Royal Gardens Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 2339 W. Valley Blvd., Alhambra, California 91803
- CMS Provider Number
- 055818
- Inspections on file
- 42
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Royal Gardens Healthcare during CMS and state inspections, most recent first.
A resident with CKD, anxiety disorder, and COPD, who required substantial assistance with ADLs, reported that a CNA pulled a sheet from under them and threw it on the floor during evening care. The facility’s CGR form for this grievance was left incomplete, with no documented steps of the investigation, no summary of findings or conclusions, and no confirmed decision date. The SSD, DON, and DSD all acknowledged that required investigative elements—such as incident details, involved staff, witness accounts, and interview documentation—were not recorded, and that the CNA involved was initially misidentified, demonstrating a failure to follow the facility’s grievance investigation policy.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for many ADLs, reported that a CNA on the evening shift was mean, pushy, and made the resident cry by roughly yanking a drawsheet, throwing it on the floor, pulling out the resident’s brief, and grabbing and holding the resident’s arm to prevent the resident from fastening the brief tabs. The facility initiated an investigation but failed to follow its abuse investigation policy: the Investigation Report and CNA statement were incomplete, missing the investigator’s name, resident and staff identifiers, dates, times, signatures, and other required details, and key leaders (ADM, DON, DHI, DSD) acknowledged that the investigation process and documentation did not meet the facility’s Abuse Investigation and Reporting requirements.
A resident with CKD, COPD, and anxiety, who needed substantial assistance with ADLs, alleged that a CNA was rough, rude, and verbally abusive during incontinence care, including yanking a drawsheet from under the resident, throwing it on the floor, and holding the resident’s arm up to prevent adjusting brief tabs. An RN supervisor heard loud voices, found both the resident and CNA upset, and was told the drawsheet had been thrown on the floor, but did not report this possible abuse due to being busy. Another CNA was told by the resident that staff had been rude but also failed to report it. The resident later informed Social Services, yet the allegation was still not immediately reported to external authorities as required by facility policy, which mandates reporting alleged abuse within 2 hours, resulting in a failure to timely notify the State Survey Agency, ombudsman, and law enforcement.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for several ADLs, reported that a CNA on the 3 PM–11 PM shift was pushy, yanked a drawsheet from under her and threw it on the floor, pulled out her brief, and roughly held her arm straight up during care, causing her to cry. The facility initiated an investigation, but the DSD did not re-interview the resident after speaking with involved CNAs, and the Investigation Report contained incomplete and inaccurate information about which CNA was allegedly rough. Multiple CNA statements were missing key elements such as dates, interviewer names, and signatures, and the DSD and SSD acknowledged that the abuse investigation and documentation did not comply with the facility’s Abuse Investigation and Reporting and Abuse Prevention Program policies.
A resident with cognitive impairment, hemiparesis after stroke, and oropharyngeal aphagia had an ST evaluation indicating the need for assisted feeding to enhance safe swallow, and care plans addressing aspiration risk and swallowing problems. However, staff did not relay the ST recommendation for feeding assistance to the physician or obtain corresponding orders for an extended period, and did not notify the physician or obtain an order for ST reevaluation after the resident was observed to be able to feed himself without 1:1 assistance. A physician order for 1:1 feeding to prevent aspiration was not in place during the timeframe when these assessments and observations occurred.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
Two residents with significant cognitive and physical impairments did not have their wound care treatments accurately documented on the TAR, despite physician orders for daily dressing changes. The responsible nurse confirmed that treatments were performed but not signed for, and the DON acknowledged the documentation lapse, resulting in incomplete medical records.
A resident with diabetes and kidney failure did not receive a recommended Controlled Carbohydrate Diet (CCHO) due to a lack of communication between the Registered Dietitian (RD) and the primary physician. The resident continued on a No Added Salt (NAS) diet, which did not meet their dietary needs. The facility's policy requires physician-prescribed therapeutic diets, but the RD's recommendations were not implemented, placing the resident at risk for uncontrolled blood sugar levels.
A facility failed to maintain a safe and homelike environment for several residents. A resident's room was excessively warm, causing discomfort, while another resident experienced frustration due to a malfunctioning television. Two residents' rooms had a strong odor of urine due to incontinence issues, and a resident's room had a chipping wall trim, posing a potential hazard. Staff acknowledged these issues, which affected the residents' well-being.
The facility failed to implement proper pressure ulcer prevention and treatment measures for three residents. A resident with a history of stage 4 pressure ulcer had a low air loss mattress set incorrectly, risking skin breakdown. Another resident with a history of pressure injuries had an alternating air pressure pad mattress set too firm, potentially causing pressure injuries. A third resident with a stage 3 pressure ulcer reported discomfort from a hard mattress, risking further skin damage. The facility did not adjust mattress settings based on residents' weights, as required by policy.
The facility failed to maintain proper pharmaceutical services, with issues such as ice build-up in the medication freezer, dusty storage room counters, and improper temperature control in the medication storage room. Medications like Valproic Acid and Lidocaine were stored at 83°F, exceeding the recommended range, leading to their disposal to prevent adverse reactions.
The facility failed to label opened food items with use-by dates, risking foodborne illnesses. Observations revealed unlabeled items like butter, chocolate syrup, and hash browns in the kitchen, and No Bake Custard and Gravy Mix in storage. The DS admitted the absence of labels, and the DON and RD confirmed the policy requirement for labeling to ensure food quality and safety.
A long-term care facility failed to follow infection prevention and control practices for several residents. A urine-soaked diaper was found on a paper towel dispenser, and two LVNs did not use required protective equipment while administering medications via gastrostomy tubes. Additionally, a nebulizer mask was found on the floor, and a urinal bottle was placed next to a water pitcher, both posing contamination risks.
A resident with dysphagia and cognitive impairment waited 32 minutes for their meal tray while others at the table were eating. The delay occurred despite meal carts arriving on time, and the resident felt uncomfortable and disrespected. The facility's policy emphasizes providing a dignified dining experience.
The facility failed to ensure call lights were within reach for three residents, violating policy. A resident with cognitive impairment had a call light out of reach, confirmed by a CNA. Another resident with right side weakness had a call light on the wrong side, confirmed by an LVN. A third resident, unable to use fingers, had a call light on the floor, leading to yelling for help. The facility's policy requires accessible call lights.
A resident receiving antibiotic and anticoagulant therapies did not have a comprehensive care plan developed, as required by facility policy. The absence of care plans for Ceftriaxone and Eliquis meant the resident was not monitored for treatment effectiveness or side effects. The MDS Nurse and DON acknowledged the oversight, which was contrary to the facility's care plan policy.
A facility failed to monitor a resident's behavior for the use of psychotropic medications, Abilify and Depakote, as required by their policy. The resident, diagnosed with dementia and schizophrenia, had no documented behavior monitoring orders, and the MAR was blank for a month, indicating a lack of monitoring. This deficiency was identified during interviews and record reviews.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An LVN administered multivitamin, vitamin C, and vitamin D3 to a resident over an hour past the prescribed time. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policy mandates medication administration within one hour of the prescribed time.
The facility did not post the required Daily Nurse Staffing Information for several days, as observed on 12/2/2024. The Assistant Administrator and Director of Nursing confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) postings were missing, which are essential for informing residents, families, and staff about staffing levels. The facility's policy requires daily posting of nurse staffing data, but this was not followed, leading to a deficiency.
The facility did not meet the minimum 80 square feet per resident requirement in 12 of 17 rooms. Despite this, residents reported adequate space for care and movement, and a room waiver was requested, asserting no impact on health and safety. Observations confirmed adequate ventilation, lighting, and privacy, with sufficient space for wheelchairs and medical equipment.
The facility did not post daily staffing information as required, with outdated and incomplete Census and Direct Care Service Hours Per Patient Day (DHPPD) forms observed. The DON was unaware of the requirement to post completed forms daily, leading to missing postings for several days in September.
Three residents in an LTC facility did not receive consistent treatment for pressure ulcers, as documented in their Treatment Administration Records. A resident with a deep tissue injury and Stage 2 ulcer, another with a Stage 4 ulcer, and a third with an unstageable ulcer all missed prescribed treatments, including zinc oxide application, low air loss mattress therapy, and wound cleaning. Interviews confirmed that blank entries in records indicated treatments were not performed, violating facility policy.
A resident with dementia was physically abused by another resident with psychosis in the activity room of an LTC facility. The incident occurred when the aggressive resident, who had a history of physical altercations, struck the vulnerable resident in the face. Staff interviews confirmed the altercation, and it was noted that no staff were present in the room at the time to prevent the incident, despite the facility's policy to protect residents from abuse.
A facility failed to update a resident's care plan after a physical altercation with another resident. The resident, who has unspecified psychosis and moderately impaired cognitive skills, showed increased agitation and aggression. Despite the incident, the care plan was not revised to include new interventions for the resident's safety and behavior management, contrary to facility policy requiring updates for significant changes in condition.
Failure to Properly Investigate and Document Resident Grievance
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance investigation and documentation procedures for a cognitively intact resident who filed a grievance about staff conduct during care. The resident, who had chronic kidney disease, anxiety disorder, and COPD, required substantial to maximal assistance with toileting, bathing, dressing, and transfers. A Complaint and Grievance Report (CGR) form documented that during an evening shift, an unidentified CNA pulled a sheet from under the resident and threw it on the floor during care. The Social Services Director (SSD) received the grievance report later and noted that the resident could not recall the CNA’s name, and the SSD endorsed the report to the Director of Staff Development (DSD) and nursing for follow-up. When surveyors reviewed the CGR form with the SSD, they found that key sections were left blank, including the steps taken to investigate the grievance, the summary of pertinent findings or conclusions, and the date the grievance decision was confirmed. The SSD acknowledged that the nursing department was responsible for follow-up interviews and documentation of the investigation, and that the CGR should have included details such as the in-service topic discussed with the CNA and a summary of the investigation. The SSD further acknowledged that she did not review or follow up on the investigation, did not complete the missing sections, and did not explain to the resident the steps taken to investigate the grievance. Additional interviews with the DON and DSD confirmed that the investigation was incomplete and not documented in accordance with facility policy. The DON stated that the CGR form lacked documentation of the steps taken to investigate and any attached investigation report, and that required elements from the grievance policy—such as date and time of the alleged incident, circumstances, location, names of witnesses and their accounts, and recommendations for corrective action—were not recorded. The DSD similarly stated that the nursing department was responsible for follow-up interviews and documentation, but the CGR form remained incomplete, missing information such as names of staff interviewed, the resident’s name, interview times and dates, and names of involved persons. The SSD later stated that the initial investigation had incorrectly identified the CNA involved, further demonstrating that the grievance investigation process and documentation were not properly carried out for this resident.
Failure to Properly Investigate Resident’s Allegation of Rough and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policies and procedures after an allegation of verbal and rough physical treatment toward a resident. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial to maximal assistance with toileting, bathing, dressing, and transfers. The resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, and was mean, and that this interaction made the resident cry. In interviews, the resident described an incident in which the CNA roughly yanked the drawsheet from under the resident and threw it on the floor near the door, pulled out the resident’s brief, and grabbed and held the resident’s right arm straight up while the resident was attempting to fasten the brief tabs, which the resident typically adjusted independently. The resident stated that this occurred on a Sunday night, that the CNA’s behavior was rough and scary, and that the resident did not like what the CNA did. The resident reported the CNA’s bad attitude to the Social Services Director the following day. Record review showed that the facility’s investigation documentation was incomplete and did not comply with the written Abuse Investigation and Reporting policy. The Investigation Report lacked the name of the investigator, the names of all staff interviewed, the name of the resident involved, and the times of the interviews. The Administrator, DON, DHI, and DSD each acknowledged that the investigation report and CNA statement were missing required elements such as dates, times, resident and staff identifiers, interviewer name, staff phone number, and signatures. The DON and DSD stated that the investigation process outlined in the abuse policy was not followed and that the documentation was inaccurate, incomplete, and not considered a valid investigation report, despite the policy requiring thorough review of documentation, resident interviews, staff interviews on all shifts, and review of events leading up to the alleged incident.
Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required 2‑hour timeframe to the State Survey Agency, state ombudsman, and local law enforcement. A cognitively intact resident with chronic kidney disease, anxiety disorder, and COPD, who required substantial to maximal assistance with several ADLs, alleged that a CNA on the 3 PM to 11 PM shift was rough, pushy, and verbally abusive during incontinence care. The resident reported that the CNA yanked a drawsheet from under her, threw it on the floor near the door, pulled out her brief, grabbed her arm, and held it straight up while changing her, preventing her from adjusting the brief tabs as she preferred. The resident stated the CNA was mean, rough, and scary, and that the interaction made her cry. On the evening of the incident, an RN supervisor heard loud voices from the resident’s room, entered, and observed both the resident and the CNA were upset. The resident told the RN supervisor that the CNA had thrown the drawsheet on the floor and was not listening to her request to have two drawsheets. The resident refused further care from the CNA, and her voice was described as shaky. The RN supervisor acknowledged that she recognized this as a possible allegation of abuse but became overwhelmed and busy with her shift and did not report the incident to the Administrator, DON, or another licensed nurse as required. Another CNA later reported that the resident had told her the CNA who took over her care after 7 PM that Sunday was rude to her, but this CNA also did not report the allegation to supervisory staff. The resident reported the incident to the Social Services Director the following day, describing the CNA’s actions with the drawsheet and her perception that the CNA was rough and rude. The Social Services Director did not immediately conduct a thorough investigation or report the allegation to the appropriate agencies at that time. The facility’s policies on Abuse Investigation and Reporting and Abuse Prevention Program required that alleged violations of abuse, neglect, exploitation, or mistreatment be reported immediately, and not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. The DON confirmed that CNAs are mandated reporters and that staff should have reported the allegation within two hours, including when the resident told a CNA that staff was mean, which the DON identified as possible verbal abuse. Despite these requirements, the allegation was not reported within the mandated timeframe, resulting in the cited deficiency.
Failure to Thoroughly Investigate Resident’s Allegation of Rough Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident, as required by its abuse policies and procedures. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial/maximal assistance with several ADLs, including toileting, bathing, dressing, and transfers. During an interview, the resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, yanked out the drawsheet from under her and threw it on the floor near the door, pulled out her brief, and grabbed and held her arm straight up while changing her, which the resident described as mean and causing her to cry. The resident stated she had reported the CNA’s bad attitude to the Social Services Director the day before the survey interview. The facility initiated an investigation documented on an Investigation Report dated 1/20/2026. That report reflected that another CNA stated the resident had told her that the CNA who took over the 3 PM–11 PM shift was rude, and that CNA 2 acknowledged taking over the resident’s care at 7 PM. CNA 2 reported that when she returned to change the resident, she rolled up and pulled out a dirty drawsheet, the resident grabbed and unrolled it, and food crumbs fell back on the bed; CNA 2 then took the drawsheet and left the room to look for the nurse in charge. The report also indicated CNA 2 informed an RN Supervisor that the resident had stated CNA 2 was being rough. However, the Director of Staff Development did not interview the resident after interviewing CNA 2 and CNA 3, explaining that the report was viewed as only involving pulling out the drawsheet and putting it on the floor. Record review and staff interviews showed that the investigation documentation was incomplete and inaccurate. The Social Services Director later acknowledged that the investigation conclusion was not accurate regarding which CNA the resident alleged was rough and that more in-depth follow-up interviews with the resident and involved staff should have been conducted. The DSD identified that CNA statements were incomplete or undated, missing the interviewer’s name, interview date, staff phone number, and staff signature, and stated that one CNA’s statement was not valid due to these omissions. The DSD also confirmed that the facility’s Abuse Prevention Program policy, which requires the investigator to record complete investigation results on approved forms and provide them to the Administrator, was not followed, as the investigation lacked essential information such as date and time, resident and staff involved, and the name of the interviewer/investigator.
Failure to Communicate ST Feeding Recommendations and Obtain Timely Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with standards of practice for one resident by not relaying a speech therapist’s recommendation for feeding assistance to the physician and not obtaining corresponding physician orders. The resident had a history of hyperlipidemia, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and oropharyngeal aphagia. An MDS dated 12/10/2025 documented cognitive impairment and a need for staff supervision with eating, as well as partial/moderate assistance for oral and personal hygiene. A speech-language pathology evaluation and plan of treatment dated 11/16/2025 indicated the resident was on three meals with assistance of feeding to enhance safe swallow. However, there was no documented evidence that this recommendation was communicated to the physician or that an order for this assistance was obtained between 11/16/2025 and 12/21/2025. During this same period, from 11/17/2025 to 12/19/2025, the resident was observed and assessed to be able to feed himself without 1:1 assistance, yet the facility did not relay this change in status to the physician or obtain an order for a new ST evaluation to reassess the resident’s feeding needs. Physician orders only reflected a 1:1 feeding requirement to prevent aspiration beginning on 12/22/2025 at 10:56 PM, with no such orders in place from 11/16/2025 to 12/21/2025. The resident’s care plan for risk of aspiration, initiated 11/18/2024 and revised 12/18/2025, directed staff to monitor for signs and symptoms of aspiration, provide prompt intervention, and inform the physician, and a separate care plan for swallowing problems was initiated on 12/4/2025. Despite these care plan directives and the ST evaluation, the facility did not ensure physician notification and appropriate orders regarding feeding assistance and ST reevaluation during the identified timeframe.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for two residents, as required by its own policy and accepted professional standards. For one resident with a sacral pressure ulcer and significant physical and cognitive impairments, the Treatment Administration Record (TAR) was left blank and not signed for a scheduled wound care treatment. The physician's order specified daily dressing changes, but the lack of documentation on the TAR for a specific date resulted in an incomplete medical record for the care provided. For a second resident with multiple pressure ulcers at various stages and severe cognitive impairment, the TAR was not signed for several wound care treatments on two separate days. The physician's orders detailed specific wound care procedures for multiple sites, but the TAR lacked the initials of the nurse responsible for administering these treatments. During interviews, the nurse who provided the care confirmed that the treatments were performed but not documented at the time, and the Director of Nursing acknowledged that the TAR should have been signed immediately after care was provided. The facility's policy on charting and documentation requires that all services provided to residents be documented in an objective, complete, and accurate manner, including the date, time, and name of the individual providing care. The failure to document wound care treatments as required resulted in medical records that did not accurately reflect the care provided to the two residents.
Failure to Implement Recommended CCHO Diet for Diabetic Resident
Penalty
Summary
The facility failed to provide a Controlled Carbohydrate Diet (CCHO diet) for a resident with type 2 diabetes mellitus, dementia, and acute kidney failure. The resident was admitted with a diagnosis that required careful management of blood sugar levels. Despite the Registered Dietitian's (RD) recommendation to change the resident's diet to a CCHO diet, this was not communicated to or ordered by the resident's primary physician. The resident continued to receive a No Added Salt (NAS) mechanical soft diet, which did not meet the specific dietary needs for managing diabetes. The deficiency was identified during a review of the resident's care plan and medical records, which showed that the RD's recommendations were not reviewed by licensed nurses or communicated to the primary physician. The resident's Minimum Data Set (MDS) indicated a need for a therapeutic diet, but the current diet order did not reflect the necessary changes. Interviews with the Licensed Vocational Nurse (LVN), Kitchen Supervisor (KS), Registered Nurse (RN), and Director of Nursing (DON) confirmed that the RD's recommendations were not implemented, and the resident's diet card did not indicate the required CCHO diet. The facility's policy and procedure for therapeutic diets require that such diets be prescribed by the attending physician and regularly reviewed by the dietitian, nursing staff, and physician. However, the failure to communicate and implement the RD's dietary recommendations placed the resident at risk for uncontrolled blood sugar levels, which could lead to serious health consequences. The DON acknowledged the importance of providing a CCHO diet for residents with diabetes to prevent potential complications.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, leading to various deficiencies. Resident 8's room was observed to be excessively warm at 83 degrees Fahrenheit, which was outside the acceptable range of 71 to 81 degrees Fahrenheit. This was confirmed by the Maintenance Supervisor, who acknowledged the discomfort caused by the high temperature and adjusted the thermostat accordingly. Resident 194 experienced frustration due to a malfunctioning television, which was described as hazy and pixelated. This issue was observed during an interview with the resident, who expressed dissatisfaction with the situation. The Licensed Vocational Nurse present agreed that the television should be repaired to alleviate the resident's frustration. Additionally, the facility failed to maintain a clean and sanitary environment for Residents 18 and 28, as both rooms had a strong odor of urine. This was attributed to Resident 18's frequent urinary incontinence, which resulted in urine on the floor. The presence of an air purifier did not sufficiently address the odor, and staff acknowledged the impact on the residents' well-being. Furthermore, Resident 19's room had a chipping wall trim, which was identified as a potential hazard by both the Registered Nurse Supervisor and the Maintenance Supervisor, who recognized the risk of injury to the resident.
Improper Pressure Ulcer Prevention and Treatment Measures
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and treatment measures for three residents, as observed during a survey. Resident 30, who was at risk for skin breakdown due to a history of a stage 4 pressure ulcer, was found to have a low air loss (LAL) mattress set at an incorrect pressure setting of more than 350 mmHg, which was not aligned with the resident's weight of 220 pounds. This setting was too firm and not in accordance with the manufacturer's guidelines, potentially compromising the effectiveness of the mattress in preventing pressure ulcers. Resident 6, who had a history of pressure injuries and was moderately at risk for skin breakdown, was observed with an alternating air pressure pad (APP) mattress set at the maximum firmness level of 5. This setting was not ideal for the resident's weight of 163 pounds and could lead to the development of pressure injuries. The facility's failure to adjust the mattress settings based on the resident's weight was noted as a deficiency. Resident 1, who had a stage 3 pressure ulcer and was moderately at risk for skin breakdown, was found with an LAL mattress set at 250 mmHg, which was not appropriate for the resident's weight of 203 pounds. The resident reported discomfort due to the mattress being too hard, which could exacerbate existing pressure ulcers or cause new ones. The facility's policy required that mattress settings be adjusted according to the resident's weight, but this was not adhered to, leading to the identified deficiencies.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services as per its policy, resulting in several deficiencies related to medication storage. During an observation and interview with the Director of Nursing (DON), it was noted that the medication storage freezer had an ice build-up, which could affect the accurate temperature maintenance for medications stored inside. Additionally, the medication storage room counters and shelves were found to be dusty, indicating a lack of cleanliness and adherence to the facility's policy of maintaining a clean, safe, and sanitary environment. Furthermore, the temperature in the medication storage room was recorded at 83°F, which exceeded the recommended storage temperature range of 68°F-77°F for certain medications. This included one bottle of Valproic Acid, two bottles of 0.9% Sodium Chloride Irrigation, and one bottle of Lidocaine 2% viscous solution. The DON acknowledged that these medications were not stored under proper temperature control and stated that they would be discarded to prevent potential adverse reactions if administered to residents.
Failure to Label Food Items with Use-By Dates
Penalty
Summary
The facility failed to ensure that food items were properly labeled with use-by dates, which is crucial for preventing foodborne illnesses. During an observation in the kitchen, several opened food items, including a container of butter, a gallon of chocolate syrup, a bag of potatoes hash brown, and 20 tomatoes, were found without labels indicating their use-by dates. The Dietary Supervisor (DS) acknowledged the absence of labels and emphasized the importance of labeling to prevent the use of expired food, which could lead to stomach illnesses among residents. Further inspection in the dry storage room revealed additional items, such as packets of No Bake Custard and bags of biscuit Gravy Mix, also lacking use-by and expiration dates. The DS admitted that the original packaging, which contained the expiration dates, had been discarded, making it impossible to determine the freshness of these items. Interviews with the Director of Nursing (DON) and a Registered Dietary (RD) confirmed that the facility's policy required all opened food items to be labeled with open and use-by dates to maintain food quality and prevent foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices for four out of fifteen sampled residents. In one instance, a urine-soaked diaper was observed on top of a paper towel dispenser in a communal bathroom, which was acknowledged by the Infection Prevention Nurse as a potential health risk. The Director of Nursing confirmed that such practices could lead to infections and hospitalizations for residents. Additionally, two Licensed Vocational Nurses (LVNs) did not follow Enhanced Barrier Precautions (EBP) while administering medications via gastrostomy tubes to residents who required such precautions. LVN 1 was observed not wearing gloves or an isolation gown while administering medication to a resident with severe cognitive impairment and multiple health issues, including hemiplegia and dysphagia. Similarly, LVN 2 did not wear an isolation gown while administering medication to another resident with severe cognitive impairment and dehydration. The absence of EBP signage and PPE outside the resident's room was also noted. Further deficiencies included a nebulizer mask found on the floor in a resident's room, which was identified as an infection control issue by LVN 5. Another resident's bedside urinal bottle filled with urine was repeatedly observed placed next to the resident's water pitcher, posing a contamination risk. The Registered Nurse Supervisor confirmed that such practices violated the facility's policy to maintain a clean and sanitary environment to prevent infections.
Resident Waits 32 Minutes for Meal Tray
Penalty
Summary
The facility staff failed to ensure a resident received their meal tray in a timely manner, resulting in the resident waiting for 32 minutes while other residents at the same table were already eating. This incident involved a resident who was admitted with diagnoses including dysphagia following a stroke and type II diabetes mellitus. The resident was cognitively impaired and dependent on assistance for eating, as indicated in their Minimum Data Set. During a dining observation, it was noted that the resident was left waiting for their meal tray, which was only provided 24 minutes after other residents had started eating. Interviews with staff and the resident revealed that the meal carts arrived on time, but the resident was not served promptly. The Activity Specialist confirmed the delay and was unsure why the resident was not assisted sooner. The resident expressed feelings of discomfort and disrespect due to the delay. The facility's administrator acknowledged that it was unacceptable for residents to wait longer than five minutes for their meals and emphasized the importance of treating residents with respect. The facility's policy on dignity, revised in February 2021, mandates that residents should be provided with a dignified dining experience, promoting their well-being and self-esteem.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for three residents, which is a violation of the facility's policy and procedure. Resident 1, who has moderately impaired cognitive skills and is dependent on assistance for various activities, was observed with a call light placed out of reach on the left upper side of the bed. This was confirmed during an interview with a Certified Nurse Assistant, who acknowledged that the call light should be within the resident's reach to enable them to call for help when needed. Resident 6, who has severely impaired cognitive skills and is dependent on assistance for daily activities, was observed with a call light placed on the right side, despite having right side weakness and a contracted right hand. A Licensed Vocational Nurse confirmed that the call light should have been placed on the left side, as the resident could not reach it with their left hand. This oversight prevented the resident from being able to call for assistance. Resident 5, who has intact cognitive skills but is dependent on assistance for daily activities, was observed with a call light on the floor, out of reach. The resident, who cannot move their fingers, stated they would call for help by yelling, which was confirmed by their roommate. A Licensed Vocational Nurse later noted that the call button was changed to a call pad that the resident could use effectively, as the previous setup was inappropriate. The facility's policy and procedure require that call lights be accessible to residents, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 22, who was receiving antibiotic and anticoagulant therapies. Upon review, it was found that the care plan did not include specific interventions for the use of Ceftriaxone, an antibiotic, and Eliquis, an anticoagulant. The MDS Nurse acknowledged that the care plan should have been established during the resident's admission, as the resident was already on antibiotic therapy. The absence of these care plans meant that the resident was not being monitored for the effectiveness of the treatments or for potential side effects, such as bleeding from the anticoagulant therapy. Resident 22 was admitted with diagnoses including osteomyelitis, congestive heart failure, and hypertension. The resident required partial to moderate assistance with various activities of daily living. The Director of Nursing confirmed that care plans should be initiated by the admitting nurse and completed by the Registered Nurse or Quality Assurance Nurse. The facility's policy indicated that comprehensive care plans should be developed within seven days of the MDS assessment and no more than 21 days after admission. However, this was not adhered to, resulting in a lack of monitoring for the resident's therapeutic treatments.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, as required by their policy and procedure. The resident, who had diagnoses including dementia, schizophrenia, and hypertension, was prescribed Abilify and Depakote for schizophrenia and bipolar disorder, respectively. However, there was no documented evidence that the resident's behavior was monitored for the use of these medications. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognitive skills and required substantial assistance with daily activities, but did not show any mood or behavior indicators. During interviews and record reviews, it was revealed that there were no physician's orders for behavior monitoring specifically for the use of Abilify and Depakote. The Medication Administration Record (MAR) was blank for the entire month of November, indicating that the resident's behavior was not monitored for the use of these medications. The facility's policy required documentation of targeted behaviors and potential interventions, but this was not done, leading to a deficiency in the care provided to the resident.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34% during a medication administration observation. This deficiency was identified when a Licensed Vocational Nurse (LVN) did not administer multivitamin, vitamin C, and vitamin D3 to a resident within the prescribed one-hour timeframe. The medications were supposed to be given at 9 AM, but were administered at 10:34 AM, exceeding the allowed time window. This practice was not in accordance with the facility's policy, which mandates that medications be administered within one hour of the prescribed time unless otherwise specified. The resident involved, identified as Resident 29, had a medical history that included mild protein calorie malnutrition, metabolic encephalopathy, and type 2 diabetes mellitus. The resident also had severe cognitive impairment and required varying levels of assistance with daily activities. During the medication pass observation, the resident was waiting for their medications, which were administered late by LVN 2. The Director of Nurses confirmed that medications should be given within the specified timeframe to prevent potential adverse effects.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Posted Nurse Staffing information for the dates 11/29/2024, 11/30/2024, and 12/1/2024, as required by their policy. During an observation on 12/2/2024, it was noted that the staffing posting area only contained forms dated 11/28/2024 and 11/29/2024, with the latter only showing projected hours rather than actual hours worked by nursing staff. Interviews with the Assistant Administrator (AADM) and Director of Nursing (DON) confirmed that the required Direct Care Service Hours Per Patient Day (DHPPD) postings were missing for the specified dates, and the purpose of these postings is to ensure transparency about staffing levels to residents, families, and staff. The facility's policy, revised in 8/2022, mandates that nurse staffing data be posted daily for each shift, including the number of nursing personnel responsible for direct care. This information should be computed and posted within two hours of each shift's start by the charge nurse or designee. The policy also requires that staffing information be maintained for 24 hours in a designated location and then filed as a permanent record for at least eighteen months. The failure to adhere to this policy resulted in a deficiency, as it potentially left residents and visitors uninformed about the facility's staffing levels.
Facility Fails to Meet Minimum Space Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for 12 out of 17 rooms. This deficiency was identified during a facility tour and confirmed through interviews and record reviews. The rooms in question were Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. Despite the deficiency, residents reported having enough space for care and storage, and those using wheelchairs stated they could maneuver without difficulty. The Assistant Administrator acknowledged the deficiency and indicated that a room waiver was requested, asserting that the deficiency did not impact residents' health and safety. The facility's room waiver letter detailed the square footage per bed for each room, confirming that the space provided was below the required standard. Observations from 12/02/2024 to 12/05/2024 noted adequate ventilation, lighting, and privacy in the rooms, with sufficient space for residents' movement and care provision. The waiver request emphasized that the rooms accommodated wheelchairs and medical equipment, and did not adversely affect residents' health or safety. The Department recommended the room waiver for the affected rooms, acknowledging the facility's efforts to maintain a safe and functional environment despite the space deficiency.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted daily in a visible and prominent place, as required. During an observation on September 30, 2024, the Census and Direct Care Service Hours Per Patient Day (DHPPD) form near the nursing station was found to be outdated, displaying the date September 27, 2024, with the section for Actual Direct Care Service Hours and DHPPD left blank. Further investigation revealed that no DHPPD forms were posted for several dates in September, including the 26th, 28th, and 29th. The Director of Nursing (DON) admitted to being unaware that the completed form with actual hours needed to be posted daily, as per the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers' dated July 2016.
Inconsistent Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide consistent treatment for pressure ulcers for three residents, leading to a deficiency in care. Resident 1, who was readmitted with a deep tissue injury and a Stage 2 pressure ulcer, did not receive the prescribed treatments consistently. The Treatment Administration Record (TAR) lacked documentation of zinc oxide application, low air loss mattress usage, heel offloading, and cleansing with normal saline on several occasions, indicating that these treatments were not administered as ordered. Resident 2, admitted with a Stage 4 pressure ulcer, also did not receive consistent care. The TAR showed missing documentation for cleaning with normal saline, barrier cream application, and dry dressing on specific dates. Additionally, the low air loss mattress therapy and monitoring for leaks and settings were not documented, suggesting these treatments were not performed as required. Resident 3, with an unstageable pressure ulcer, experienced similar issues. The TAR lacked entries for cleaning with normal saline, applying barrier cream, and using a dry dressing. Monitoring of the low air loss mattress for leaks and settings was also not documented on several shifts. Interviews with the treatment nurse confirmed that blank entries in the TAR indicated treatments were not provided, which is against the facility's policy for documenting care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse when Resident 2 struck them in the face. Resident 1, who was readmitted to the facility with diagnoses including difficulty in walking, type 2 diabetes mellitus, dementia, and chronic kidney disease, was in the activity room when the incident occurred. Resident 1's Minimum Data Set indicated severely impaired cognitive skills and required assistance with daily activities. On the day of the incident, Resident 1 was subjected to physical aggression from Resident 2, resulting in a care plan to prevent further injuries and emotional distress. Resident 2, who was also readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension, was involved in the altercation. Resident 2's records indicated moderately impaired cognitive skills and a history of physical altercations. On the day of the incident, Resident 2 exhibited increased agitation and aggression, leading to the physical altercation with Resident 1. The facility's records showed that Resident 2 had a care plan to prevent physical altercations and was under staff supervision for signs of danger to self or others. Interviews with facility staff, including the Director of Nursing, Infection Preventionist Nurse, Assistant Activities Director, and Registered Nurse Supervisor, confirmed the altercation between the two residents. Staff members witnessed Resident 2's aggressive behavior and the subsequent physical contact with Resident 1. The facility's policy on abuse prevention emphasized the residents' right to be free from abuse and the facility's responsibility to protect them from such incidents. However, at the time of the incident, there was no staff present in the activity room to prevent the altercation.
Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the care plan for a resident following a physical altercation with another resident. The care plan, which is intended to provide personalized care with measurable objectives and timeframes, was not updated to include specific interventions for the resident's care and safety after the incident. This oversight was identified during a review of the resident's records and an interview with the Registered Nurse Supervisor, who acknowledged that the care plan should have included new interventions and goals to address the resident's behavior and prevent future incidents. The resident involved in the incident was readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension. The resident had moderately impaired cognitive skills and required assistance with daily activities. Following the altercation, the facility's protocol was to notify authorities, but no new interventions were added to the care plan to manage the resident's increased agitation and aggression. The facility's policies require care plans to be revised when there is a significant change in a resident's condition, but this was not done in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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