Royal Terrace Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 1340 Highland Ave., Duarte, California 91010
- CMS Provider Number
- 055541
- Inspections on file
- 32
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Royal Terrace Healthcare during CMS and state inspections, most recent first.
The facility did not have a full-time RN serving as DON for an extended period, instead relying on RN consultants who visited part-time and floor RNs/LVNs to provide oversight. This was contrary to facility policy, which requires a full-time DON to oversee nursing services and ensure regulatory compliance.
Two residents were not adequately protected from accident hazards when a bed sensor alarm failed to alert staff as one resident got up unassisted, and another resident experienced multiple falls with head injuries due to inaccurate or missing fall risk assessments and lack of updated care plan interventions by the IDT.
A resident with severe dementia and psychosis, known for hypersexual and inappropriate public behavior, was placed in a shared room and engaged in indecent exposure and masturbation in front of another resident. Despite the affected resident expressing fear and discomfort to nursing staff, the only response was to advise use of the call light, and the incident was not reported or investigated as required by facility policy. Staff were aware of the ongoing behavior but did not take adequate steps to protect the resident or follow abuse reporting protocols.
A resident with dementia and psychosis repeatedly exposed himself and engaged in inappropriate sexual behavior in the presence of another resident who required substantial assistance with daily activities. Despite staff awareness of the ongoing behavior, it was not reported as sexual abuse to the administrator or authorities, as required by facility policy. Staff later acknowledged the failure to recognize and report the incidents appropriately.
A resident with severe dementia and psychosis exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. Although staff were aware of and reported the behavior, no care plan was developed to address or manage it, and the affected resident reported feeling unsafe. Facility policy required care planning for significant behavioral changes, but this was not followed.
A resident with multiple chronic conditions expressed a desire to leave the facility but did not receive a new elopement risk assessment or increased supervision as required by policy. After the resident verbalized wanting to leave, staff did not implement additional monitoring or interventions, resulting in the resident leaving the facility unsupervised.
The facility did not ensure that two residents had properly completed and accessible Advance Directives and Acknowledgement Forms in their medical records, despite both having significant medical conditions and cognitive impairments. Staff interviews and record reviews confirmed that required documentation was either missing or incomplete, contrary to facility policy.
Surveyors found that kitchen staff failed to label and date leftover food from outside the facility stored in the refrigerator, and did not label or discard expired items in the dry storage area. The Dietary Supervisor and Lead Cook confirmed these practices were not in line with facility policy, which requires all food to be labeled with delivery, opened, and used by dates, and prohibits storage of outside food in the kitchen.
A resident with a G-tube and severe cognitive impairment was exposed when a staff member checked the G-tube site without closing the privacy curtain, leaving the resident's abdomen and lower extremities visible to others. Both the DSD and DON acknowledged that privacy should have been maintained during care, in accordance with facility policy.
A resident with muscle weakness and contractures was unable to reach the call light, which was found behind the resident and out of reach while in bed. Staff confirmed the call light should have been accessible, and facility policy required it to be within reach. This failure had the potential to delay assistance for the resident.
A resident admitted with cirrhosis, hepatic encephalopathy, and CHF was placed on hospice care, but neither the hospice provider nor facility staff developed or initiated a coordinated hospice care plan as required. Interviews with the SSD and DON confirmed that a comprehensive, individualized plan was not created, despite facility policy mandating such collaboration.
A resident with a Stage 4 sacral pressure ulcer and morbid obesity was found lying on a low air loss (LAL) mattress that was not set according to their actual weight, as required by the care plan, physician orders, and the manufacturer's instructions. Staff confirmed the mattress was set incorrectly, and the resident reported a change in bed firmness. The deficiency was identified through observation, record review, and staff and resident interviews.
A resident dependent on hemodialysis, with end stage renal disease and moderately impaired cognition, did not have a required dialysis emergency kit (E-kit) at the bedside. Observation and staff interviews confirmed the absence of the E-kit, despite facility policy and the resident's care plan specifying its necessity for immediate intervention in case of bleeding from the dialysis access site.
A resident with rib fractures and intact cognition was assessed with severe pain, but a nurse administered Dilaudid as ordered for moderate pain instead of notifying the physician for appropriate orders. Facility policy required medications to be given per prescriber orders, and the DON confirmed the parameters were not followed, resulting in a medication error.
Surveyors found that the medication refrigerator was not consistently maintained within the required temperature range of 36 to 46°F, with temperature logs showing readings both above and below this range. Staff, including an LVN and the DON, confirmed the importance of proper temperature control for medication efficacy, and facility policy also required daily monitoring and adjustment.
Two resident rooms were found to have less than the required 80 square feet per resident, with each room measuring 156 square feet and housing two beds. Staff reported that care could be provided safely and residents had adequate space for mobility and equipment use, and no concerns were raised by residents regarding room size. The facility had requested a waiver for these rooms, and no changes to occupancy were made.
The facility failed to properly handle Advance Directives for two residents, risking treatment against their wishes. One resident's AD was not screened or documented upon admission, while another's AD Acknowledgement form was incomplete. The Social Service Director and Director of Nursing confirmed these oversights, which contradict the facility's policy.
The facility failed to manage and label IV lines appropriately for three residents, leading to potential infection risks. A resident's PICC line port was left uncapped, another's peripheral IV site was unlabeled, and a third's PICC line dressing lacked date labeling. These actions were contrary to the facility's policies, as confirmed by staff interviews.
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. A resident was observed not using oxygen, with the oxygen tubing found on the floor. Another resident was using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. A third resident used a facemask for breathing therapy that was not labeled with the date of use. Additionally, a fourth resident had oxygen tubing touching a trash bin, which was identified as a contamination risk.
A facility failed to create an individualized care plan for a resident with chronic cystitis, who was prescribed Bactrim. Despite the resident's moderate cognitive impairment and dependency on staff for daily activities, no care plan was documented to guide treatment. This deficiency was confirmed by the RN Supervisor and DON, who acknowledged the oversight in care planning.
A facility failed to perform a smoking assessment for a newly admitted resident with a history of smoking, as required by their policy. The resident, who had acute respiratory failure and hypertension, was observed smoking in the designated area without prior assessment. An LVN confirmed the oversight, highlighting a deficiency in adhering to the facility's smoking policy.
A resident with hemiplegia and hemiparesis required a plate guard and supervision during meals. Despite orders and care plans indicating the need for assistance, the resident was observed eating alone with the plate guard improperly positioned, leading to food spillage. Interviews confirmed the need for proper supervision and positioning to maintain the resident's independence and nutritional status.
A resident's POLST inaccurately indicated the presence of an Advance Directive, leading to potential miscommunication among healthcare providers. The Social Service Director admitted to incorrect documentation, which could result in inconsistent care during emergencies. The resident required substantial assistance and had diagnoses of hydrocephalus and hypertension.
The facility failed to meet the required square footage per resident in two rooms, each housing two residents, which were found to be 156 square feet instead of the required 160 square feet. Despite this, residents were able to move freely, and staff had enough space to provide care. The Administrator acknowledged the issue and planned to submit a room waiver request.
The facility failed to accommodate a resident's needs by not ensuring timely responses to call lights, not assisting with ADLs as per the care plan, and leaving the resident soiled in urine for prolonged periods. Staffing shortages led to delays in care and unmet needs.
The facility failed to implement individualized care plans for six residents, including not performing prescribed ROM exercises and not applying a left elbow splint, potentially diminishing their quality of life.
The facility failed to provide restorative nursing services as ordered by the physician for six residents, leading to potential declines in their range of motion and mobility. Staffing shortages caused RNAs to be reassigned to CNA duties, resulting in missed RNA services for multiple days in April 2024.
The facility failed to ensure sufficient nursing staff, resulting in unmet resident needs and inconsistent RNA services. Multiple residents did not receive timely care or physician-ordered RNA services due to staffing shortages and inadequate responses from the Director of Staff Development.
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies, including expired CNA certifications, lack of Skills Competency tests for newly hired CNAs, and missing CPR/BLS certifications. Additionally, the facility did not address staffing shortages, affecting the quality of care provided to residents.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required, from December 9, 2025, to December 23, 2025. During this period, there was no RN working as a full-time DON, despite a census of 52 residents. Observations on December 22 and 23, 2025, confirmed the absence of a designated full-time DON. Interviews with the former DON, the Administrator, and several RNs revealed that the previous DON had resigned in early December, and since then, no RN had been assigned to the full-time DON role. Instead, oversight was provided by RN consultants who visited the facility only 8 to 24 hours per week, and floor RNs and LVNs were considered to be acting as DONs in their absence. Facility policy and job descriptions reviewed during the survey indicated that the DON must be a state-licensed RN with experience in nursing service administration and must be employed full-time (40 hours per week). The policies also specified that RNs report to the DON, and the DON is responsible for overseeing nursing services and ensuring compliance with regulations. Despite these requirements, the facility did not have a full-time DON in place during the specified period, as confirmed by staff interviews and policy review.
Failure to Prevent Accidents and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of falls, dementia, and impaired cognition, a physician order required the use of a bed sensor pad alarm for safety. However, during observation, the resident was able to get up from bed and walk unassisted to the bathroom without the alarm sounding or staff responding. The resident reported multiple prior falls and stated she was not supposed to walk alone, but did so because staff did not always respond promptly when she needed to use the toilet. Another resident, admitted with diagnoses including metabolic encephalopathy and seizures, experienced multiple falls resulting in head lacerations. Documentation showed that after each fall, the facility's licensed nursing staff either failed to conduct a fall risk assessment or completed it inaccurately, incorrectly assessing the resident as low risk despite repeated incidents. The Director of Nursing confirmed that required fall risk evaluations were not completed or were inaccurate, and acknowledged that this increased the likelihood of further falls. Additionally, the facility's Interdisciplinary Team did not conduct comprehensive root cause analyses following the resident's falls, nor did they update the resident's care plan interventions to address the ongoing risk. The care plan was not reviewed or revised after repeated falls, and the team did not consider the resident's diagnoses as contributing factors. The facility's own policy required post-fall management, including care plan updates and multidisciplinary review, but these steps were not followed after the incidents.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Response to Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in one resident being subjected to indecent exposure by another resident. Specifically, a resident with severe dementia, psychosis, and a history of bizarre and hypersexual behavior, including public masturbation and exposing himself in hallways, was placed in a shared room. Despite staff being aware of this resident's ongoing inappropriate sexual behavior, including an incident where he masturbated in the presence of his roommate, the facility did not take adequate measures to prevent further exposure or ensure the safety of the roommate. The affected roommate, who had a history of acute subdural hemorrhage and mobility difficulties but was cognitively intact, reported feeling unsafe and unable to sleep due to fear of what might happen. The roommate communicated his discomfort and concerns to nursing staff, who only advised him to use the call light if something happened, rather than taking immediate protective action or removing him from the situation. Staff interviews confirmed that the inappropriate behavior was known and had been reported to the previous DON, but the behavior was attributed to the resident's dementia and not recognized as sexual abuse. Facility policy required prompt reporting and thorough investigation of all abuse allegations, but the incident was not reported to the administrator as required. Staff interviews indicated a lack of clarity regarding which residents were exposed and whether the situation was safe, with one RN supervisor acknowledging that it was not safe for the roommate to be alone with the resident exhibiting inappropriate sexual behavior. The facility's failure to act on known risks and to follow abuse reporting protocols resulted in a resident being subjected to sexual abuse and feeling unsafe in his living environment.
Failure to Report and Supervise Sexual Abuse Incidents
Penalty
Summary
The facility failed to ensure residents' right to be free from sexual abuse, specifically in the case involving one resident with a history of dementia, psychosis, and hypersexual behavior. This resident was observed exposing himself and masturbating in the presence of another resident, despite prior knowledge by staff of similar inappropriate behavior occurring in the hallways. Staff interviews and record reviews revealed that the behavior was ongoing, with nursing staff noting repeated incidents and acknowledging that the resident would only stop the behavior when prompted. The staff associated the behavior with the resident's dementia but did not recognize or report it as sexual abuse at the time. The incident involved another resident who required significant assistance with daily activities and had the capacity to understand and make medical decisions. The facility's policy required prompt reporting and investigation of abuse, but the RN Supervisor only reported the behavior to the previous DON and not to the administrator or external authorities. The staff later acknowledged that the behavior constituted sexual abuse and should have been reported according to policy, but this was not done at the time of the incidents.
Failure to Initiate Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to initiate a care plan for a resident who exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. The resident had a history of severe dementia with psychotic disturbance, unspecified psychosis, depression, and delirium, and was admitted to the facility following psychiatric evaluation for bizarre behavior and significant cognitive impairment. Despite these behaviors being observed and reported by nursing staff, no care plan was developed to address or manage the resident's hypersexual behavior. Interviews with staff revealed that the inappropriate behavior was known to the nursing team, and it was reported to the previous Director of Nursing. Staff acknowledged the behavior as related to the resident's dementia diagnosis but did not consider it sexual abuse. The affected resident who witnessed the behavior reported feeling uncomfortable and unsafe, and communicated these concerns to the nursing staff, who advised using the call light if further incidents occurred. However, there was no evidence in the medical record that a care plan was initiated to address the behavior or to protect other residents. Facility policies required that significant changes in a resident's condition, including behavioral changes, be assessed and addressed through interdisciplinary care planning. The policies also specified that such changes should be documented and that a comprehensive assessment should be conducted. Despite these requirements, the facility did not develop or implement a care plan for the resident's inappropriate sexual behavior, resulting in a deficiency related to the failure to meet the resident's needs and ensure the safety and well-being of other residents.
Failure to Reassess and Intervene After Resident Expressed Intent to Leave
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including cirrhosis of the liver, chronic congestive heart failure, and hepatic encephalopathy, expressed a desire to leave the facility but did not receive appropriate interventions for elopement risk. The resident had previously been assessed as not at risk for elopement upon admission, with the initial evaluation indicating no verbalization of wanting to leave. However, on the day of the incident, the resident told RN 1 that he wanted to leave and go to a friend's house but was unable to provide an address. Despite this verbalization, RN 1 did not complete a new elopement risk evaluation as required by facility policy, nor were additional monitoring or interventions implemented. Subsequently, the resident was discovered missing from the facility, prompting staff to search both inside and outside the premises and in the surrounding community. The Director of Nursing confirmed that the facility's policy required a new elopement risk assessment and closer monitoring when a resident verbalizes intent to leave. The failure to reassess and implement interventions after the resident expressed a desire to leave resulted in the resident leaving the facility unsupervised.
Failure to Complete and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and AD Acknowledgement Forms were properly completed and included in the medical records for two residents. For one resident with end stage renal disease, hydronephrosis, and dependence on hemodialysis, there was no copy of an AD or AD acknowledgement form in either the paper chart or electronic medical record. The Social Services Director confirmed that these documents should be updated and accessible with each admission or readmission to inform staff of the resident's wishes and preferences. The Director of Nursing also stated that all residents should have updated AD and ADA forms in their records, completed and signed upon admission or readmission, to ensure residents and their representatives are informed of their rights regarding medical treatment and advance directives. Another resident, admitted with type 2 diabetes mellitus and unspecified dementia, had an AD Acknowledgement Form that was not filled out completely. The Social Worker and Director of Nursing both confirmed that the form was incomplete and emphasized the importance of having it fully and accurately completed to reflect the resident's medical wishes. The facility's policy and procedure required inquiry about advance directives and provision of written information about the right to refuse or accept treatment prior to or upon admission, but this was not followed for the sampled residents.
Deficient Food Storage and Labeling Practices in Kitchen and Dry Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen. Specifically, leftover food from outside the facility, including beef, chicken, macaroni salad, and rice, was found in the kitchen refrigerator in unmarked to-go boxes. These items were not labeled or dated and were stored alongside food intended for residents. The Lead Cook confirmed that all food items in the kitchen refrigerator should be labeled with the date received, opened, and used by date, and that food from outside the facility should not be stored in the kitchen refrigerator for infection control purposes. Further observations in the dry storage area revealed multiple food items, such as an open box of chocolate powder, unopened boxes of thickened lemon-flavored water, a bag of hotdog buns, and cans of chocolate pudding, that were not labeled with delivery, opened, or used by dates. Additionally, an opened gallon of teriyaki sauce with a use-by date that had already passed was found on the rack. The Dietary Supervisor acknowledged that all food items should be properly labeled and expired items discarded, in accordance with facility policy. Review of facility policies confirmed requirements for labeling, dating, and discarding expired or partially eaten food, which were not followed in these instances.
Failure to Provide Privacy During G-Tube Care
Penalty
Summary
Staff failed to provide privacy for a resident with a gastrostomy tube during a care procedure. During an observation, the Director of Staff Development (DSD) entered the resident's room and pulled up the resident's gown to check the G-tube site without closing the privacy curtain. This action exposed the resident's abdominal area and lower extremities to both the roommate and the hallway. The resident was noted to have severely impaired cognition and was dependent on staff for all activities of daily living, including personal hygiene and dressing. Interviews with the DSD and the Director of Nursing (DON) confirmed that the privacy curtain should have been closed during care and activities of daily living to maintain the resident's dignity and privacy. The facility's policy on dignity and quality of life also required staff to promote and protect resident privacy during personal care and treatment procedures. The failure to close the privacy curtain resulted in unnecessary exposure of the resident's body during a medical check.
Call Light Inaccessible to Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a call light was within reach and appropriate to the physical abilities of a resident with significant mobility limitations. The resident, who had muscle weakness and contractures affecting both hips, both knees, and the left elbow, was found lying on his left side and unable to locate or reach his call light. A CNA confirmed that the call light was positioned behind the resident's right backside, making it inaccessible, and handed it to the resident. The resident stated he was unable to reach the call light on his own. The resident's care plan and occupational therapy evaluation documented limited mobility, decreased strength, and the need for assistance with activities of daily living. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been within the resident's reach to allow for timely assistance. The facility's policy also required that the call light be accessible to residents when in bed. The failure to ensure the call light was within reach had the potential to delay meeting the resident's needs for assistance.
Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive hospice plan of care for a resident who was admitted with diagnoses including cirrhosis, hepatic encephalopathy, and congestive heart failure. The resident was admitted to hospice care upon entry to the facility, as indicated in the Order Summary Report. However, upon review of both the hospice medical record and the facility's electronic medical record, it was found that no hospice care plan had been developed or initiated by either the hospice provider or the facility. Interviews with the Social Services Director and the Director of Nursing confirmed that a coordinated hospice care plan should have been created upon admission to address the resident's specific needs, goals, and interventions. The facility's policy and procedures also require collaboration between facility staff and the hospice agency to establish a care plan based on the resident's assessment. Despite these requirements, the necessary hospice care plan was not in place for the resident.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set up accurately according to the manufacturer's instructions for a resident with a history of a Stage 4 sacral pressure ulcer and morbid obesity. The resident's care plan and physician orders specified that the LAL mattress settings should be adjusted based on the resident's weight and personal preference. However, during observation, the mattress was found to be set at a weight setting between 350 lbs to firm, while the resident's actual weight was 144 lbs. Multiple staff members, including the Director of Staff and Development and the Infection Prevention Nurse, confirmed that the mattress was not set according to the resident's actual weight, as required by both the care plan and the manufacturer's user manual. The resident was dependent on staff for most activities of daily living and had impaired skin integrity related to a sacral coccyx Stage 4 pressure injury. During interviews, the resident reported that the bed was not as firm as before, indicating a change in the mattress setting. The Director of Nursing also acknowledged that the LAL mattress needed to be set based on the resident's weight and comfort level to prevent deterioration of wounds or development of new pressure injuries. The user manual for the mattress confirmed that the pressure should be adjusted using the patient's weight as a guide.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis had a dialysis emergency kit (E-kit) at the bedside, as required for immediate intervention in case of complications such as unexpected bleeding from the hemodialysis access site. Observation and interview confirmed that the resident, who had diagnoses including end stage renal disease, hydronephrosis, and dependence on hemodialysis, did not have an E-kit available at the bedside. The resident's care plan specified the need for immediate intervention for dialysis-related complications, and the Director of Nursing confirmed that all dialysis residents should have an E-kit readily accessible. The deficiency was identified during a review of the resident's records, care plan, and through direct observation and staff interviews. The resident was noted to have moderately impaired cognition and required varying levels of assistance with daily activities. The facility's policy and procedures indicated the need for immediate action and supplies in the event of bleeding from the dialysis access site, but these supplies were not present at the resident's bedside at the time of the survey.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple left-sided rib fractures and high blood pressure, who was cognitively intact and able to make decisions, did not receive pain medication in accordance with physician orders. The resident had an active order for Dilaudid 1 mg by mouth every four hours as needed for moderate pain (pain scale 4-6). During a medication administration observation, a nurse assessed the resident's pain at a level of seven, which is categorized as severe pain, but still administered Dilaudid as ordered for moderate pain. The nurse stated that pain medication for severe pain was unavailable and planned to reassess and contact the physician for further orders. The facility's care plan indicated that Dilaudid should be administered as ordered by the physician, and facility policy required medications to be given in accordance with prescriber orders. The DON confirmed that the physician should have been notified to obtain appropriate orders for severe pain and acknowledged that the ordered parameters were not followed. Facility policy also defined a medication error as administering drugs not in accordance with physician orders or accepted professional standards.
Failure to Maintain Medication Refrigerator Within Required Temperature Range
Penalty
Summary
The facility failed to maintain the medication refrigerator (MR) within the required temperature range of 36 to 46 degrees Fahrenheit, as evidenced by temperature logs and direct observation. The MR temperature log showed that on two consecutive days, the temperature was recorded at 48 degrees Fahrenheit, which is above the recommended range. Additionally, during an observation in the medication room, the MR temperature was found to be 34 degrees Fahrenheit, which is below the required minimum. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that maintaining the MR temperature within the specified range is necessary to ensure the efficacy and stability of stored medications. A review of the facility's policy and procedure on temperature control confirmed that drugs requiring refrigeration must be stored between 36 and 46 degrees Fahrenheit, and that daily temperature logs should be maintained to ensure compliance. The failure to keep the MR within the recommended temperature range was directly observed and acknowledged by facility staff, with no indication in the report of corrective actions taken at the time of the survey.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in two out of twenty-three resident rooms, as determined by observation, interview, and record review. The Client Accommodations Analysis indicated that the identified rooms had a total of 156 square feet of floor area and housed two beds, which does not meet the regulatory requirement for space per resident. The facility had submitted a waiver request for these rooms, stating that the space was sufficient for safe resident mobility and accessibility, and that care and services would not be impeded. During the health recertification survey, it was observed that the rooms in question allowed for adequate nursing care, comfort, and privacy. Staff, including a CNA and an LVN, reported that there was enough space to use necessary equipment such as Hoyer lifts and walkers, and residents were able to move freely within the rooms. No residents expressed concerns about the room sizes, and staff confirmed that care could be provided without issue. The facility administrator confirmed that a waiver had been requested for these rooms and that there had been no changes to bed occupancy.
Failure to Properly Handle Advance Directives
Penalty
Summary
The facility failed to ensure proper handling of Advance Directives (AD) for two residents, which could lead to treatment against their wishes. For Resident 99, the facility did not perform a screening for an AD upon admission, nor did they obtain a copy of the AD to maintain in the resident's medical record. This oversight was confirmed during an interview with the Social Service Director (SSD), who acknowledged that the screening for ADs is part of the facility's admission process. Additionally, Resident 99's family member confirmed that the resident had an AD, but the facility did not request a copy for the medical record. For Resident 9, the facility failed to ensure that the AD Acknowledgement form was filled out completely. The form lacked checks in the boxes indicating whether the resident had executed an AD. This was noted during a review of the resident's medical record and confirmed by the SSD, who stated that it was necessary to complete the form to respect the resident's treatment preferences. The Director of Nursing also acknowledged the incomplete form, emphasizing the need for it to be filled out by the SSD. The facility's policy requires that ADs be inquired about and documented upon admission, but this was not adhered to in these cases.
Deficiencies in IV Line Management and Labeling
Penalty
Summary
The facility failed to provide appropriate care and services for intravenous (IV) lines for three residents, leading to potential risks of infection and complications. For one resident, a PICC line port was observed to be exposed and not covered with a cap, contrary to the facility's policy on preventing intravenous catheter-related infections. This resident was admitted with sepsis and cellulitis, requiring IV medications via a PICC line, and the care plan aimed to avoid complications related to IV therapy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that all PICC line ports should be capped when not in use to prevent infection. Another resident had a peripheral IV site that was not labeled with the date of insertion, which is against the facility's policy requiring labeling with the date, time, and nurse's initials. This resident was admitted with cellulitis and had a physician's order for the peripheral site dressing to be changed every 72 hours. Observations and interviews with nursing staff revealed that the lack of labeling made it difficult to determine when the dressing was last changed, increasing the risk of infection. A third resident had a PICC line dressing that was not labeled with the date of insertion or change. This resident was admitted with acute osteomyelitis and anemia and required assistance with personal hygiene and transfers. The facility's policy mandates that PICC line dressings be labeled and changed every 5-7 days to prevent bacterial accumulation and infection. The Infection Preventionist Nurse confirmed that the dressing should be labeled to ensure timely changes, highlighting a lapse in adherence to infection prevention protocols.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. Resident 151, who was admitted with conditions including hemiplegia, hemiparesis, and pneumonitis, was observed not using oxygen, with the oxygen tubing found on the floor. Interviews with staff, including the Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that the oxygen tubing should have been placed in a transparent bag when not in use to prevent contamination and infection. Resident 27, admitted with acute respiratory failure and pneumonitis, was observed using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. This labeling is crucial to ensure timely changes and prevent infection. Interviews with the Infection Preventionist Nurse and the Registered Nurse Supervisor highlighted the importance of labeling to maintain infection control standards. Resident 25, diagnosed with hydrocephalus and hypertension, used a facemask for breathing therapy that was not labeled with the date of use. The Infection Preventionist Nurse indicated that the facemask should be labeled and changed every seven days to prevent bacterial accumulation. Additionally, Resident 199, with pulmonary hypertension, had oxygen tubing touching a trash bin, which was identified as a contamination risk by the Licensed Vocational Nurse and the Director of Nursing. The facility's policy requires oxygen equipment to be stored properly to prevent infection, which was not adhered to in these cases.
Failure to Develop Individualized Care Plan for Resident with Cystitis
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for Resident 19, who was diagnosed with chronic cystitis and was prescribed Bactrim. Despite the facility's policy requiring a comprehensive care plan to be developed within seven days of the Minimum Data Set (MDS) assessment and no more than 21 days after admission, there was no clinical documentation of a care plan addressing Resident 19's cystitis or the use of Bactrim. This oversight was identified during a review of Resident 19's medical records, which revealed the absence of a care plan to guide staff in providing appropriate treatment. Resident 19 was admitted to the facility with diagnoses including chronic cystitis and overactive bladder. The resident's cognitive abilities were moderately impaired, and they were dependent on staff for various activities of daily living. Despite these needs, the facility did not create a care plan to address the resident's specific medical condition and medication regimen. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the lack of a care plan, acknowledging that it should have been developed to ensure the resident received necessary care and treatment.
Failure to Conduct Smoking Assessment for New Resident
Penalty
Summary
The facility failed to conduct a smoking assessment for a newly admitted resident, identified as Resident 100, who had a history of smoking for more than a specified number of years. This oversight was discovered during an observation in the facility's designated smoking area, where Resident 100 was seen smoking with a visitor. The resident's admission record indicated diagnoses of acute respiratory failure and hypertension, and the history and physical examination confirmed the resident's capacity to understand and make decisions. However, the medical record lacked any documentation of a smoking assessment. During an interview with Licensed Vocational Nurse 5, it was revealed that the facility was unaware of Resident 100's smoking status upon admission, and no smoking assessment was performed. The facility's policy, revised in October 2023, mandates that residents be informed of the smoking policy and evaluated for smoking status upon admission. The failure to adhere to this policy resulted in a deficiency, as the necessary assessment to ensure safe smoking practices was not conducted.
Failure to Supervise Resident Using Plate Guard
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required the use of a plate guard during meals. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis, had an order for a plate guard at mealtime and required supervision or assistance with eating. Despite these requirements, observations revealed that the resident was eating alone with the plate guard improperly positioned, leading to food spillage. Interviews with the Director of Nursing and a Certified Nurse Assistant confirmed that the resident needed assistance to use the plate guard effectively, and the Dietary Supervisor indicated that the plate guard should be positioned to accommodate the resident's dominant hand. The resident's care plan and order summary report indicated the need for supervision during meals, yet the resident was observed eating without the necessary assistance. The facility's policy on assistive devices emphasized the importance of maintaining and supervising the use of such equipment to support resident independence and safety. However, the lack of proper supervision and incorrect positioning of the plate guard during meals demonstrated a failure to adhere to these guidelines, potentially impacting the resident's nutritional status and independence during mealtime.
Inaccurate POLST Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of the Physician Orders for Life-Sustaining Treatment (POLST) for a resident, identified as Resident 25. The POLST, which is crucial for recording a patient's treatment preferences in emergencies, inaccurately indicated that the resident had an Advance Directive (AD). However, upon review, it was found that the resident did not execute an AD, as confirmed by the AD acknowledgment form and the Social Service Director (SSD). This inconsistency between the POLST and the AD acknowledgment form was acknowledged by the SSD, who admitted to incorrect documentation. Resident 25 was admitted with diagnoses including hydrocephalus and hypertension and required substantial assistance for personal hygiene and transfers. The inaccurate documentation in the POLST had the potential to cause miscommunication among healthcare providers, leading to inconsistent care and possibly administering treatment against the resident's wishes during emergencies. The facility's policy on charting and documentation emphasizes the need for objective, complete, and accurate records, which was not adhered to in this case.
Room Size Deficiency in Two Resident Rooms
Penalty
Summary
The facility failed to ensure that two of its rooms met the required square footage per resident in multiple resident rooms. Specifically, rooms 12 and 32, each housing two residents, were found to be 156 square feet, falling short of the 160 square feet minimum requirement. Despite this deficiency, observations indicated that residents in these rooms were able to ambulate freely and maneuver in their wheelchairs without difficulty. Nursing staff also had sufficient space to provide care with dignity and privacy, and there was adequate room for beds, side tables, dressers, and other medical equipment. During an interview, the Administrator acknowledged the deficiency and indicated plans to submit a room waiver request for the affected rooms. The waiver request letter stated that there was ample room to accommodate wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. Interviews with residents revealed no concerns regarding the size of their rooms, suggesting that the deficiency did not adversely affect their well-being or the provision of care.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring timely responses to the resident's call light, not assisting with activities of daily living (ADL) as per the care plan, and leaving the resident soiled in urine for prolonged periods. The resident, who had multiple diagnoses including a history of stroke, osteoarthritis, epilepsy, and mobility impairments, was totally dependent on staff for personal and toileting hygiene. Despite the care plan indicating the need for substantial assistance and frequent incontinence care, the resident reported having to wait for assistance to get out of bed and being left soiled due to staff shortages. Interviews with Certified Nursing Assistants (CNAs) revealed that due to staffing shortages, they were unable to change incontinence briefs and reposition residents every two hours as required. The CNAs admitted to only being able to change residents twice per shift and acknowledged delays in answering call lights. The facility's policies on answering call lights and supporting ADLs were not adhered to, leading to the resident's needs not being met in a timely and appropriate manner.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for six residents in accordance with physician's orders. For Resident 7, the care plan did not include a physician's order for Assisted Active Range of Motion (AAROM) exercises to both lower extremities. Additionally, the facility did not perform Passive Range of Motion (PROM) exercises for Resident 9's right upper extremity, Resident 10's lower extremities and right upper extremity, and Resident 11's lower extremities as indicated in their care plans. Furthermore, Active Range of Motion (AROM) exercises were not performed for Resident 13's lower extremities, and Resident 14 did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity as indicated in the care plan. Resident 7 was admitted with multiple diagnoses including dementia and morbid obesity and required assistance with mobility and personal care. The care plan for Resident 7 included AAROM exercises for both lower extremities, but there was no corresponding physician's order. Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive PROM exercises for the right upper extremity on several documented dates. Similarly, Resident 10, who had hemiplegia and hemiparesis, did not receive PROM exercises for the lower extremities and right upper extremity on multiple occasions. Resident 11, with a history of falling and a displaced bimalleolar fracture, did not receive PROM exercises for the lower extremities as ordered. Resident 13, who had a right femoral neck fracture and other mobility issues, did not receive AROM exercises for the lower extremities on several dates. Lastly, Resident 14, who had hemiplegia and contractures, did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity on multiple occasions. These failures had the potential to diminish the residents' quality of life related to a further decline in their physical and psychosocial well-being.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered by the physician for six residents. For Resident 7, who had multiple diagnoses including dementia and morbid obesity, RNA services were not provided for five days in April 2024. The resident required assistance with mobility and personal care, and the lack of RNA services was confirmed through interviews and record reviews. Similarly, Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility, and the absence of RNA services was also confirmed through documentation review and interviews. Resident 10, diagnosed with hemiplegia and hemiparesis, did not receive RNA services for six days in April 2024. The resident was dependent on staff for toileting hygiene, showering, and mobility. The lack of RNA services was confirmed through record reviews and interviews. Resident 11, who had a history of falling and a displaced bimalleolar fracture, did not receive RNA services for three days in April 2024. The resident had severe cognitive impairment and was dependent on staff for all self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. Resident 13, who had multiple diagnoses including a right femoral neck fracture and heart failure, did not receive RNA services for three days in April 2024. The resident was dependent on staff for various self-care activities and transfers. The lack of RNA services was confirmed through record reviews and interviews. Lastly, Resident 14, diagnosed with hemiplegia and contractures, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. The Director of Nursing acknowledged that RNA services must be provided consistently to prevent further decline in residents' range of motion and mobility, but staffing shortages led to RNAs being reassigned to CNA duties, resulting in the failure to provide the necessary services.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff, including CNAs and RNAs, to provide care for seven of 15 sampled residents. This deficiency was observed through various interviews and record reviews, revealing that residents' needs and preferences were not met, and physician-ordered RNA services were not consistently provided. For instance, Resident 1 had to wait until 10 AM to get out of bed due to a lack of staff, and incontinence brief changes were not performed as frequently as required. Multiple CNAs reported being overworked and unable to respond to call lights promptly, leading to delays in care and resident dissatisfaction. The report also highlighted that RNA services were not provided as ordered by the physician for several residents. Resident 7, for example, did not receive RNA services on multiple days in April 2024, as documented in the facility's records. Similar deficiencies were noted for Residents 9, 10, 11, 13, and 14, who did not receive their prescribed RNA services on various dates. Interviews with RNAs confirmed that they were often reassigned to perform CNA duties due to staffing shortages, leaving them unable to fulfill their RNA responsibilities. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed a consistent theme of staffing shortages and inadequate responses from the Director of Staff Development (DSD). Staff reported that the DSD did not call for additional help or use registry staff effectively, leading to an overwhelming workload and insufficient care for residents. The facility's policy on staffing emphasized the need for sufficient numbers of skilled staff to meet residents' needs, but this was not adhered to, resulting in significant care deficiencies.
Failure to Verify Competencies and Address Staffing Shortages
Penalty
Summary
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies. Three of nine sampled CNAs did not have active CNA certifications. Interviews revealed that errors in filling out certification renewal paperwork and providing required in-services delayed the renewal process. Despite expired certifications, some CNAs continued to work in non-resident care-related duties. The facility's policy required maintaining current certifications, but this was not adhered to, as evidenced by the employee files and timecards reviewed by the Director of Nursing (DON). Additionally, the facility's DSD job description mandated maintaining employee files and health records, which was not followed in this case. The facility also failed to conduct Skills Competency tests for newly hired CNAs before they began working independently. Performance evaluations and Skills Competency tests were supposed to be conducted upon hire and annually, but there was no documented evidence that these tests were performed for two newly hired CNAs. The DON confirmed the absence of these tests and noted that the Pre-Employment Reference Verification Checklist for one CNA was questionable. The facility's DSD job description required assessing the learning needs of personnel and monitoring continuity between classroom and clinical application, which was not done. Furthermore, the facility did not ensure that all nursing staff had current CPR/BLS certifications. Four sampled nursing staff members lacked documented evidence of current CPR/BLS certifications. The DSD was responsible for verifying these certifications upon hiring and organizing renewal classes if needed, but this was not done. Interviews with staff revealed that the DSD did not address staffing shortages, which affected the quality of care provided to residents. Staff reported being overwhelmed with the workload, unable to take breaks, and struggling to provide adequate care due to insufficient staffing. The facility's policy required providing sufficient numbers of staff with the necessary skills and competency, which was not met.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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