Medication Administration Record (MAR) and Pain Assessment Flowsheet immediately after administering the medication. This oversight was identified during a review of the resident's medication records, which revealed a discrepancy between the number of doses recorded and the actual number of tablets remaining in the medication bubble pack. The resident involved had a history of dementia, chronic kidney disease, and contractures, and was dependent on staff for various activities of daily living. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and the need for pro re nata (PRN) pain medication. The LVN admitted to administering Norco to the resident but failing to document the administration on the MAR and Pain Assessment Flowsheet, which are essential for tracking medication administration and assessing the effectiveness of pain management. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document medication administration immediately after giving the medication to ensure proper communication and prevent potential double dosing. The facility's policy on administering medications outlined the necessary documentation steps, including recording the date, time, dosage, and any symptoms or results observed. The failure to document the administration of Norco as per the facility's policy posed a risk of double dosing and potential overdose for the resident.
Failure to Provide Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that nursing staff used communication boards for three residents who did not speak English, the predominant language of the facility. This deficiency was identified through observations, interviews, and record reviews. Resident 15, who only spoke Spanish, did not have a language board in their room, despite their care plan indicating the need for one. The resident's family confirmed the language barrier, and a Certified Nursing Assistant (CNA) acknowledged the absence of the board, which was necessary for effective communication. Similarly, Resident 84, who spoke limited English, also lacked a language board in their room. The resident's care plan specified the need for a Spanish language board, but it was not provided. A CNA confirmed the necessity of the board to communicate with the resident and prevent delays in care. The resident's medical history included hepatic failure, dysphagia, hypertension, chest pain, and anemia, with intact cognitive skills for daily decision-making. Resident 40, who had fluctuating capacity to understand and make decisions, was also without a Spanish language board. Despite being able to communicate in both English and Spanish, the care plan required a Spanish board to facilitate communication. Observations and interviews with staff confirmed the absence of the board, which was essential for meeting the resident's needs. The facility's policy on interpreter services mandated the provision of communication boards for non-English speakers, which was not adhered to in these cases.
Failure to Transfer Residents Out of Bed
Penalty
Summary
The facility failed to ensure that dependent residents were taken out of bed, affecting three out of eight sampled residents. Observations revealed that Resident 121 was consistently found lying in bed watching television over several days. The resident's records indicated severe cognitive impairment and dependency on staff for activities of daily living (ADLs). The ADL flowsheet showed that Resident 121 was not transferred out of bed from the beginning of November until the 14th. Similarly, Resident 5 was observed lying in bed during multiple observations. The resident's medical history included major depressive disorder and anxiety disorder, with severe cognitive impairment noted in the Minimum Data Set (MDS). The ADL flowsheet for October showed limited instances of being transferred out of bed, and none from November 1st to 14th. Resident 14 was also observed lying in bed during several observations. The resident had a diagnosis of anxiety disorder and hemiplegia, with moderate cognitive impairment and dependency on staff for ADLs. The ADL flowsheet indicated that Resident 14 was not transferred out of bed throughout October and the first half of November. Interviews with staff, including Licensed Vocational Nurses and the Director of Staff Development, revealed that the facility allowed residents to choose when to get out of bed. However, it was acknowledged that getting residents out of bed was important for socialization, preventing depression, and offloading pressure from the body. The Assistant Director of Nursing stated that staff should offer all residents the opportunity to get out of bed daily to aid circulation and provide a change in environment. The failure to regularly transfer these residents out of bed was identified as a deficiency that could negatively impact their well-being and psychosocial status.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that floor mats were placed on both sides of the bed for a resident with a history of falls, increasing the potential for injury. The resident, who was admitted with diagnoses including lack of coordination, generalized muscle weakness, osteoporosis, and Alzheimer's disease, was assessed as having severe cognitive impairment and was dependent on staff for activities of daily living and mobility. Physician orders specifically required floor mats on both sides of the bed to minimize injury risk, and the resident was part of the Falling Star Program due to a high risk of falls as indicated by a Morse Fall Scale score of 55. Observations and interviews revealed that only one floor mat was consistently placed on the right side of the resident's bed, contrary to the physician's orders and the facility's policies. Staff, including a CNA and an RN, confirmed the absence of a floor mat on the left side of the bed, acknowledging the discrepancy with the physician's orders. The facility's policies required staff to implement appropriate fall interventions, which were not followed in this case, as evidenced by the lack of a floor mat on both sides of the bed as prescribed.
Failure to Provide Salt Alternative and RD Referral Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide a salt alternative seasoning for a resident on a no added salt (NAS) diet, as well as failed to refer the resident to a Registered Dietician (RD) as ordered by the physician. The resident, who had diagnoses including heart failure, stroke, and high blood pressure, experienced unplanned weight loss over several months. Despite the physician's order for a NAS diet, the facility did not have salt alternatives available, which led to the resident's complaints of unappetizing and flavorless meals, resulting in decreased intake of facility-provided meals. The resident's weight loss was documented from June to November, with a total loss of 14 pounds. The facility's interdisciplinary care team did not address the resident's weight loss in care conferences, and dietary staff were not present at these meetings. The resident's care plan was not revised to address the ongoing weight loss, and the RD was not involved in the care planning process until November, despite a physician's order in September to refer the resident to the RD. Interviews with facility staff revealed that the Dietary Supervisor was aware of the lack of salt alternatives but did not order them from a more expensive vendor. The RD confirmed that she had not received any referrals for the resident prior to November. The facility's policy indicated that care planning for weight loss should be a multidisciplinary effort, including input from the RD, but this was not followed. The resident expressed feeling hungry and noted that the weight loss was unintentional.
Failure to Display Oxygen Safety Signage
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its policy for two residents, as observed by surveyors. Specifically, the facility did not display 'No Smoking/ Oxygen in Use' signs on the doors or inside the rooms where oxygen was being used for two residents. This oversight was noted during multiple observations over two days, where both residents were using oxygen concentrators at their bedsides without the required signage. Resident 32, who was using oxygen via a nasal cannula, had a history of congestive heart failure, pneumonia, epilepsy, generalized muscle weakness, and dementia. The resident's cognitive skills were severely impaired, and they were dependent on assistance for self-care and mobility. Despite these conditions, the necessary safety signage was absent from their room, as confirmed by both a CNA and an RN during interviews. Similarly, Resident 15, who also required oxygen, had diagnoses including sepsis, pleural effusion, COPD, anemia, and dementia. Although this resident was more independent in daily activities, the absence of 'No Smoking/ Oxygen in Use' signs was again noted. An RN confirmed the lack of signage and acknowledged the potential fire hazard posed by this deficiency. The facility's policy, revised in 2010, clearly required such signage for oxygen administration, but it was not adhered to in these cases.
Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate and complete documentation of the administration of Norco, a medication used to treat moderate to severe pain, for a resident. The resident, who was admitted with diagnoses including dementia, chronic kidney disease, and contractures, was prescribed Norco to be administered every six hours as needed for severe pain. During an observation and interview, it was found that there was a discrepancy between the number of Norco tablets recorded on the Medication Count Sheet and the actual number of tablets remaining in the bubble pack. Specifically, the Medication Count Sheet indicated that 24 doses should remain, but only 23 doses were present in the bubble pack. The Licensed Vocational Nurse (LVN) responsible for administering the medication admitted to not documenting the administration of a dose on the Medication Count Sheet after giving it to the resident. The Director of Nursing confirmed that the LVN was responsible for documenting the administration of controlled medications immediately after dispensing them to ensure accountability and prevent drug diversion. The facility's policy on controlled substances requires that an individual resident controlled substance record be maintained, including the number of doses on hand and the signature of the nurse who administered the dose.
Failure to Provide Salt Alternatives for NAS Diet
Penalty
Summary
The facility failed to provide a salt alternative seasoning for a resident on a no added salt (NAS) diet, leading to complaints of unappetizing and flavorless meals. This deficiency was identified for a resident who had been admitted with diagnoses including heart failure, stroke, and hypertension. Despite having the capacity to understand and make decisions, the resident experienced consistent weight loss over several months, which was not planned or intentional. The resident resorted to using high-sodium hot sauce packets to add flavor to her meals, unaware of their sodium content, due to the unavailability of salt alternatives. Interviews with the Dietary Supervisor (DS) revealed that the facility did not have salt alternatives available, and the DS had not ordered them from a more expensive vendor despite knowing their importance for residents on a NAS diet. The DS acknowledged that decreased palatability could lead to reduced food intake and weight loss. The Licensed Vocational Nurse (LVN) responsible for checking meal trays admitted to not checking for high-sodium condiments, which could exacerbate the resident's medical conditions. The facility's Registered Dietician confirmed that the resident was not on a planned weight loss regimen, and the Registered Nurse (RN) noted that the facility should have addressed the resident's oral intake and food palatability. The facility's policies indicated that care planning for weight loss should be a multidisciplinary effort, including input from the RD, and that documenting meal refusal due to non-compliance was inappropriate. However, these policies were not effectively implemented, contributing to the resident's undesirable weight loss and dissatisfaction with meals.
Failure to Adhere to NAS Diet for Resident
Penalty
Summary
The facility failed to notify the physician and obtain orders before providing Tapatio brand hot sauce packets to a resident on a no added salt (NAS) diet. The resident, who had heart failure, stroke, and hypertension, was observed with hot sauce packets on her meal tray, despite her diet restrictions. The dietary supervisor acknowledged the absence of salt alternatives and admitted that the resident was given hot sauce packets due to her preference, even though it was not compliant with her dietary orders. The resident was unaware of the high sodium content in the hot sauce and used it to enhance the flavor of her meals, as no salt alternatives were available. The licensed vocational nurse confirmed that the resident's physician was not informed about the hot sauce use, and the registered dietician was only consulted after the issue was identified. The facility's policy indicated that staff should create a care plan that satisfies the resident if they are unhappy with their prescribed diet, but this was not done in this case.
Failure to Ensure Residents Understood Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents understood the binding arbitration agreement they entered into upon admission. The residents, identified as Resident 39, 107, and 339, were not adequately informed about the nature of the arbitration agreement, which is a method of resolving disputes without going to court. Despite having intact cognitive skills for daily decision-making, as indicated by their Minimum Data Set (MDS) assessments, these residents were not provided with a clear explanation of the arbitration agreement by the facility staff. Interviews with the residents revealed that they were unaware that signing the agreement waived their right to resolve disputes in court. The deficiency was further highlighted during interviews with the facility's Admissions Coordinator and Administrator. The Admissions Coordinator acknowledged her responsibility to explain admission paperwork, including the arbitration agreement, to residents or their representatives. However, the residents reported that they did not receive such explanations. The Administrator emphasized the importance of ensuring residents understand the complex terms of the arbitration agreement and their right to accept or decline it. This lack of communication and understanding led to the residents unknowingly entering into binding arbitration agreements with the facility.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to comply with regulations regarding the maximum number of residents per room, as observed during a survey. Specifically, two rooms were found to accommodate more residents than allowed. Room [ROOM NUMBER] had five residents, and room [ROOM NUMBER] had four residents, exceeding the limit of four residents per room. This was confirmed through a review of the facility's Census dated 11/12/2024, which listed the residents occupying these rooms. Additionally, a Room Variance Waiver letter submitted by the Administrator indicated that these rooms were used for higher acuity residents requiring more care, and the waiver was intended to address the special needs of these residents without adversely affecting their health and safety. During a facility tour and interview with the Administrator, it was observed that the rooms had sufficient space for residents to move around, and there was adequate room for beds, side tables, and care equipment. However, the Administrator acknowledged the risk of decreased space for residents, staff, and equipment, and the potential discomfort for residents due to the overcrowding. The waiver was submitted because the rooms were occupied by more than the allowed number of residents, highlighting the facility's awareness of the issue but not addressing the regulatory requirement.
Deficient Room Space in Facility
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, affecting 31 out of 50 rooms. According to federal regulations, each resident in a shared room should have at least 80 square feet of space. However, the facility's census and room measurements revealed that several rooms did not meet this requirement. Specifically, rooms designated for two residents measured between 142.30 and 157.98 square feet, while rooms for three residents measured between 197.96 and 259.48 square feet, all falling short of the required space per resident. During a facility tour and interview with the Administrator (ADM), it was noted that although there was space for residents to move and for necessary furniture and equipment, the rooms did not meet the federal space requirements. The ADM acknowledged the risk of decreased space for residents, staff, and equipment, which could lead to discomfort for the residents. A room variance waiver had been submitted for these 31 rooms, indicating that the space constraints were recognized by the facility but were deemed not to adversely affect the residents' health and safety or their ability to achieve their highest practicable well-being.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident who was transferred to a General Acute Care Hospital (GACH) after refusing care at the facility. The resident, who was initially admitted with cellulitis, type two diabetes mellitus, and a pressure ulcer, was deemed appropriate to return to the facility by the hospital. Despite the resident's willingness to return and the facility's capability to provide necessary care, the facility refused readmission, citing the resident's previous refusal of care. The resident's initial assessment indicated they were alert, oriented, and cooperative, with multiple open lesions due to cellulitis and an unstageable pressure injury. The resident refused some medications and care, leading to a transfer to the hospital. The facility's interdisciplinary team (IDT) discussed the resident's refusal of care but did not explore alternative options or assess the reasons for the refusal. The facility's policy allowed for readmission if a bed was available, which was the case, but the IDT decided against it, stating the resident's refusal of care as the reason. Interviews with facility staff revealed that the resident was not combative and had agreed to return to the facility if treated for pain and cellulitis. The facility's Director of Nursing (DON) and administrator confirmed the decision not to readmit the resident, despite available beds and the facility's ability to provide necessary care. The facility's assessment and policies indicated they could manage the resident's conditions, but the decision was made based on the resident's initial refusal of care, which was not considered a behavior issue by the facility.
Failure to Conduct Pain Assessments as Ordered
Penalty
Summary
The facility failed to ensure that pain assessments were conducted every shift for a resident, as ordered by the physician. The resident, who had a history of a broken left hip bone, gait and mobility abnormalities, generalized muscle weakness, osteoporosis, contracture of the right hip, and unspecified dementia, was dependent on staff for activities of daily living and mobility. The Minimum Data Set indicated that the resident had severely impaired cognitive skills, which could hinder their ability to communicate pain effectively. During a review of the resident's Medication Administration Record (MAR) for October 2024, it was found that the staff did not assess the resident's pain during the 3:00 PM to 11:00 PM shift on October 9, 2024. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that the pain assessment was missed, despite the physician's orders requiring such assessments every shift. The facility's policy and procedure on pain management emphasized the importance of identifying and assessing pain consistently, especially in residents at risk of having pain.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that Resident 1 was free from injury as indicated in the resident care plan. Resident 1, who had diagnoses including a nondisplaced transverse fracture of the left tibia and fibula, osteoporosis, and functional quadriplegia, was dependent on staff for all activities of daily living. The care plan specified that Resident 1 required a two-person assist for bed mobility, transferring, and toileting, and that staff should handle the resident gently and carefully during care. However, during an incident on 3/16/2024, a CNA attempted to reposition Resident 1 by herself without adjusting the low air loss mattress settings, which led to Resident 1 sliding near the edge of the bed and experiencing pain due to sudden movement. This resulted in a fracture of the left lower leg that required hospitalization for evaluation and treatment. The CNA did not follow the care plan's instructions to use a two-person assist and to adjust the mattress settings, contributing to the resident's injury. Interviews with staff confirmed that the CNA did not change the mattress settings and attempted to reposition the resident alone, contrary to the care plan and facility policies. The Director of Nursing and other staff acknowledged that the proper procedures were not followed, which led to the resident's injury. The facility's policy emphasized the importance of safety and supervision to prevent accidents, but these measures were not adequately implemented in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
