Rosemead Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 4096 Easy Street, El Monte, California 91731
- CMS Provider Number
- 055202
- Inspections on file
- 34
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Rosemead Healthcare Center during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report highlights insufficient hazard identification and lack of proper supervision in the affected area.
A resident with multiple diagnoses who required significant assistance experienced two falls after falling asleep in a wheelchair. The facility did not ensure the IDT Falls Committee met or documented findings and interventions after these incidents, as required by facility policy. The DON confirmed the lack of documentation and meetings following the falls.
A resident with severe cognitive impairment and multiple comorbidities experienced a fall that was not properly documented in the medical record by an LVN. Although the incident was recorded in risk management, the required details were missing from the resident's progress notes, contrary to facility policy. Both the DON and an RN confirmed that such documentation was necessary to inform the healthcare team.
A resident with dementia and hemiplegia experienced two falls resulting in injuries after staff failed to keep personal items within reach and did not complete a required quarterly fall risk assessment. Additionally, the facility did not develop a care plan to address the resident's or family's preference for dining location, leading to inconsistent support of the resident's rights and autonomy.
A resident with severe cognitive impairment and mobility issues experienced two unwitnessed falls, resulting in injury, due to the facility's failure to promptly revise the care plan after each incident. Despite facility policy requiring care plan updates after significant changes in condition, the care plan was not revised until several days after the second fall, leaving the resident without appropriate, individualized interventions.
A resident with severe cognitive impairment and physical limitations was not consistently allowed to choose their preferred dining location, despite family requests for dining room meals. Staff determined meal location based on their own discretion, and the resident's care plan did not include interventions to address this preference, resulting in a failure to support the resident's right to self-determination.
Two residents in an LTC facility experienced a breach of privacy and dignity during personal care. One resident, who was cognitively impaired, was exposed due to early return to a room being deep cleaned, while another resident was exposed to a roommate during perineal care. Staff acknowledged the lack of privacy and the importance of maintaining resident dignity.
The facility failed to ensure call lights were within reach for three residents, including those with dementia and Parkinson's Disease, leading to potential delays in care. Observations revealed call lights were either on the floor or out of reach, contrary to care plans and facility policy. Staff acknowledged the importance of accessible call lights for resident communication.
The facility failed to provide information regarding Advance Directives (AD) for four residents, potentially leading to treatment against their wishes. Residents with impaired cognition and dependence on staff had incomplete AD Acknowledgement Forms, as confirmed by staff interviews. The facility's policy requires these forms to be filled out and accessible to ensure care aligns with residents' wishes.
A resident with osteomyelitis and diabetes did not receive prescribed IV antibiotics on a specific day, and the midline IV site was not labeled with the date of dressing change, contrary to facility policy. This failure in administration and labeling was confirmed by staff and records, highlighting a lapse in infection control and adherence to professional standards.
The facility failed to follow its oxygen administration policy for three residents, leading to potential complications. A resident's nasal cannula tubing was not dated, risking infection. Another resident's inhalation tubing was undated, and no care plan was developed for their oxygen use. Additionally, a third resident's nasal cannula was improperly placed, and a 'no smoking' sign was missing, posing a fire risk.
Three residents requiring dialysis did not have emergency kits at their bedside, as required by facility protocols. This deficiency was identified through observations and interviews, revealing that the absence of E-kits posed a risk of delayed emergency treatment for complications such as bleeding from dialysis access sites. Despite care plans indicating the need for immediate intervention, the necessary emergency supplies were not available, highlighting a lapse in adherence to established care protocols.
The facility failed to follow its policy on the use of bed rails for two residents, leading to potential risks of entrapment and injury. Both residents had grab bars installed without documented attempts of alternative interventions, informed consent, or physician's orders. The residents required varying levels of assistance with daily activities and had moderately impaired cognition.
The facility failed to provide sufficient nursing staff on weekends during Q4 2024, not meeting the required 3.5 nursing hours per patient day and 2.4 CNA direct care hours per patient day on several occasions. The California Department of Public Health denied the facility's request for a workforce shortage waiver, and the facility's policy required these staffing levels. Interviews with the BOM and DON confirmed the staffing shortfalls, which had the potential to affect the quality of care and residents' quality of life.
The facility did not post actual nursing staffing information for three consecutive days, potentially misleading residents and visitors about staffing levels. The Daily Staffing Grid was outdated or missing in Nursing Station 2, contrary to the facility's policy requiring posting in both stations. Interviews confirmed the lack of compliance with the policy.
The facility failed to implement proper infection control measures, including incorrect isolation signage and lack of PPE for residents with MDROs. Residents with infections were not properly isolated, and staff did not adhere to PPE protocols, increasing the risk of infection transmission.
A facility failed to obtain informed consent from a resident's responsible party before administering Ativan, a psychotropic medication. The resident, who was moderately cognitively impaired and required significant assistance, was readmitted with multiple diagnoses. The Assistant Director of Nursing confirmed the absence of consent, which violated the facility's policy and the resident's rights.
A facility failed to accurately code a resident's discharge destination in the MDS, recording it as a short-term general hospital instead of home or community. This error was confirmed by the DON during a review of the resident's records, which indicated the correct discharge destination. The facility's policy requires accurate assessment coordination and certification by a registered nurse.
A facility failed to provide a communication device for a resident whose primary language was Spanish, despite the resident's diagnoses of Parkinson's disease and bipolar disorder. The resident did not have a communication board in their room, which was necessary for effective communication with staff. Interviews with nursing staff confirmed the need for such devices, as outlined in the facility's policy on translation services.
A facility failed to reposition a resident every two hours as required, risking the development of pressure ulcers. The resident, with conditions such as hemiplegia and dependence on dialysis, was observed lying on their back for extended periods. Staff interviews confirmed the necessity of regular repositioning, which was not followed, despite the facility's policy and the resident's care plan indicating the need for such care.
A resident at high risk for pressure ulcers did not receive proper preventive care as ordered. The resident lacked bilateral heel protectors, and the low air loss mattress was set incorrectly, increasing the risk of pressure ulcer development. Staff confirmed these oversights, which were contrary to the facility's policy on pressure ulcer prevention.
A resident experienced severe pain due to the facility's failure to implement non-pharmacological interventions and notify the medical doctor when pain was uncontrolled. Despite a care plan outlining these measures, the resident reported pain levels of 8-9/10 without receiving appropriate interventions or timely medication, leading to significant discomfort.
Expired chicken nuggets were found in the facility's refrigerator, which were confirmed by dietary staff and the RD as expired. The presence of expired food in the kitchen was against the facility's policy on food storage, which requires adherence to good sanitary practices to prevent foodborne illnesses.
A facility failed to complete a required Surveillance Data Collection form for a resident receiving antibiotics for Vancomycin Resistant Enterococcus bacteremia. The resident had moderately impaired cognition and was dependent on staff for daily activities. The Infection Preventionist Nurse was unable to locate the form and was on vacation during the period it should have been completed. The facility's policy emphasizes the importance of monitoring antibiotic use.
The facility failed to maintain a functioning call light system in eight resident rooms, with observations showing inoperable call lights and a lack of alternative call bells provided. Staff interviews confirmed non-compliance with the facility's policy to provide call bells and conduct documented safety rounds when the call system was down, potentially delaying resident care.
A resident with multiple health conditions did not receive their morning medications on time, as observed during a survey. The medications were scheduled for 9 AM but were not administered until after 11 AM. The LVN responsible admitted to falling behind, and the facility's policy requires medications to be given within one hour of the scheduled time to ensure effectiveness.
A resident with significant medical conditions was found with an electronic smoking device in their room, contrary to the facility's policy requiring secure storage and supervision during smoking. Staff interviews revealed that the resident's room sometimes smelled like smoke, and the CNA had reported the issue to a nurse supervisor. The facility's policy prohibited smoking inside and required all smoking materials to be stored securely, but this was not adhered to in this case.
A resident with severe cognitive impairment accessed a meal cart unsupervised and without performing hand hygiene, contrary to the facility's infection control policy. Staff interviews confirmed that residents should not handle meal trays due to safety and infection control concerns, and hand hygiene is required before and after handling trays.
A resident with a history of hemiplegia and dementia fell and sustained a head injury when a CNA attempted a Hoyer lift transfer alone, contrary to facility policy requiring two-person assistance. The resident, dependent on staff for transfers, was injured during the transfer process, highlighting a failure to adhere to safety protocols.
The facility failed to readmit three residents after hospitalization due to a lack of available isolation rooms, despite the residents being cleared for discharge. The residents were initially transferred for emergency medical care, and repeated attempts by the hospital to return them were unsuccessful. The facility's policies on bed hold and transfer/discharge were not adhered to, potentially violating the residents' rights to return.
A resident's medical records were not provided within the required two working days after a request was made, as per the facility's policy. The delay was due to the need for administrative consultation on legal matters, and the records were eventually mailed after the stipulated timeframe.
A facility failed to enforce its COVID-19 Mitigation Plan by allowing two family members to visit a resident under Novel Respiratory Precautions without wearing the required PPE. Despite clear signage, the family members entered the room with only surgical masks. Staff interviews confirmed the oversight, acknowledging the risk of virus spread due to non-compliance with PPE protocols.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Convene and Document IDT Falls Committee After Resident Falls
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) Falls Committee met to review and document findings and interventions after a resident experienced two falls. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, and schizophrenia, required substantial to maximal assistance for several activities of daily living. According to facility records, the resident fell on two separate occasions while in the facility, both times reportedly after falling asleep in a wheelchair. Despite the facility's policy requiring the IDT-Falls Committee to meet within 72 hours of a fall to review the event, conduct a root cause analysis, and document interventions, there was no documentation in the resident's medical record indicating that such meetings occurred after either fall. The Director of Nursing confirmed that the required IDT meetings were not held or documented following these incidents, as evidenced by the absence of relevant entries in the progress notes or IDT assessment forms.
Incomplete Documentation of Resident Fall in Medical Record
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to document the details of a resident's fall in the medical record. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebrovascular disease, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for most activities of daily living. The facility's records indicated that the resident had experienced multiple falls, with the most recent incidents occurring on consecutive days. On the date in question, the LVN was informed by a Certified Nursing Assistant (CNA) that the resident had fallen, and upon assessment, found the resident lying on the floor beside the bed. Despite the incident being recorded in the facility's risk management system, the LVN did not document the fall or the surrounding circumstances in the resident's progress notes, as required by facility policy. The Change in Condition Evaluation noted the occurrence of the fall but lacked pertinent details about the event. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the fall should have been documented in the resident's medical record to ensure the healthcare team was aware of the resident's status. The facility's policy specified that licensed nurses must document the date, time, and relevant details of such incidents in the nursing notes, which was not done in this case.
Failure to Implement Comprehensive Care Plan and Respect Resident Preferences
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including dementia, hemiplegia, and bullous pemphigoid. The care plan for falls, dated 10/16/2023, required staff to keep the resident's personal items within reach and to complete quarterly fall risk assessments as per the facility's fall protocol. However, staff did not ensure personal items were accessible, and a required quarterly fall risk assessment was not completed in March 2025. These omissions were confirmed through record review and staff interviews, with both the MDS Nurse and DON acknowledging the lack of documentation and the importance of these interventions for fall prevention. The resident experienced two unwitnessed falls, one in March and another in April 2025, resulting in injuries such as redness, skin discoloration, and swelling. Observations showed that the resident's personal items, including glasses and water, were placed on a storage container out of reach, prompting the resident to attempt to retrieve them independently, which led to a fall. Staff interviews revealed that the overbed table was left empty because the resident would knock items off, but no alternative intervention was documented or implemented to ensure items remained within safe reach. Additionally, the facility did not develop a care plan to address the resident's or family’s expressed preference for dining location. Although the family requested that the resident eat meals in the dining room, and staff sometimes accommodated this, there was no documented care plan or consistent intervention to support the resident's right to choose meal location. Staff decisions about meal location were made on a day-to-day basis without reference to a care plan, and both the MDS Nurse and DON confirmed the absence of a documented plan addressing this preference.
Failure to Timely Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to timely revise the care plan for a resident identified as a known fall risk, who experienced two falls from bed on 3/20/2025 and 4/9/2025. Despite the resident's complex medical history, including dementia, hemiplegia, and severe cognitive impairment, the care plan was not updated promptly after each fall event. The care plan in place prior to the incidents had last been revised in 10/2023 and included general fall prevention interventions, but did not reflect the specific circumstances or new interventions following the actual falls. After the first fall on 3/20/2025, documentation showed the resident was found on the floor, but the care plan was not revised to address this incident. Following a second unwitnessed fall on 4/9/2025, which resulted in bruising to the resident's face, the care plan was again not updated until 4/25/2025. Interviews with the MDS nurse and DON confirmed that the care plan should have been revised immediately after each fall, in accordance with facility policy and standard care practices, but this did not occur. Facility policies required that the care plan be reviewed and revised after significant changes in condition, including post-fall events, and that new interventions be implemented as appropriate. The delay in revising the care plan meant that the resident did not receive updated, individualized interventions following each fall, resulting in a lack of appropriate care and services and contributing to recurrent falls and injury.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred dining location during mealtimes. The resident, who had diagnoses including bullous pemphigoid, dementia, and hemiplegia/hemiparesis following a stroke, was assessed as having severely impaired cognitive skills and required moderate assistance with eating and full assistance with transfers. Despite a documented request from the resident's family members for the resident to eat meals in the dining room, staff determined the meal location based on the CNA's decision or upon family request during visitation, rather than consistently honoring the resident's or family's stated preference. Review of the resident's care plan revealed no documented interventions addressing the preference for dining location, and staff interviews confirmed that this preference was not incorporated into the care plan. Facility policies indicated that residents should be allowed to choose their schedules and activities, including meal locations, but these policies were not followed in practice for this resident. The lack of a care plan intervention and inconsistent respect for the resident's and family's wishes led to a failure to promote the resident's right to self-determination and a dignified existence.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, identified as Residents 75 and 80, during personal care activities. Resident 80, who was moderately cognitively impaired and dependent on staff for personal care, was observed with exposed genitalia and without privacy curtains in their room. This occurred because the room was being deep cleaned, and the resident was brought back too early, resulting in exposure to the hallway and a visitor. Staff members acknowledged the lack of privacy and the importance of providing decency to the resident. Resident 75, who was dependent on staff for perineal care and had a diagnosis of dementia, was exposed to their roommate during a change of incontinence brief. The curtain was left open, compromising the resident's privacy. The CNA involved admitted the oversight and recognized that it would make the resident feel uncomfortable and disrespected. The Assistant Director of Nursing confirmed that the curtain should have been closed to ensure privacy during such care. The facility's policy on resident rights and quality of life emphasizes the importance of maintaining and protecting resident privacy during personal care. However, in these instances, the staff failed to adhere to these guidelines, resulting in a breach of the residents' rights to dignity and privacy.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which is a critical aspect of accommodating their needs and preferences. Resident 20, who has a history of falling and unspecified dementia, was observed on multiple occasions with the call light out of reach. On one occasion, the call light was hanging on an oxygen concentrator three feet away, and on another, it was found on the floor. Certified Nurse Assistant 3 confirmed that the call light was not accessible, which is against the care plan that requires the call light to be within reach. Resident 55, who has unspecified dementia and is at risk for falls due to gait and balance problems, was also found with the call light out of reach. During an observation, the call light was hanging on the side rails, and the resident confirmed they could not reach it. Registered Nurse 1 acknowledged that the call light should always be within reach, as it is the resident's mode of communication with the staff. Resident 50, diagnosed with Parkinson's Disease and osteoarthritis, was observed with the call light hanging on the opposite side of the bed, making it inaccessible. Certified Nurse Assistant 1 noted that the call light should be placed where the resident can see and use it. The Director of Nursing reiterated that the call light should be placed near the resident's strong arm or hand. The facility's policy on the call system emphasizes that it should be accessible to residents, highlighting the importance of this deficiency.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding Advance Directives (AD) for four of six sampled residents, which could lead to medical or surgical treatment being administered against the residents' wishes. Resident 55, who had moderately impaired cognition and was dependent on staff for various activities, did not have a completely filled out AD Acknowledgement Form. The Assistant Social Service Director (ASSD) confirmed that the form should be filled out completely and discussed with the resident or responsible party to ensure the resident's wishes are followed. Resident 24, with severely impaired cognition and dependence on staff for daily activities, also had an incomplete AD Acknowledgement Form. The ASSD and the Director of Nursing (DON) both stated that the form should be filled out completely upon admission to assess if the resident executed an AD. The DON emphasized that an incomplete form would not be valid. Similarly, Resident 36, who had moderately impaired cognition and was dependent on staff, had an incomplete AD Acknowledgement Form, as confirmed by a Licensed Vocational Nurse (LVN). Resident 190, with moderately impaired cognition and dependence on staff, did not have copies of the Physician Orders for Life-Sustaining Treatment (POLST) or the AD Acknowledgement Form in their chart or uploaded in the PointClickCare system. The LVN and the Social Services Assistant (SSA) both stated that these documents should be accessible to staff to provide care according to the resident's wishes. The facility's policy indicated that if no advance directive exists, the facility should provide the resident with an opportunity to complete the form, and a copy should be maintained as part of the resident's medical record.
Failure in IV Administration and Labeling
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the provision of a midline intravenous catheter. Resident 238, who was admitted with osteomyelitis and type 2 diabetes mellitus, required intravenous therapy for antibiotic treatment. However, the facility did not adhere to professional standards of practice and the facility's policy and procedure for midline dressing changes. During an observation, it was noted that the midline intravenous site on Resident 238's right upper arm was not labeled with the date of the dressing change, which is crucial for infection control. Additionally, Resident 238 did not receive the prescribed IV antibiotics on a specific day, as confirmed by both the resident and the facility's records. The Assistant Director of Nursing acknowledged the missed administration and emphasized the importance of timely antibiotic delivery to prevent delays in the resident's healing process and potential worsening of the infection. The facility's policy requires that the IV site be labeled with the date and the licensed nurse's initials to prevent infection, which was not followed in this instance.
Oxygen Administration Policy Failures
Penalty
Summary
The facility failed to adhere to its policy on oxygen administration for three residents, leading to potential complications related to oxygen therapy. For Resident 292, the nasal cannula tubing was not dated, contrary to the medical order requiring weekly changes with labeling. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse, who acknowledged the risk of infection due to the lack of dating, as staff would be unaware of when the tubing was last changed. Resident 43's inhalation tubing set was also not dated, and there was no care plan developed for the resident's oxygen use and breathing treatments. During an observation, a Certified Nurse Assistant noted the absence of a label on the inhalation tubing set, which was not in use. The Director of Nursing confirmed that the tubing should be labeled and stored properly to prevent cross-contamination. Additionally, the lack of a care plan was acknowledged by a Registered Nurse Supervisor, who stated that a care plan is necessary to ensure specific care and interventions for the resident. For Resident 24, the nasal cannula was not placed in both nostrils, and there was no 'no smoking' sign posted outside the resident's room, despite the requirement for oxygen use. This was observed during an interview with a Licensed Vocational Nurse, who noted the absence of the sign, which is essential to prevent fire hazards. The Infection Prevention Nurse confirmed that the nasal cannula needed to be properly placed to ensure the resident received the prescribed oxygen, as improper placement could lead to reduced oxygen saturation and respiratory distress.
Failure to Provide Dialysis Emergency Kits at Bedside
Penalty
Summary
The facility failed to ensure that three residents who required dialysis had a dialysis emergency kit (E-kit) at their bedside, as per the standards of practice. This deficiency was identified during observations, interviews, and record reviews. The absence of E-kits was noted for three residents, all of whom were dependent on renal dialysis due to end-stage renal disease or chronic kidney disease. The lack of E-kits at the bedside posed a potential risk of delayed emergency treatment in case of complications such as bleeding from the dialysis access site. Resident 292, who was alert and oriented, had a care plan indicating the need for immediate intervention in case of dialysis complications. However, during an observation, it was found that there was no E-kit at the bedside. Similarly, Resident 66, who had severely impaired cognitive abilities, also lacked an E-kit despite the care plan specifying the need for a shunt clamp at the bedside for emergencies. The Registered Nurse Supervisor confirmed the absence of E-kits and acknowledged the risk of not having emergency supplies available. Resident 36, who had moderately impaired cognition and was dependent on hemodialysis, also did not have an E-kit at the bedside. The Director of Nursing confirmed the necessity of an E-kit to control bleeding from the dialysis access site. The facility's policy and procedure on dialysis care emphasized the importance of monitoring and maintaining the integrity of dialysis access sites, yet the required emergency kits were not in place, highlighting a lapse in adherence to the established care protocols.
Failure to Implement Policy on Bed Rail Use
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of grab bars/bed rails for two residents, placing them at risk for entrapment and injury. Resident 7, who was admitted with osteoporosis, hemiplegia, and hemiparesis, had grab bars installed on both sides of the bed without documented evidence of alternative interventions being attempted. The resident required substantial assistance with daily activities and had moderately impaired cognition. During an observation, the resident was not using the grab bars while trying to sit in a wheelchair, and there was no informed consent or physician's order for the installation of the grab bars. Similarly, Resident 8, diagnosed with generalized muscle weakness, dementia, and Alzheimer's disease, had grab bars installed without documented attempts of alternative interventions. The resident required partial to full assistance with daily activities and had moderately impaired cognition. During an observation, the resident was in bed with grab bars up on both sides, and there was no informed consent or physician's order documented. The facility's policy required an assessment of alternatives and informed consent before the installation of bed rails, which was not followed in these cases.
Insufficient Weekend Staffing in Q4 2024
Penalty
Summary
The facility failed to provide sufficient nursing staff on seven out of thirteen Saturdays and eleven out of thirteen Sundays during the fourth quarter of 2024, as indicated by the Payroll Based Journal (PBJ) Staffing Data Report. The facility did not meet the required 3.5 nursing hours per patient day on multiple dates, including 7/6/2024, 7/7/2024, 7/13/2024, and others. Additionally, the facility failed to meet the required 2.4 CNA direct care hours per patient day on several dates, such as 7/6/2024, 7/7/2024, 7/13/2024, and others. These deficiencies were confirmed through interviews with the Business Office Manager (BOM) and the Director of Nursing (DON), who acknowledged the shortfall in staffing levels necessary to meet residents' needs. The facility's request for a workforce shortage waiver was denied by the California Department of Public Health, as noted in a letter dated 6/14/2024. The facility's policy and procedure, revised in January 2024, required a minimum daily average of 3.5 nursing hours per patient day, with 2.4 of those hours performed by CNAs. Despite this policy, the facility's staffing levels were insufficient, particularly on weekends, as evidenced by the PBJ Staffing Data Report and interviews with facility staff. The lack of adequate staffing had the potential to affect the quality of care and negatively impact the residents' quality of life.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post actual nursing staffing information for three consecutive recertification days, which could potentially misinform residents and visitors about the staffing levels and affect the quality of care provided. On the first day of observation, the Daily Staffing Grid (DSG) at Nursing Station 1 was outdated, showing the previous day's date, while Nursing Station 2 had no DSG posted at all. This pattern continued over the next two days, with Nursing Station 2 consistently lacking a posted DSG. Interviews with the Director of Staff Development (DSD), Business Office Manager (BOM), and Director of Nursing (DON) revealed that the DSG was only posted in Nursing Station 1, contrary to the facility's policy which requires posting in both stations. The DSD admitted that the DSG was posted at midnight and covered all shifts, but was not accessible to residents, visitors, and staff in Nursing Station 2. The facility's policy mandates that staffing data be posted daily at the beginning of each shift in a clear and accessible manner, which was not adhered to during the survey period.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement and follow proper infection prevention procedures, leading to potential transmission of infectious organisms among residents. Specifically, the facility did not post the correct isolation signs for residents with multidrug-resistant organisms (MDROs) and failed to provide necessary personal protective equipment (PPE) for staff. For instance, Resident 294, who had osteomyelitis and was resistant to certain antibiotics, was not placed under the correct Contact Isolation, and the wrong sign was posted outside their room. Additionally, Resident 66, who had a physician order for Contact Precautions due to Vancomycin-resistant Enterococci (VRE) bacteremia, did not have a PPE cart or isolation sign outside their room, and was improperly cohorted with a roommate who did not have the same infection. Resident 238, who had a midline IV catheter and was at high risk for infection, did not have Enhanced Barrier Precaution (EBP) signage or a PPE cart outside their room. This oversight was confirmed during an observation and interview with the Infection Prevention Nurse, who acknowledged the absence of necessary precautions to prevent the spread of infection. Similarly, Resident 190, who required EBP due to a gastrostomy tube and wound, was not provided with the appropriate PPE by Certified Nurse Assistant 3 during care activities, as the CNA only wore gloves and not a gown. Interviews with various staff members, including Licensed Vocational Nurse 3, Registered Nurse Supervisor 1, and the Infection Prevention Nurse, revealed a lack of adherence to the facility's policies and procedures regarding infection control. The staff acknowledged the risks associated with not following proper isolation protocols, such as cross-contamination and the spread of infections to other residents. The facility's failure to implement these precautions as per their own policies and physician orders posed a significant risk of infection transmission within the facility.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a signed Informed Consent from the responsible party of a resident prior to administering Ativan, a medication used to treat anxiety disorders. This oversight involved a resident who was readmitted to the facility with diagnoses including toxic encephalopathy, cerebral infarction, and chronic obstructive pulmonary disease. The resident was assessed as moderately cognitively impaired and required substantial assistance with daily activities. The physician's order for Ativan was documented, but the necessary informed consent was not found in the resident's clinical record. During an interview and record review, the Assistant Director of Nursing acknowledged the absence of the informed consent and emphasized the importance of obtaining consent for psychotropic medications due to their potential adverse effects. The facility's policy on psychotherapeutic drug management requires that residents or their responsible parties be informed of the risks and benefits of such medications before consent is obtained. However, this procedure was not followed, resulting in a violation of the resident's rights and the potential for the resident to receive medication without the responsible party's approval.
Inaccurate MDS Coding of Discharge Destination
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's discharge destination in the Minimum Data Set (MDS), which is a federally mandated resident assessment tool. Specifically, Resident 85 was discharged to home or community, but the MDS inaccurately recorded the discharge destination as a short-term general hospital. This discrepancy was identified during a review of Resident 85's records, including the Admission Record, Order Summary Report, and Progress Notes, which all indicated that the resident was discharged to home or community. The Director of Nursing (DON) confirmed the error during an interview and acknowledged that the MDS should have been coded to reflect the correct discharge destination. The facility's policy and procedure for the Resident Assessment Instrument (RAI) process, dated 10/1/2023, mandates that each resident's assessment be coordinated and certified by a registered nurse, with all individuals completing a portion of the assessment signing and certifying its accuracy. The failure to accurately code the discharge destination resulted in incorrect reporting to the Centers for Medicare and Medicaid Services (CMS), potentially impacting the interventions provided to address specific care concerns for Resident 85.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication device in the language understood by Resident 189, who was admitted with diagnoses of Parkinson's disease and bipolar disorder. The resident's primary language was Spanish and Castilian, as indicated in the Admission Record. During an observation and interview, it was noted that Resident 189 did not have a communication board in their room, which was necessary for effective communication with the staff. Interviews with Registered Nurse Supervisor 1 and RN 2 confirmed that non-English speaking residents should have access to a communication board or translator to prevent miscommunication. The facility's policy on Translation or Interpretation Services stated that translation and interpretation services should be culturally relevant and appropriate for individuals with limited English proficiency. Despite this policy, the necessary communication tools were not provided to Resident 189, potentially affecting their ability to communicate needs and delaying care.
Failure to Reposition Resident as Required
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for Resident 292 by not turning and repositioning the resident every two hours as required. Resident 292, who was admitted with conditions including hemiplegia, hemiparesis, dependence on dialysis, and peripheral vascular disease, was identified as being at risk for developing pressure ulcers. The care plan for Resident 292 specifically indicated the need for turning and repositioning every two hours to prevent skin breakdown. Observations and interviews revealed that Resident 292 was left lying on their back for extended periods without being repositioned. The resident reported that staff did not turn them because it took too long. The Assistant Director of Nursing confirmed the necessity of repositioning residents, especially those on dialysis, every two hours to prevent skin breakdown. A Certified Nursing Assistant, unfamiliar with Resident 292's care, acknowledged the risk of wound development if the resident was not turned regularly. The facility's policy also required repositioning every two hours, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention care for a resident, identified as Resident 27, who was at high risk for developing pressure ulcers due to conditions such as peripheral vascular disease, paraplegia, and muscle contracture. The resident's medical orders included the use of bilateral heel protectors and a low air loss mattress set according to the resident's weight to prevent pressure ulcers. However, during an observation, it was noted that the resident did not have the heel protectors on, and the low air loss mattress was set incorrectly at 150 pounds, while the resident weighed 122 pounds. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that the heel protectors were not in use and the mattress setting was incorrect, both of which could lead to the development of pressure ulcers. The facility's policy emphasized the importance of mechanical offloading and pressure-reducing devices in preventing pressure ulcers, but these measures were not properly implemented for Resident 27, leading to a deficiency in care.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 140, as outlined in the resident's care plan. The care plan specified the use of non-pharmacological interventions for pain management, such as gentle range of motion exercises, meditation, positioning, massage, and music, and required documentation of the resident's response to these interventions. However, the facility did not implement these non-pharmacological measures, nor did they document any attempts to do so, despite Resident 140 experiencing severe pain levels between 8-9/10 over several days. Additionally, the facility did not notify Resident 140's medical doctor when the resident's pain remained uncontrolled with the current pain medication regimen. The resident was prescribed Gabapentin, Oxycodone Hydrochloride, and Acetaminophen for pain management, but continued to report severe pain, particularly in the left abdomen, which was exacerbated by breathing. Despite these complaints, there was no documentation of any communication with the resident's physician to reassess or adjust the pain management plan. The failure to provide timely and appropriate pain management resulted in Resident 140 experiencing significant discomfort, having to wait over an hour for pain medication, and not receiving any documented non-pharmacological interventions. Interviews with the nursing staff revealed an acknowledgment of the importance of non-pharmacological interventions and the need to document them, yet these measures were not implemented or recorded in the resident's medical record.
Expired Chicken Nuggets Found in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as evidenced by the presence of expired chicken nuggets in the refrigerator. During an initial tour of the kitchen, a clear plastic bag of chicken nuggets with an expiration date was observed. Dietary staff confirmed that the chicken nuggets were expired. The Consultant Registered Dietitian and the Dietary Supervisor both acknowledged that the expired chicken nuggets should not have been in the refrigerator, emphasizing the importance of discarding expired food to prevent potential foodborne illnesses. The facility's policy and procedure on food storage indicated that food items should be stored and prepared in accordance with good sanitary practices.
Failure to Complete Antibiotic Surveillance Form
Penalty
Summary
The facility failed to complete a Surveillance Data Collection form for a resident receiving antibiotics, which is a requirement under their Antibiotic Stewardship Program. The resident, who had moderately impaired cognition and was dependent on staff for various daily activities, was receiving Daptomycin intravenously for Vancomycin Resistant Enterococcus bacteremia. Despite the resident's condition and the ongoing antibiotic treatment, the necessary surveillance form was not filled out to ensure the appropriateness of the antibiotic use. During an interview, the Infection Preventionist Nurse (IPN) admitted to being unable to locate the Antibiotic Surveillance Form for the resident. The IPN was on vacation during the period when the form should have been completed and was unaware of why it was not done. The Assistant Director of Nursing confirmed the necessity of antibiotic stewardship to determine if residents meet the criteria before receiving antibiotic therapy. The facility's policy on the Antibiotic Stewardship Program emphasizes the importance of collecting and analyzing infection surveillance data to monitor adherence to the program.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was functioning in eight of 35 resident rooms, specifically Rooms 7, 20, 21, 24, 25, 26, 29, and 36. Observations revealed that call lights in these rooms did not activate lights above the room doors or at the nurses' station panel. Additionally, some residents in these rooms were not provided with call bells as an alternative means of communication, contrary to the facility's policy. The Maintenance Log for October 2024 indicated issues with call lights in several rooms, but the facility did not adequately address these issues. Interviews with staff, including the Director of Maintenance and the Director of Nursing, confirmed that the facility's protocol required providing call bells when call lights were inoperable, which was not consistently done. Furthermore, there was no documentation of resident safety check rounds, which were supposed to be conducted hourly when the call system was not functioning. This lack of adherence to the facility's policy and procedures had the potential to delay care for residents, as staff would not be aware of residents' needs without a functioning call system.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely for a resident, identified as Resident 3, as per the facility's policy and procedure on medication administration. Resident 3, who was admitted with multiple diagnoses including type 2 diabetes mellitus, muscle wasting, dysphagia, and dementia, was scheduled to receive morning medications at 9 AM. However, during an observation at 11 AM, it was noted that the medications had not yet been administered. The Licensed Vocational Nurse (LVN) responsible for administering the medications admitted to falling behind on the medication schedule. The facility's policy requires medications to be administered within one hour before or after the scheduled time to ensure their effectiveness. Interviews with the LVN, a Registered Nurse (RN), the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed the importance of timely medication administration to maintain therapeutic drug levels. The failure to administer medications on time had the potential to negatively affect Resident 3, who was dependent on these medications for managing their health conditions.
Failure to Secure Smoking Devices and Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure that smoking devices were stored securely for a resident, as per the facility's policy and procedure and the resident's care plan. On a specific date, a resident was observed with an electronic smoking device resting on their lap in their room, which had a fruity smoke-like smell. The resident, who had been admitted with several medical conditions including hemiplegia and hemiparesis, required substantial assistance with activities of daily living and was unable to ambulate due to medical conditions or safety concerns. The resident's care plan indicated that they were allowed to smoke only in designated areas and required supervision while smoking. Interviews with staff revealed that the resident had been seen with the electronic smoking device in their room, and the room sometimes smelled like smoke. The Certified Nursing Assistant (CNA) stated that smoking in a shared room was a safety issue and could potentially harm other residents due to secondhand smoke inhalation. The facility had a designated smoking area and schedule, and the Activities Director or receptionist assisted residents during smoking hours. However, the CNA was unsure if the Director of Nursing or the Administrator had been informed about the resident having the electronic smoking device. The Director of Nursing confirmed that the facility's policy prohibited smoking inside the facility and required all smoking materials to be stored in a secure lock box. The facility's policy aimed to respect the choice to smoke while maintaining a safe environment for all residents. The policy applied to both cigarettes and electronic cigarettes, and residents who could not smoke independently and safely were to be accompanied by staff. Despite these policies, the resident was found with a smoking device in their room, indicating a lapse in adherence to the facility's smoking policy.
Infection Control Breach: Resident Accesses Meal Cart Unsupervised
Penalty
Summary
The facility failed to adhere to infection control practices for one resident, who accessed the meal cart unsupervised and without performing hand hygiene. This incident involved a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dysphagia. The resident independently retrieved their meal tray from the cart without staff assistance, which was against the facility's infection control policy. Interviews with staff, including a CNA, RN, DSD, IP, and DON, confirmed that residents should not access meal carts due to safety and infection control concerns. The staff acknowledged that hand hygiene should be performed before and after handling meal trays, and residents should not be allowed to remove trays themselves. The facility's policy emphasized the importance of maintaining a safe and sanitary environment to prevent disease transmission, which was not followed in this instance.
Failure to Follow Hoyer Lift Protocol Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) followed the required protocol for using a Hoyer lift. The resident, who had a history of hemiplegia, hemiparesis, and dementia, was at high risk for falls and required total dependence on staff for transfers. Despite the facility's policy mandating two-person assistance for Hoyer lift transfers, CNA 1 attempted to transfer the resident alone, leading to the resident falling from a shower chair and sustaining a head laceration. The incident occurred when CNA 1 was transferring the resident from the bed to a shower chair using the Hoyer lift without assistance from another staff member. During the transfer, the resident fell and hit their head on a doorknob, resulting in a laceration that required medical attention and sutures. The resident was subsequently transferred to a hospital for further evaluation and treatment of the injury. Interviews with facility staff, including the Director of Rehabilitation, Director of Staff Development, and Director of Nursing, confirmed that the facility's policy required two-person assistance for Hoyer lift transfers to ensure resident safety. The CNA admitted to not following this protocol, which directly contributed to the resident's fall and injury. The facility's policy and procedure titled 'Total Mechanical Lift' clearly indicated that at least two people should be present during such transfers, highlighting the failure to adhere to established safety protocols.
Failure to Readmit Residents After Hospitalization
Penalty
Summary
The facility failed to readmit three residents to the nursing home after they were cleared for discharge from a General Acute Care Hospital (GACH). These residents were initially transferred to the hospital for emergency medical care due to various health conditions. Resident 2 was transferred for sepsis, Resident 3 for right eye bleeding due to thrombocytopenia, and Resident 4 for abdominal issues related to a gastrostomy tube. Despite being cleared for return, the facility did not readmit them, citing a lack of available isolation rooms. Interviews with the Director of Care Coordination at GACH revealed that repeated attempts were made to contact the facility for the residents' return, but the facility staff indicated that no isolation rooms were available. The facility's Infection Preventionist and Admissions Coordinator confirmed that the facility was accepting new residents and could cohort residents with the same infection, but could not accommodate those with different types of isolation needs. The facility's bed hold policy allowed for a seven-day hold, after which residents could be readmitted if not on isolation. The Director of Nursing acknowledged the importance of readmitting the residents for continuity of care and because the facility was their home. However, the facility's policy and procedure on bed hold and transfer/discharge indicated that residents should be readmitted to the first available bed if they met the criteria for skilled nursing care. The failure to readmit these residents was a deficiency in adhering to these policies, potentially violating the residents' rights to return to the facility.
Delay in Providing Resident's Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records within the stipulated two working days as per their policy and procedure titled 'Resident Access to PHI.' The resident, who was admitted with conditions including sequelae of cerebral infarction, dysphagia, and mobility issues, had the capacity to understand and make decisions. A request for the resident's medical records was made by the resident's requesting party on June 25, 2024, via fax. However, the facility did not fulfill this request within the required timeframe. Interviews with the Medical Records staff and the administrator revealed that the request was acknowledged, but there was a delay in processing due to the need to consult with administration regarding legal matters. The Medical Records staff confirmed the importance of timely provision of records for reasons such as insurance, billing, and health. Despite the facility's policy requiring records to be provided within two working days, the records were only mailed on July 8, 2024, resulting in a delay for the requesting party.
Failure to Enforce PPE Use for Visitors in COVID-19 Precaution Area
Penalty
Summary
The facility failed to implement its Mitigation Plan regarding visitation guidelines for COVID-19, specifically for a resident under Novel Respiratory Precautions. Two family members were allowed to enter the resident's room without donning the required personal protective equipment (PPE), which included an N95 mask, face shield, gown, and gloves. This oversight was observed during a visit, where the family members were only wearing surgical masks despite the clear signage outside the room indicating the need for full PPE. Interviews with staff, including a Certified Nursing Assistant (CNA), the Assistant Director of Nursing (ADON), and the Infection Preventionist Nurse (IPN), confirmed that the family members were not informed of the PPE requirements. The staff acknowledged that the failure to enforce these precautions could potentially lead to the spread of the COVID-19 virus within the facility. The facility's Mitigation Plan clearly stated that visitors should be provided with PPE and instructed on its proper use, which was not adhered to in this instance.
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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