San Gabriel Valley Medical Ctr D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 438 W. Las Tunas Drive, San Gabriel, California 91776
- CMS Provider Number
- 555237
- Inspections on file
- 26
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at San Gabriel Valley Medical Ctr D/p Snf during CMS and state inspections, most recent first.
A resident with complex medical needs and high dependence on staff for daily care was discharged without receiving the required 30-day written notice. Facility staff communicated discharge plans verbally but did not provide written notification to the resident or family, and the facility's policy lacked the required notice provision. The responsible party and ombudsman raised concerns about the discharge process, and staff interviews confirmed the deficiency.
Two residents with severe cognitive impairment did not receive care that promoted dignity and respect. One was addressed by a term of endearment rather than by name or title by an LVN during medication administration, and another was provided incontinent care by a CNA without the privacy curtain fully drawn or the door closed, exposing the resident. Staff and facility policy confirmed the expectation to use proper names and ensure privacy during care.
Three residents at risk for or with existing pressure ulcers were found with low air loss mattresses set below the required weight-based settings, contrary to physician orders and facility policy. Nursing staff confirmed the incorrect settings and acknowledged that this could compromise pressure ulcer prevention and wound healing.
Two residents with G-tubes did not receive care in accordance with facility policy: one had medications administered while tube feeding was running, and another received multiple medications mixed together and rapidly pushed through the tube with a syringe plunger, rather than by gravity. Facility policy requires tube feedings to be paused and medications to be given separately and by gravity, but these procedures were not followed.
Surveyors observed multiple failures in infection prevention and control, including a catheter drainage bag left on the floor, staff not changing gloves or performing hand hygiene between tasks during medication administration and dressing changes, and unclean medical equipment. These lapses involved residents with significant cognitive and physical impairments and were confirmed by staff interviews and facility policy reviews.
A resident's confidential medical information, including medication list and date of birth, was left visible on an unattended computer monitor on a medication cart in the hallway. The resident had multiple diagnoses and was fully dependent on staff. Staff interviews and facility policy confirmed that monitors should be turned off or blanked when unattended to comply with HIPAA, but this procedure was not followed, resulting in a breach of confidentiality.
A resident with severe cognitive impairment and multiple health conditions was prescribed Apixaban via G-tube, with a care plan requiring monitoring for bleeding and medication effectiveness. Facility staff failed to document or perform this monitoring, as confirmed by record review and staff interview, resulting in a deficiency in care planning and implementation.
A resident who was fully dependent on staff for ADLs and had significant cognitive and physical impairments was found with long, untrimmed fingernails on both contracted hands. Staff confirmed that nail care is part of daily grooming responsibilities, and facility policy requires CNAs to provide such care as needed for hygiene and safety.
Two residents at high risk for venous thromboembolism did not receive sequential compression device (SCD) therapy as ordered by their physicians. Observations showed that SCD sleeves were either not applied or the machines were turned off while the residents were in bed, despite staff acknowledging the importance of SCD use for VTE prevention.
A nurse mixed Lactulose and Rivastigmine together with water and administered the combined medications rapidly through a G-tube to a resident with multiple diagnoses, including Alzheimer's disease and Parkinson's disease. This action was not in accordance with facility policy, which required medications to be given separately and via gentle instillation or gravity, with flushing between each medication.
A nurse mixed and administered Lactulose and Rivastigmine together via G-tube to a resident with multiple complex conditions, contrary to facility policy and accepted standards, resulting in a medication error rate of 8% during observation.
The facility did not ensure that opened refrigerated food items and unopened food items removed from their original packaging were properly labeled with required information such as used by date, opened date, and item name. This was observed during a kitchen inspection, where containers of peeled garlic and various salad dressings lacked appropriate labeling, contrary to facility policy and staff statements.
A facility failed to report a bruise on a resident's leg to the physician and next of kin in a timely manner, violating its policy on changes in resident condition. The bruise was discovered but not reported for two days, despite the resident's complex medical history and comatose state. The resident's daughter was upset upon discovering the bruise, highlighting a communication lapse.
The facility failed to provide necessary treatment and services to prevent and heal pressure injuries for three residents. One resident developed a new stage 2 pressure injury due to inadequate monitoring and documentation. Two other residents had their low air loss mattresses set incorrectly, placing them at risk for pressure injuries.
The facility failed to follow its policy for verifying G-tube placement by auscultating the epigastric area while injecting air for two residents with severe cognitive impairment. Both the LVN and RN admitted to forgetting this critical step, which is necessary to ensure proper G-tube placement and reduce the risk of complications.
The facility failed to provide necessary respiratory care services for three residents with tracheostomies by not having emergency equipment available in the activity room for accidental decannulation. The residents were observed without a respiratory therapist present and without necessary emergency equipment, contrary to the facility's policy.
The facility failed to ensure safe pharmaceutical services by not disposing of expired medication, not properly storing medications, and not keeping medication carts locked. An expired Desitin paste was found in a medication cart, a Primidone blister packet was found on the floor near a resident's doorway, and medication carts were observed unlocked and unattended.
The facility failed to label food items with names, dates opened, and expiration dates, and did not maintain clean kitchen surfaces. Additionally, personal belongings were found in the kitchen storage room, all of which could lead to food contamination.
The facility failed to properly dispose of garbage in the kitchen by not having lids on the garbage containers, contrary to the facility's policy. Multiple uncovered garbage cans were observed, and the Dietary Director acknowledged the need for fitting lids to prevent food contamination.
A facility failed to ensure a resident's indwelling catheter urine collection bag was covered by a dignity bag, exposing the urine and allowing the bag and tubing to touch the floor. This oversight was confirmed by staff and violated the facility's policy on resident privacy and dignity.
The facility failed to ensure a homelike environment for a resident by using the room to store hospital equipment, not replacing a broken window screen, and leaving a used disposable cup on the floor. The resident had severe cognitive impairment and required assistance for daily activities. The facility's policy emphasized creating a homelike atmosphere, which was not followed in this case.
The facility failed to post complete Nurse Staffing Information by not including the total and actual number of hours worked by licensed and unlicensed nursing staff per shift. This was confirmed by the Unit Secretary and the Director of Nursing, who acknowledged the lack of a compliant policy.
Failure to Provide Written Discharge Notice and Safe Discharge Planning
Penalty
Summary
The facility failed to implement an appropriate discharge plan for a resident by not providing a written discharge notice to the resident and their family, and by not re-evaluating the resident's condition prior to discharge. The resident, who was admitted with chronic hypoxic respiratory failure, recent subdural hemorrhage status post craniotomy, and protein malnutrition, was highly dependent on staff for all activities of daily living, requiring assistance from one or two helpers for basic care tasks. Despite these significant care needs, the facility only communicated discharge plans verbally and did not issue the required 30-day written notice to the resident or their responsible party. Interviews with the responsible party, clinical manager, and case manager confirmed that the discharge process was handled without proper written notification, and the facility's policy did not specify the 30-day written notice requirement. The responsible party and ombudsman both raised concerns about the lack of written notice and the safety of the discharge plan, especially given the resident's ongoing high level of care needs and the family's preference for transfer to another skilled nursing facility. The facility's failure to follow regulatory requirements for discharge notification and planning was confirmed through record review and staff interviews.
Failure to Promote Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not ensuring proper communication and privacy during care. In the first instance, a Licensed Vocational Nurse addressed a resident with a term of endearment ('honey') instead of using the resident's name or appropriate title prior to administering medication. The resident in question had severe cognitive impairment and was dependent on staff for all activities of daily living. Facility policy and staff interviews confirmed that residents should be addressed by their names or titles to maintain respect and dignity. In the second instance, a Certified Nurse Assistant provided incontinent care to another resident without fully drawing the privacy curtain or closing the room door, leaving the resident exposed. This resident also had severe cognitive impairment and was dependent on staff for personal care. The care plan for this resident specifically included interventions to provide privacy during personal care. Staff interviews acknowledged the importance of maintaining privacy and dignity during such procedures, and facility policy emphasized the preservation of patient rights and dignity.
Failure to Set Low Air Loss Mattresses Correctly for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and care by not ensuring that low air loss mattresses (LALM) were set according to residents' weights, as required by facility policy and physician orders. For three residents, the LALM settings were observed to be incorrect during multiple observations and interviews. Specifically, one resident with a history of cerebrovascular accident, right-sided hemiplegia, and high risk for pressure ulcers had their LALM set at a lower zone than required for their weight, despite care plans and physician orders specifying the need for correct settings. Nursing staff confirmed the mattress was set incorrectly and acknowledged that improper settings could worsen pressure injuries. Another resident, diagnosed with Parkinson's disease, chronic respiratory failure, and a stage 4 pressure ulcer, was also found with their LALM set below the appropriate zone for their weight. This resident was highly dependent for all activities of daily living and had multiple pressure ulcers upon admission. Staff interviews confirmed the mattress was not set according to the resident's weight, and that this could compromise wound healing, as the therapeutic effect of the mattress would not be effective if set incorrectly. A third resident, with severe cognitive impairment and a history of healed pressure ulcers, was observed with their LALM set at a lower zone than required for their current weight. Staff confirmed the mattress should have been set higher and that incorrect settings could lead to skin breakdown. Facility policy and procedure documents reviewed indicated that mattress settings must be appropriate to the resident's weight to provide effective pressure relief and prevent skin breakdown. The failure to follow these protocols was confirmed through staff interviews and record reviews.
Failure to Follow Enteral Medication Administration Protocols
Penalty
Summary
The facility failed to provide appropriate care to prevent complications related to enteral feeding for two residents with gastrostomy tubes. For one resident with chronic respiratory failure, aspiration pneumonia, and diabetes mellitus, a nurse administered medications via the G-tube without turning off the enteral feeding pump, contrary to facility policy. The nurse stated that tube feeding is only held during a specific morning shift and not during other medication administrations. The facility's policy requires that continuous tube feedings be put on hold before administering medications through a feeding tube. For another resident with Parkinson's disease, diabetes mellitus, and a PEG tube, a nurse prepared and administered medications by mixing them together and rapidly pushing the mixture through the G-tube using a syringe plunger. The medications were not given one at a time, nor were they allowed to infuse by gravity as required by facility policy. The nurse stated it was acceptable to mix medications, while the interim DON clarified that medications should be given separately and by gravity, not by force. Facility policies reviewed indicated that tube feedings should be paused before medication administration, medications should not be mixed unless compatible, and medications should be administered by gentle instillation or gravity, flushing between each medication. These procedures were not followed for the two residents, as observed and confirmed by staff interviews and record reviews.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices for five of thirteen sampled residents, as evidenced by multiple direct observations and staff interviews. In one instance, a resident with severe cognitive impairment and total dependence for activities of daily living was observed with a Foley catheter drainage bag resting on the floor and not covered with a dignity bag, contrary to the care plan and facility policy. Both a registered nurse and the interim director of nursing confirmed that the drainage bag should not be on the floor due to infection control concerns and that it should be covered for both dignity and infection prevention. During medication administration and dressing changes, two LVNs did not change gloves or perform hand hygiene between tasks. One LVN, while administering medications to a resident with severe cognitive impairment and multiple comorbidities, picked up a medication bottle from the floor with gloved hands, continued preparing medications without changing gloves, touched various surfaces and the resident’s linens, and administered medications and eye drops—all without changing gloves. The LVN admitted to not being aware of the need to change gloves between tasks. Another LVN, during a G-tube dressing change and medication administration for two different residents, failed to change gloves after touching potentially contaminated surfaces, such as the resident’s clothes and their own mask, before proceeding with invasive procedures. Both LVNs acknowledged during interviews that they should have changed gloves to prevent possible contamination. Additionally, the facility did not ensure that medical equipment was properly cleaned and disinfected. A feeding pump used by a resident with chronic respiratory failure and end-stage ALS was observed with visible brown/yellow stains, and a CNA confirmed that the equipment should be cleaned daily. The infection prevention nurse also stated that daily cleaning of medical equipment is essential for infection control. Facility policies reviewed supported the need for proper hand hygiene, glove changes, and daily cleaning of patient care equipment, but these were not followed in the observed instances.
Failure to Secure Resident Medical Records and Maintain Confidentiality
Penalty
Summary
The facility failed to secure confidential medical records for one resident, as required by its own policy. During an observation, a computer monitor displaying the resident's medication list and personal information, including date of birth, was left turned on and unattended on top of a medication cart in the hallway, directly in front of the resident's room. This allowed the resident's protected health information to be visible and accessible to unauthorized individuals. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes mellitus, and a history of seizures, and was assessed as having severely impaired cognitive skills, being dependent on staff for all activities of daily living. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, confirmed that staff are expected to turn off or blank computer screens when stepping away to comply with HIPAA privacy and security rules. A review of the facility's policy on resident privacy and confidentiality further indicated that all staff must not leave workstations unattended without first logging off or blanking the screen. The failure to follow these procedures resulted in the exposure of the resident's confidential information.
Failure to Monitor Anticoagulant Therapy as Required by Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident receiving Apixaban (Eliquis) for atrial fibrillation. The resident, who had multiple diagnoses including respiratory failure, COPD, and atrial fibrillation, was severely cognitively impaired and dependent on staff for all activities of daily living. The physician's order specified Apixaban administration via gastrostomy tube, and the care plan included interventions to monitor for bruising, bleeding, and the effectiveness and side effects of the medication. However, a review of the resident's progress notes revealed no documentation that nursing staff monitored for side effects or the effectiveness of the anticoagulant therapy as required by the care plan and facility policy. During interviews, the MDS Coordinator confirmed that the lack of documentation indicated staff were not checking the resident for bleeding or other side effects while on Eliquis. The facility's policy required assessment and care planning to meet individual resident needs, but this was not followed in this case.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs), including grooming, was observed to have long and untrimmed fingernails on both contracted hands. The resident's medical history included chronic subdural hematoma, respiratory failure, and chronic obstructive pulmonary disease. Assessment records indicated the resident was severely cognitively impaired and required total assistance for toileting hygiene, oral hygiene, and dressing. During an observation, the resident was found lying in bed with long fingernails touching the skin. Certified Nursing Assistant 1 confirmed that the resident's fingernails were long, untrimmed, and in contact with the skin, acknowledging that nail care is part of daily grooming and that long nails could harbor bacteria and potentially cause skin tears. The Director of Staff Development stated that CNAs are responsible for providing grooming care, including nail care, to ADL-dependent residents. Facility policy indicated that grooming activities, including nail care, should be provided as needed for resident hygiene and safety.
Failure to Administer SCDs as Ordered for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents received treatment and care as ordered by not administering sequential compression devices (SCDs) according to physician orders. For one resident with chronic respiratory failure, encephalopathy, and quadriplegia, records showed a high risk for venous thromboembolism (VTE) and a physician's order for SCD use. Observations revealed that the SCD sleeves were either not applied or, when applied, the machine was turned off. Nursing staff confirmed that the SCD should have been in use and acknowledged that the physician's order was not being followed. Similarly, another resident with chronic subdural hematoma, respiratory failure, and chronic obstructive pulmonary disease was also identified as high risk for VTE and had a physician's order for SCD use. Observations found the SCD machine turned off and the sleeves not applied while the resident was in bed. Nursing staff confirmed that the SCD should have been applied and in use as ordered. Facility policy required implementation of appropriate VTE prevention measures based on risk, but these were not followed for the two residents.
Improper Mixing and Administration of Medications via G-Tube
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) mixed Lactulose and Rivastigmine together with water and administered the combined medications via a gastrostomy tube (G-tube) to a resident. The resident had multiple diagnoses, including Parkinson's disease, diabetes mellitus, Alzheimer's disease, and was dependent on a G-tube for medication administration. The nurse prepared the medications by opening the Rivastigmine capsule, mixing its contents with Lactulose and water, and then administering the mixture in two rapid boluses through the G-tube. The facility's policy and procedure specifically instructed staff not to mix incompatible medications and to administer medications one at a time, flushing the tube with water between each medication. The policy also required medications to be administered via gentle instillation or gravity, not by force or rapid bolus. The LVN stated it was acceptable to mix some medications, while the Interim Director of Nursing clarified that medications should not be mixed due to risks such as tube clogging and drug interactions. The nurse's actions were not in accordance with the facility's established medication administration protocols.
Medication Error Rate Exceeds 5% Due to Improper G-Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of 25 observed opportunities, resulting in an 8% error rate. Specifically, a Licensed Vocational Nurse (LVN) prepared and administered Lactulose and Rivastigmine together by mixing the contents of a Rivastigmine capsule with Lactulose liquid and water, then administering the mixture via a gastrostomy tube to a resident. This method of administration was observed during a medication pass and was not in accordance with the prescriber's order, manufacturer's specifications, or accepted professional standards. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes mellitus, a gastrostomy tube, and Alzheimer's disease, and was assessed as having severely impaired cognitive skills and being fully dependent for daily activities. The facility's policy and procedure on medication administration specifically indicated that incompatible medications should not be mixed and that medications should be administered one at a time. The Interim Director of Nursing confirmed during an interview that medications should not be mixed due to risks such as tube clogging and drug interactions.
Failure to Properly Label and Store Food Items in Kitchen
Penalty
Summary
The facility failed to ensure proper storage and preparation of food items served to residents by not labeling refrigerated opened food items with a used by date and not labeling unopened food items that had been removed from their original boxes with the name of the item, expired date, opened date, and used by date. During an observation of the walk-in refrigerator, it was found that an opened container of peeled garlic lacked a label indicating the opened and used by dates. Additionally, several unopened containers of salad dressings that had been removed from their original packaging were not labeled with the required information. Interviews with the Dietary Supervisor and Food Service Director confirmed that these labeling and storage practices were not followed, despite facility policy requiring all prepared and unserved food, as well as items not in their original containers, to be clearly labeled and dated. The failure to adhere to these procedures was acknowledged by staff and was identified as a deficient practice with the potential to result in foodborne illness for all residents consuming food prepared by the facility kitchen.
Failure to Report Change in Resident Condition
Penalty
Summary
The facility failed to adhere to its policy titled 'Change in Resident Condition' by not reporting a bruise sustained on the left leg of Resident 1 to the physician and the resident's next of kin in a timely manner. The bruise, which was approximately 5 cm by 5 cm, was discovered on 11/19/2024, but the physician was not notified until 11/21/2024, two days later. The facility's policy requires that any sudden or serious change in a resident's condition be communicated to the physician and family or legal representative promptly. However, this protocol was not followed, as evidenced by the delayed notification. Resident 1, who was admitted for chronic respiratory failure with hypoxia, had been comatose in the subacute unit for about 9 years. The bruise was discovered by the nursing staff, but there was no history of trauma, swelling, redness, or pain on palpation reported. The resident was not on blood thinners, and lab work was ordered the day before the physician was notified. The resident's daughter was upset upon discovering the bruise during a visit, indicating a lack of communication from the facility regarding the change in condition.
Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to ensure that three residents received necessary treatment and services to prevent the formation and promote the healing of pressure injuries. For Resident 3, the facility did not accurately monitor, assess, and document the resident's skin condition from 4/1/2024 to 4/26/2024. This included failing to measure and document a newly developed stage 2 pressure injury on the right shoulder, as well as failing to measure existing stage 2 and stage 3 pressure injuries on the left and right ischium, respectively. This lack of proper assessment and documentation resulted in the development of a new stage 2 pressure injury on Resident 3's right shoulder and had the potential to delay healing and worsen existing pressure injuries. For Resident 27, the facility did not ensure that the low air loss mattress (LALM) was set according to the resident's weight. The LALM was observed to be set at 315 pounds, while Resident 27 weighed only 117 pounds. This incorrect setting placed Resident 27 at risk of developing pressure injuries due to receiving more pressure than needed while in bed. Both Licensed Vocational Nurses (LVNs) confirmed that the LALM setting was incorrect and emphasized the importance of having the correct setting to prevent skin breakdown. Similarly, for Resident 236, the facility failed to ensure that the LALM was set according to the resident's weight. The LALM was observed to be set at Zone 5 (210 pounds), while Resident 236 weighed 165 pounds. This incorrect setting placed Resident 236 at risk for the progression of pressure injuries. The LVN confirmed that the LALM setting was incorrect and stressed the importance of having the correct setting to ensure comfort and prevent worsening of pressure injuries. The facility's policy and procedure for skin care and the use of pressure-relieving devices were not followed in these cases, leading to the deficiencies observed.
Failure to Follow G-Tube Placement Verification Policy
Penalty
Summary
The facility failed to follow its policy for checking gastrostomy tube (G-tube) placement by auscultating the epigastric area while injecting a small amount of air for two residents. Resident 14, who had severe cognitive impairment and was dependent on assistance for daily activities, experienced coughing and stomach content backing up into the syringe during medication administration. The Licensed Vocational Nurse (LVN) did not auscultate the epigastric area before aspirating stomach contents, which is a required step to ensure proper G-tube placement. The LVN acknowledged forgetting this step and recognized its importance in verifying the G-tube's position. Similarly, Resident 24, who also had severe cognitive impairment and was dependent on assistance, had their G-tube placement checked by a Registered Nurse (RN) without auscultating the epigastric area. The RN aspirated stomach contents but did not listen for abdominal sounds, which is necessary to confirm the G-tube is correctly positioned. The RN admitted to forgetting this step and noted that the head of the bed should be elevated higher than 30 degrees to reduce the risk of vomiting. The facility's policy clearly states the need to auscultate the epigastric area while injecting air to check G-tube placement, which was not followed in these instances.
Failure to Provide Necessary Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents by not having emergency equipment available in the activity room for accidental decannulation. Resident 4, who had a history of seizure disorder, hypertension, and chronic respiratory failure with a tracheostomy, was observed in the activity room without a respiratory therapist present and without necessary emergency equipment. Similarly, Resident 28, with a history of acute respiratory failure and a tracheostomy, and Resident 34, with chronic respiratory failure and a tracheostomy, were also observed in the activity room without the required emergency equipment or a respiratory therapist present. During interviews, the Activities Assistant and the Registered Nurse Supervisor confirmed that residents with tracheostomies did not bring their trach kits, inner cannulas, or obturators to the activity room. The Respiratory Therapist stated that each resident should have a spare trach and an Ambu bag with them at all times, but was unsure of the facility's policy regarding this. The Director of Nursing and the MDS Coordinator also confirmed that residents did not need to bring their trach kits to the activity room, which contradicted the facility's policy. The facility's policy, as reviewed and confirmed by the Director of Nursing, indicated that there must be two staff members present in the activity room at all times, including a respiratory therapist, and that an Ambu bag, oxygen, and a spare trach must always accompany the resident. The lack of adherence to this policy resulted in the potential for respiratory distress for the residents with tracheostomies during accidental decannulation.
Failure to Ensure Safe Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not disposing of expired medication, not properly storing medications, and not keeping medication carts locked. During an observation of Medication Cart 1, a Desitin diaper rash paste with an expired date was found, and the drawers were observed to be dusty. The Registered Nurse Supervisor acknowledged the importance of discarding expired medications and maintaining cleanliness to prevent infections. The facility's policy indicated that storage, administration, and documentation of medications should be managed to maintain patient safety. Resident 4, who had a history of seizure disorder, hypertension, chronic respiratory failure, and other conditions, was found to have a Primidone medication blister packet on the floor by their doorway. The Director of Nursing confirmed that the medication should not have been on the floor. The Licensed Vocational Nurse who administered the medication stated that the blister packet was not on the floor when she entered the room and acknowledged that medications should not be left on the floor to prevent unauthorized access. Additionally, medication carts were observed to be unlocked and unattended, allowing staff to access medications without entering a code or using a key. Licensed Vocational Nurses and the Director of Pharmacy confirmed that medication carts should always be locked to prevent theft, tampering, and unauthorized access. The facility's policy stated that medications should be stored securely and that medication carts should be locked when unattended to ensure resident safety.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to follow proper food handling practices in accordance with its policy and procedure. Specifically, the facility did not label food in the kitchen with item names, dates opened, and expiration dates. Observations revealed that containers of rice, flour, oyster sauce, and salsa were not properly closed, and frozen chicken, sherbet, and ranch dressing lacked appropriate labeling. The Dietary Staff and Dietary Supervisor confirmed that all food items should be labeled to prevent contamination and ensure food safety, as per the facility's policy revised in February 2022. Additionally, the facility did not maintain clean kitchen surfaces. Dust was observed on the shelves and windowsill near the tray line table, and there was a pool of water on the tray line table surface. The Dietary Director acknowledged the importance of keeping surfaces clean and dry to prevent food contamination. Furthermore, personal belongings, specifically two hooded jackets, were found hanging in the kitchen storage room, which the Dietary Director stated could lead to food contamination. The facility's policy mandates that all food be covered, labeled, and stored appropriately, with expiration dates adhered to and items discarded if expired.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to properly dispose of garbage in the kitchen by not having lids on the garbage containers, contrary to the facility's policy and procedure. During an observation and interview with the Dietary Director (DTD), multiple uncovered garbage cans were noted in the kitchen. The DTD initially stated that it was acceptable not to have covers to avoid touching the lid each time trash was disposed of. However, during a later interview and record review, the DTD acknowledged that the facility's policy required fitting lids on garbage cans to prevent food contamination. The garbage can in the dirty dishwashing area was also observed to be full and uncovered, further contributing to the unsanitary conditions.
Failure to Maintain Resident Dignity and Infection Control
Penalty
Summary
The facility failed to promote respect and dignity for a resident by not ensuring the resident's indwelling catheter urine collection bag was inside the dignity bag. The resident, who was alert and oriented, had an indwelling catheter and was dependent on assistance for daily activities. During an observation, it was noted that the catheter bag was not covered by the dignity bag, and the urine was exposed. Additionally, the catheter bag and tubing were touching the floor, which was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the importance of covering the bag for dignity and infection control. Further interviews with the Minimum Data Set Coordinator (MDSC) confirmed that the catheter bag should be fully covered and not touching the floor to maintain dignity and infection control. The facility's policy on Resident Privacy and Confidentiality emphasized the importance of treating residents with respect and ensuring their dignity and privacy. The failure to adhere to this policy resulted in a potential loss of dignity and self-esteem for the resident.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a homelike environment for one of the sampled residents by using the resident's room to store three hospital computer workstations and a tablet stand. Additionally, the facility did not replace a broken window screen, leaving it propped against the wall, and left a used disposable plastic cup on the floor next to the trash. These actions were observed during a survey and were confirmed through interviews with the MDS Coordinator and the Director of Nursing, who both acknowledged that the resident's room should not be used for storing facility equipment and that the room should be maintained in a homelike manner. The resident involved had a history of hypertension, type 2 diabetes mellitus, ventilator-dependent respiratory failure, and a tracheostomy. The resident was assessed as having severely impaired cognitive skills and was dependent on assistance for daily activities such as eating, oral hygiene, bathing, and dressing. The facility's policy and procedure emphasized the importance of creating a homelike atmosphere to enhance the well-being of residents, but this was not adhered to in the case of this resident, leading to an unsanitary and unkempt environment that could negatively impact the resident's quality of life.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the Nurse Staffing Information posted was complete by not reflecting the total and actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This was observed on 4/27/2024 at 11:11 AM, where the Daily Posted Nurse Staffing for the 7 am to 3 pm shift indicated a census of 38 but did not include the total and actual number of hours worked for both licensed and unlicensed nursing staff. The Unit Secretary confirmed that the posting on 4/26/2024 also lacked this information for each shift. Further review of the Daily Posted Nurse Staffing from 4/21/2024 to 4/26/2024 revealed that the postings included the census and the total number of RNs, LVNs, and CNAs but did not include the total and actual worked hours per shift for licensed and unlicensed nursing staff. The Director of Nursing confirmed this deficiency and stated that the facility did not have a policy for Daily Posted Nurse Staffing to be compliant with the regulation.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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