Shoreline Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxnard, California.
- Location
- 5225 South J Street, Oxnard, California 93033
- CMS Provider Number
- 555163
- Inspections on file
- 58
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Shoreline Care Center during CMS and state inspections, most recent first.
A resident with dementia and other comorbidities fell while attempting an unassisted transfer, after which an RN obtained a verbal physician order for a hip and sacrum x‑ray and PRN Tylenol. The nurse documented the fall and family notification but did not transcribe the x‑ray order into the EHR, complete a requisition, or contact the diagnostic company, and no other staff implemented the order. Record review confirmed no x‑ray order or results, and leadership later identified the omission when the resident began complaining of hip pain during transfers. The resident was then sent to the ED, where an intertrochanteric right hip fracture was diagnosed, demonstrating a failure to follow physician orders and facility policies for post‑fall diagnostics.
A resident on hospice with severe cognitive impairment and multiple comorbidities had an unwitnessed fall with subsequent complaints of left hip pain. Although initial documentation noted no swelling, slight swelling of the left hip was observed several days later and reported to nursing, and an x‑ray was obtained after a physician order. However, nursing staff did not initiate a new electronic COC, did not document the responsible party’s refusal for hospital transfer, and did not complete the required 72‑hour follow‑up assessments and documentation in PCC, resulting in a lack of documented monitoring of the resident’s swollen hip as required by facility policy and professional standards.
A resident on hospice care with vascular dementia, anemia, physical debility, and COPD had multiple physician orders for morphine sulfate oral solution for severe pain, each specifying that the dose be held if the respiratory rate (RR) was less than 12. Medication Administration Records showed that morphine was given on numerous occasions under both PRN and scheduled orders, but there was no documentation that RR was obtained prior to administration. During interviews, an LN, the ADON, and the DON all confirmed that RR should have been checked and documented before giving morphine and acknowledged that this documentation was missing.
A resident with Alzheimer's disease, psychosis, and depression had multiple documented episodes of hallucinations and was prescribed antipsychotic medication for these symptoms. However, the MDS assessment did not reflect the presence of hallucinations, despite supporting evidence in the resident's records and acknowledgment by the Health Information Manager that the assessment was inaccurate.
A resident was not readmitted after a hospital transfer for medication adjustment, despite being told a bed would be held. Facility staff did not document which needs could not be met or what attempts were made to meet those needs, and key sections of the discharge notice were left blank. The administrator later cited behavioral issues as the reason for declining readmission, but this was not reflected in the official records or physician summary.
Two residents and their representatives were not provided with required written bed-hold notifications upon transfer to hospitals, and one responsible person was not given information about private pay or reserve bed-payment requirements. Staff interviews and record reviews confirmed that the necessary documentation was incomplete or missing at the time of transfer, contrary to facility policy.
A resident with multiple medical and psychiatric conditions was physically abused by another resident with a history of aggressive outbursts, resulting in bruising. Despite a psychiatrist's recommendation for 1:1 staffing, both residents were observed together without supervision, and the facility failed to implement protective measures as outlined in its abuse prevention policy.
A resident with a history of schizophrenia and psychosis began refusing psychiatric medications, leading to escalating psychosis, aggression, and multiple incidents of harm and fire-setting. Despite these significant changes, the IDT did not initiate a Significant Change in Status Assessment or conduct required interdisciplinary reviews, as confirmed by staff interviews and record review.
A resident's admission MDS was completed with inaccurate information, including incorrect responses regarding fall history and the inclusion of schizophrenia as an active diagnosis without supporting documentation. The MDS Coordinator and DON confirmed that the documentation did not support these entries, and the errors were identified through interviews and record review.
A resident with psychosis, schizophrenia, and bilateral heel fractures did not receive care in accordance with their person-centered care plan, as male staff were assigned for 1:1 ADL assistance despite a directive for female staff only. Additionally, after the resident's left foot was placed in a non-weight bearing immobilizer cast, the care plan was not updated to include protocols for cast care or circulatory monitoring.
A resident with multiple respiratory and mental health diagnoses had a nebulizer and oxygen tubing that were not dated or properly stored, contrary to facility policy. A nurse confirmed the equipment should have been dated and stored in a plastic bag, but it was left on the bedside table without proper labeling or containment.
Surveyors found the South Side dining room in unsanitary and unsafe condition, including a dirty container with fruit flies under a nonfunctional sink, a trash can surrounded by flies, dirty walls with food particles, exposed plumbing, cracked floor tiles, and stained floors. Staff confirmed these issues, and there was no documentation of regular floor cleaning or maintenance, in violation of facility policies and infection control standards.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a left hip fracture. The incident was reported internally to nursing staff and the DON, but not to the Department within the required 48-hour period, delaying external investigation.
A resident's hearing aid filter was not changed as scheduled according to instructions from an outside clinic. The filter change was delayed because staff were unaware of the care instructions until the resident's responsible party requested the change, and the facility could not provide documentation of when the instructions were received.
A resident suspected of having scabies was not placed on required isolation precautions upon return from a dermatology visit, and there was no documentation of enhanced barrier precautions. The Infection Preventionist did not develop a contact identification list, and nursing staff had not received training on recognizing or reporting scabies symptoms, in violation of the facility's infection control protocol.
A resident with diabetes mellitus received incorrect doses of insulin on two occasions, as nursing staff failed to follow physician orders for insulin administration. The resident's care plan required specific doses of Novolog insulin based on blood sugar levels, but the staff administered lower doses than prescribed. The facility's DON and HIM confirmed the discrepancies and lacked documentation of physician notification or response.
A resident with end-stage renal disease and diabetes missed multiple doses of prescribed medications due to being offsite for dialysis, without the facility notifying the physician or adjusting administration times. The resident also did not receive the full schedule of ordered physical therapy sessions, and there was a delay in implementing a physician's order for weight-bearing therapy due to an order discrepancy.
A facility failed to maintain complete medical records for a resident during an IDT admission assessment. The assessment form was incomplete, missing critical sections such as diagnosis, high-risk medications, and functional status. The DON acknowledged the oversight. The facility's policy requires comprehensive assessments within 72 hours of admission, which was not met in this case.
A resident with dementia and anxiety was not properly assessed for elopement risk and did not receive adequate supervision or medication management, leading to their unsupervised exit from the facility and subsequent fatal accident on a busy street.
A facility failed to accurately complete an MDS Assessment for a resident with dementia, resulting in an incorrect elopement risk assessment. The resident had an incident of following a visitor outside, but the Nurse Supervisor did not review the resident's history or other staff input before concluding the resident was not at risk. Additionally, the Social Services Assistant did not check the MAR for behavior monitoring, missing documented episodes of anxiety and paranoia.
A facility failed to implement a behavioral care plan for a resident with dementia, resulting in increased aggression, anxiety, and paranoia. Despite multiple episodes, staff did not document non-pharmacological interventions or administer prescribed anti-anxiety medication. Interviews revealed a lack of communication with the physician or psychiatrist about the resident's behavior, contrary to the facility's care coordination policy.
The facility failed to maintain a clean and homelike environment in two shower rooms, where clean razors were improperly stored on dirty sharps containers, and broken floor tiles were observed. The Health Information Manager confirmed these issues, which were contrary to the facility's policy on maintaining a safe and comfortable environment.
The facility failed to maintain food safety and sanitation standards, with issues including unclean food preparation equipment, undated and unlabeled leftovers, improper thawing of raw meat, and inadequate use of gloves and hair restraints. The Manager of Dietary cited short staffing as a challenge in maintaining cleanliness, while the Registered Dietitian and Executive Director emphasized the importance of adhering to food safety protocols.
The facility failed to properly dispose of garbage and refuse, with dumpster lids left open and trash overflowing, affecting all 171 residents. Despite staff acknowledging the issue and daily cleaning efforts, the problem persisted, posing potential infection control and rodent infestation risks.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple incidents of physical abuse against other residents. Despite the facility's policy to monitor and intervene, the resident's care plan interventions were not effectively implemented, leading to altercations. Staff were aware of the resident's behavior but failed to prevent further incidents, highlighting a deficiency in protecting residents from abuse.
The facility failed to ensure accurate Level I PASRR screenings for three residents with mental disorders or intellectual disabilities. One resident was admitted with psychosis and depression, but their screening inaccurately indicated no serious mental illness. Another resident with schizophrenia and anxiety disorder also had an inaccurate screening. A third resident's screening indicated an exempted hospital discharge, but a new screening was not submitted after the 30-day exemption period. The DON acknowledged the inaccuracies and the need for proper screenings.
The facility failed to serve meals according to planned recipes for residents on pureed diets, affecting 22 residents. Staff pureed plain beef instead of beef stew, used breadcrumbs instead of sliced bread, and served applesauce instead of pureed baked apple slices. The Manager of Dietary noted staff felt overwhelmed and opted for easier methods, while the RD confirmed staff training on recipe adherence.
A resident received psychological services without a physician's order, as confirmed by the Health Information Manager and the Director of Nursing. The facility's policy mandates a physician's order for such services, which was not obtained, leading to a deficiency.
A facility failed to follow physician orders for a resident's wound care, missing documentation for Hydrogel application on two occasions. The resident had an unstageable pressure ulcer, Type Two Diabetes, and mobility issues, which could complicate healing. The facility's policy required adherence to physician orders, but the Health Information Manager confirmed the missing entries and lack of records to show compliance.
A resident missed doses of Lacosamide due to the facility's failure to reorder the medication timely, as per policy. The resident, with a seizure diagnosis, was at risk due to missed doses. Staff interviews revealed a lack of clear processes for ordering and tracking medication refills, leading to oversight and delay in pharmacy delivery.
A facility failed to maintain a resident's room and restroom in a clean and homelike manner. The room had walls in disrepair with scrapes and missing paint, and the restroom's hand sanitizing dispenser was missing a front cover. These issues were not reported by staff or logged for maintenance, contrary to the facility's policy requiring immediate reporting of such issues.
Failure to Implement Physician-Ordered X-Ray After Resident Fall
Penalty
Summary
The facility failed to ensure that services met professional standards of quality when nursing staff did not transcribe and implement a physician’s x‑ray order following a resident’s fall. The resident, who had anemia, dementia, depression, and anxiety and a BIMS score indicating severe cognitive impairment, experienced a fall onto her bottom while attempting an unassisted transfer from bed to wheelchair. A licensed nurse notified the physician and received verbal orders for a hip and sacrum x‑ray and PRN Tylenol for pain, and documented leaving a message for the resident’s daughter about the fall and the new x‑ray order. However, the x‑ray order was never entered into the electronic health record, no paper requisition was completed, and the diagnostic company was not contacted, contrary to facility policy requiring that personnel receiving verbal or telephone orders transcribe them into the system. Record review confirmed there were no x‑ray orders or results in the resident’s chart following the fall. The licensed nurse later acknowledged she did not transcribe the order or call the diagnostic company and that the x‑ray was never done. The RN supervisor confirmed the absence of x‑ray results in the medical record, and the DON stated that the facility discovered the missed x‑ray only after the resident complained of hip pain during a transfer several days later. The resident was subsequently evaluated in the emergency department, where an intertrochanteric fracture of the right hip was identified. Facility policies on physician orders and fall response, as well as a nursing textbook excerpt on the obligation to follow physician orders, were cited in relation to the failure to carry out the ordered diagnostic testing.
Failure to Document and Monitor Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing care and services met professional standards of quality through complete and timely documentation and monitoring following a change in condition. A hospice resident with vascular dementia, anemia, physical debility, and COPD experienced an unwitnessed fall, documented on a Change of Condition Evaluation (COC) as occurring without injury or swelling, though the resident complained of pain in the left elbow and left hip. The responsible party and physician were notified and pain medication was ordered. Nursing progress notes indicated that paramedics were called and the responsible party declined hospital transfer and x‑ray at that time. According to the facility’s policy and the ANA guidance on nursing documentation, clear, accurate, and accessible documentation is essential for communication and continuity of care. In the days following the fall, a CNA reported that there was no swelling or discoloration immediately after the fall and that they continued to care for the resident until slight swelling of the left hip was observed several days later, which was reported to the nurse. On that date, nursing notes indicated slight swelling of the left hip and that an x‑ray was taken after an order from the hospice physician. However, there was no documentation of the responsible party’s refusal to send the resident to the hospital, and no follow‑up documentation was found to show that the swollen left hip was monitored. One LVN acknowledged not initiating a new electronic COC when the swelling was observed, and another LVN stated that without a COC, the required 72‑hour follow‑up monitoring and documentation in the electronic system would not occur. The ADON confirmed the observation of mild left hip swelling and acknowledged the missing COC and lack of 72‑hour follow‑up monitoring and documentation, and was unable to provide proof that the swelling was monitored by nurses, contrary to the facility’s Change in Condition Reporting policy requiring assessment and documentation every shift for at least 72 hours after an acute medical change.
Failure to Monitor and Document Respiratory Rate Before Morphine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order requiring respiratory rate (RR) monitoring prior to administering morphine sulfate to a resident. The facility’s medication administration policy states that medications are to be administered in accordance with written physician orders. The resident was admitted under hospice care with diagnoses including vascular dementia, anemia, physical debility, and COPD. Physician orders for morphine sulfate oral solution were entered on multiple dates with instructions to administer specific doses for severe pain and to hold the medication if the RR was less than 12. These orders applied both when the medication was ordered as needed and when it was ordered routinely every eight hours. Review of the resident’s Order Summary Reports and Medication Administration Records showed that morphine sulfate was administered on multiple days under each of the active orders, but there was no documented evidence that the resident’s RR was obtained prior to any administration. During interviews and concurrent record reviews, a licensed nurse stated that the current order required checking the RR before giving morphine and acknowledged there was no documentation of the RR. The Assistant DON also stated that RR must be documented prior to morphine administration and acknowledged the missing documentation. The DON later confirmed that the RR should have been included and monitored per the physician’s instructions and acknowledged the lack of documentation that this was done.
Inaccurate MDS Assessment of Resident's Behavioral Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the behavioral status of a resident with diagnoses including Alzheimer's disease, psychosis, and depression. Despite documented evidence in the resident's records, such as the Medication Administration Record and Order Summary Report, indicating multiple episodes of hallucinations and the use of antipsychotic medication for psychosis manifested by auditory and visual hallucinations, the MDS assessment did not indicate the presence of hallucinations. Additionally, a Change In Condition Evaluation documented an incident involving the resident in a physical altercation, with behavioral symptoms noted. During an interview and record review, the Health Information Manager acknowledged that the MDS assessment was inaccurate and that the section for hallucinations should have been marked. The facility's policy requires that each person completing a section of the MDS attests to its accuracy, referencing the Resident Assessment Instrument User's Manual as guidance. The failure to accurately document the resident's behavioral symptoms on the MDS constitutes a deficiency in the assessment process.
Failure to Readmit Resident After Hospital Transfer and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to readmit a resident after transfer to a VA hospital for medication evaluation and adjustment, despite informing the resident's responsible person that a bed would be held and the resident could return following hospitalization. Documentation for the transfer indicated it was necessary for the resident's welfare and that the resident's needs could not be met at the facility, but did not specify which needs could not be met or what attempts were made to address those needs. Key sections of the transfer/discharge notice were left blank, and there was no documentation supporting the facility's claim that the resident's behavior endangered the safety or health of others. Interviews with facility staff revealed inconsistencies in communication regarding the bed hold policy and the resident's eligibility for readmission. The responsible person was told a bed would be held, but the business office manager later stated that information about bed hold payment was not provided because the resident would not be readmitted. The administrator cited behavioral issues as the reason for declining readmission, but this was not documented in the transfer or discharge records, nor in the physician's discharge summary. The facility's own policy indicated that residents should be allowed to return if eligible and requiring skilled nursing services, but this was not followed in this case.
Failure to Provide Bed-Hold Notifications and Payment Information Upon Resident Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notifications to two residents or their representatives upon transfer to acute care hospitals. In both cases, documentation showed that while an initial bed-hold notification was given at admission, the second notification, which should have been completed and provided at the time of transfer, was left blank and not delivered. Interviews with staff, including the assistant director of nursing and the licensed vocational nurse involved in the transfer, confirmed that the bed-hold notification forms were not completed or provided as required by facility policy. Additionally, the facility did not provide information regarding private pay or reserve bed-payment requirements to the responsible person of one resident prior to the resident's transfer to another facility. The business office manager confirmed that this information was not given. These actions were inconsistent with the facility's own policy, which requires that residents or their representatives be notified of bed-hold duration and payment requirements both at admission and prior to transfer or therapeutic leave.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident who exhibited undirected behavioral symptoms and outbursts. The incident involved one resident slapping another, resulting in visible bruising on the left arm, shoulder, and hand. Documentation showed that the resident who was assaulted had multiple medical conditions, including chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, and depression. The assaulted resident reported feeling unsafe and expressed reluctance to change rooms unless another roommate also moved. The facility's records indicated that the aggressor had a history of psychosis, schizophrenia, and repeated aggressive behaviors toward staff and other residents, with interventions from crisis teams and law enforcement documented. A psychiatrist had recommended 1:1 staffing for the resident with behavioral issues. Despite this recommendation, observations revealed that both residents were present together in the smoking patio without visible 1:1 staff supervision. Facility documentation and interviews confirmed that the facility was aware of the behavioral risks and the need for protective measures but failed to consistently implement them. The facility's policy stated that each resident has the right to be free from abuse, including resident-to-resident abuse resulting in physical injury, pain, or mental anguish. The Director of Nurses acknowledged the facility's responsibility to protect residents.
Failure to Initiate Significant Change Assessment After Resident's Behavioral Decline
Penalty
Summary
The facility's Interdisciplinary Team (IDT) failed to initiate a Significant Change in Status Assessment (SCSA) for a resident who experienced a major decline in mental and behavioral health. The resident, admitted with multiple diagnoses including schizophrenia, psychosis, depression, and chronic pain, began refusing critical psychiatric medications such as aripiprazole and sertraline. This refusal persisted over several days, during which the resident exhibited escalating symptoms of psychosis, including delusions, hallucinations, paranoia, and severe behavioral disturbances. Despite these significant changes, there was no evidence in the clinical record of an IDT review or a determination to initiate an SCSA during this period. The resident's behavior became increasingly aggressive and erratic, with documented incidents of physical and verbal aggression towards other residents and staff, refusal to comply with facility rules, and multiple altercations. The resident was involved in several incidents, including slapping another resident, threatening staff, and starting fires within the facility. The crisis team and police were called multiple times, but no effective clinical interventions or comprehensive assessments were implemented by the facility. The resident's actions resulted in harm to other residents, such as bruising, and placed both residents and staff at risk. Throughout the period of behavioral escalation, the facility's records showed no evidence of an SCSA or other required assessments being completed after the resident's admission. Interviews with facility staff, including the DON and MDS RN, confirmed that no additional assessments were performed despite the resident's significant changes in condition. The facility's own policy required the IDT to assess and determine the cause of behavioral symptoms through the MDS/CAA process or team evaluation, but this was not documented or carried out in response to the resident's decline.
Inaccurate MDS Assessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident's health status was accurately documented on the admission Minimum Data Set (MDS). Specifically, the MDS sections regarding active diagnoses and fall history did not accurately reflect the resident's condition. The MDS indicated that the resident had not experienced a fall or sustained a fracture related to a fall in the months prior to admission, despite the admission record showing diagnoses of bilateral calcaneus fractures. Additionally, the MDS listed schizophrenia as an active diagnosis, although the psychiatric discharge note and health and physical did not support this diagnosis, instead documenting psychosis, anxiety disorder, and opiate dependency. Interviews with the MDS Coordinator and review of the resident's Medication Administration Record confirmed that the MDS was completed with incorrect information. The MDS Coordinator acknowledged that the fall history questions were answered incorrectly and that schizophrenia was selected as an active diagnosis based on a history rather than current documentation or treatment. Review of the CMS Resident Assessment Instrument manual with facility staff further confirmed that only active diagnoses with direct relevance to current treatment during the look-back period should be included, and that the documentation did not support the inclusion of schizophrenia as an active diagnosis.
Failure to Implement Person-Centered Care Plan and Update for Orthopedic Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including psychosis, schizophrenia, and bilateral calcaneus fractures. The care plan specified that only female staff should be assigned to provide 1:1 assistance with activities of daily living due to the resident's psychosocial needs. However, daily assignment sheets showed that male staff were assigned to provide 1:1 care on two occasions, contrary to the care plan and interdisciplinary team notes. The Director of Nursing confirmed that this assignment was not in accordance with the established care plan. Additionally, the resident's care plan was not updated to reflect a change in orthopedic treatment. After the resident's left foot was placed in a non-weight bearing immobilizer cast, there were no new interventions or protocols added to the care plan regarding the care of the cast or monitoring of circulatory function in the affected foot. The Director of Nursing acknowledged that the care plan did not include the necessary updates or interventions related to the immobilizer cast.
Failure to Properly Store and Label Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for one of two sampled residents when respiratory care equipment was not stored or labeled according to policy. Specifically, a nebulizer that was not in use was observed on a bedside table without any dates on the tubing and was not stored in a bag or enclosed container. Additionally, the resident's nasal cannula oxygen tubing had no date indicating when it was last changed. These observations were confirmed during an interview with a licensed nurse, who acknowledged that the equipment should be dated and properly stored to ensure staff know when to change them and to prevent contamination. A review of the resident's admission record showed diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety disorder, and depression. Facility policies required that humidifiers be labeled with the date and time opened and that nebulizers be stored in a plastic bag labeled with the resident's name and room number. The observed practices did not comply with these policies, resulting in a deficiency related to infection prevention and control.
Dining Room Environmental Deficiencies and Infection Control Lapses
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the South Side dining room, as evidenced by multiple observations of unsanitary and unsafe conditions. Surveyors observed a wet and dirty plastic container surrounded by fruit flies underneath a nonfunctional sink while ten residents were present and eating lunch. The shift coordinator and nursing supervisor confirmed the presence of the fruit flies and the dirty container but did not remove it. Additionally, a trash can next to the sink was also surrounded by flies, and the corner near the sink was visibly dirty, with food particles adhered to the wall and liquid stains running down another wall. The infection preventionist acknowledged these issues and identified them as an infection control problem. Further inspection revealed that the sink in the dining room had been nonfunctional for several weeks, with the cabinet door removed and an open pipe exposed. There was no signage indicating the sink was out of order, and the area was not isolated or covered to prevent resident exposure to possible contaminants. The director of maintenance and housekeeping confirmed the ongoing repairs and lack of notification or barriers. Additionally, the dining room floor had approximately twelve cracked tiles, with some pieces detached and loose, particularly between the sink and the dining table. The director of maintenance was unaware of the damaged tiles and had not been notified by staff. The floor throughout the dining room was noted to have numerous dark stains, especially in the corners, and there was no documentation or logs available to indicate when the floor was last buffed or waxed. The infection preventionist and nursing supervisor confirmed the lack of cleaning records and the visible dirt and stains. These observations were in direct violation of the facility's own policies regarding cleanliness, maintenance, and infection control, as well as CDC guidelines for infection-control measures during repairs.
Failure to Timely Report Resident Fall with Fracture
Penalty
Summary
The facility failed to report a resident's unwitnessed fall that resulted in a left hip fracture to the Department within the required 48-hour timeframe. The incident involved a resident with dementia and a history of falls and fractures prior to admission. The resident was found on the floor in a supine position at the end of the bed and complained of left hip pain. An X-ray confirmed an acute intertrochanteric femoral fracture. The fall was reported internally to the charge nurse and DON, but not to the Department as required by state law. Interviews with staff, including a licensed nurse, the DON, and a CNA, confirmed the details of the fall and the subsequent injury. Review of the medical record and incident reports corroborated the timeline and the nature of the injury. The failure to report the incident to the Department delayed the Department's investigation into the event.
Failure to Timely Change Hearing Aid Filter per Clinic Instructions
Penalty
Summary
The facility failed to change a hearing aid filter for one resident according to instructions provided by an outside clinic. After an outpatient appointment, the resident returned with new hearing aids and instructions from the clinic to change the hearing aid filter monthly. The filter was due to be changed on 3/27/25, but the change did not occur until 4/8/25. Facility staff were unable to provide documentation of when they received the office visit summary with care instructions from the clinic. Progress notes indicated that the facility was not aware of the need to change the hearing aid filter until the resident's responsible party made a request on 4/2/25.
Failure to Implement Scabies Protocol and Isolation Precautions
Penalty
Summary
The facility failed to follow its established protocol for infection prevention and control regarding a resident suspected of having scabies. Upon review of the resident's medical record, it was found that after being seen by a dermatologist and prescribed Permethrin 5% cream for suspected scabies, there was no documentation that the resident was placed on enhanced barrier precautions upon return to the facility. The Assistant Director of Nursing confirmed the absence of such documentation. Further review with the Infection Preventionist revealed that the resident was not placed on isolation precautions as required for suspected scabies cases. Additionally, the Infection Preventionist did not develop a contact identification list for potential exposures, and facility nursing staff had not received training on recognizing and reporting signs and symptoms of scabies infestation. The facility's scabies protocol, which mandates contact isolation and staff training, was not adhered to in this instance.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for insulin administration for a resident with diabetes mellitus, leading to potential medication errors. On two separate occasions, the resident's blood sugar levels were significantly high, necessitating specific doses of Novolog insulin as per the sliding scale orders. However, the nursing staff administered incorrect doses of insulin, deviating from the prescribed amounts. On January 25, the resident's blood sugar was 481, and the nurse administered 14 units of insulin instead of the ordered 16 units. Similarly, on February 24, the resident's blood sugar was 485, and the nurse administered 4 units instead of the prescribed 5 units. The Director of Nursing and Health Information Manager confirmed these discrepancies during record reviews and interviews. They acknowledged that the nurses failed to administer the correct insulin doses and could not provide documentation that the resident's physician was notified or responded to the notifications. The resident's care plan, which included administering diabetes medication as ordered by the doctor, was not followed, exposing the resident to potential unsafe insulin doses and preventable medication errors.
Failure to Administer Medications and Provide Ordered Therapy
Penalty
Summary
The facility failed to provide quality care for a resident who was admitted with diagnoses including end-stage renal disease, type two diabetes, and dependence on renal dialysis. The resident missed numerous doses of prescribed medications, including Farxiga, Insulin Glargine, and several others, due to being offsite at a dialysis center. The facility did not inform the resident's physician about the missed medications, nor did they document any attempts to adjust medication administration times or hold orders to ensure the resident received the necessary medications. Additionally, the resident did not receive the full schedule of physical therapy sessions as ordered. The treatment plan required physical therapy services five times a week for four weeks, but the resident only received four sessions per week during two specific weeks. This discrepancy was confirmed by the Rehabilitation Director, indicating a failure to adhere to the prescribed therapy regimen. Furthermore, there was a delay in implementing a physician's order for the resident to begin weight-bearing physical therapy. The order was received on January 31, but due to an order discrepancy, it was not implemented until February 12. This delay in following the physician's order resulted in a postponement of the resident's evaluation by the physical therapy department for weight-bearing therapy, as acknowledged by the Assistant Director of Nursing and the Rehabilitation Director.
Incomplete IDT Admission Assessment for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 1, during an interdisciplinary team (IDT) admission assessment. The assessment form, dated 2/18/25, was found to be incomplete during a review conducted on 2/28/25. Several critical sections of the assessment were left blank, including sections on IDT review date, hospitalizations and procedures, diagnosis, high-risk medications, current functional status, specific functional status and goals, skin and continence, psychoactive medications, medication reconciliation, pain, advanced directive, safety risk, devices, bed rails or positioning/transfer bars, education, and CNA narrative. The Director of Nursing (DON) acknowledged the incompleteness of the IDT Admission Assessment. The facility's policy and procedure titled Interdisciplinary Walking Rounds, dated 2017, requires a comprehensive assessment to be completed within 72 hours of admission or readmission. Each discipline is responsible for collecting pertinent data and documenting it on the IDT WR Assessment within this timeframe. The failure to complete the IDT Admission Assessment for Resident 1, who was admitted with diagnoses including COVID-19 and Alzheimer's Disease, resulted in potentially inaccurate and incomplete medical records, which could affect the care provided to the resident.
Failure to Supervise and Assess Resident Leads to Fatal Elopement
Penalty
Summary
The facility failed to provide adequate supervision and assessment for a resident, leading to a tragic accident. The resident, who had a history of dementia, anxiety, and aggressive behavior, was not accurately assessed for elopement risk. Despite previous incidents of aggression and wandering, the resident was evaluated as not being at risk for elopement without a thorough review of their history and behavior patterns. This oversight contributed to the resident's ability to leave the facility unsupervised. The resident's care plan included interventions for managing anxiety and aggression, such as administering anti-anxiety medication and providing one-to-one supervision. However, these interventions were not consistently followed. Staff failed to administer prescribed medications or document non-pharmacological interventions during episodes of increased anxiety and paranoia. Additionally, the facility did not notify the psychiatric practitioner of the resident's escalating behaviors, missing an opportunity for medication adjustment or other interventions. On the day of the incident, the resident exited the facility through a fire exit door, which was alarmed but not secured, and walked onto a busy street where they were fatally struck by a vehicle. The resident's room was located near this exit, increasing the risk of elopement. The facility's policies on elopement and behavioral health services were not effectively implemented, contributing to the resident's unsupervised departure and subsequent accident.
Inaccurate MDS Assessment Leads to Elopement Risk Misjudgment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) Assessment for a resident, leading to an inaccurate elopement risk assessment. The resident, who was admitted with unspecified dementia, had an incident in January 2025 where they followed a visitor outside the main entrance door, indicating a potential elopement risk. Despite this, the Nurse Supervisor completed an elopement risk assessment on January 10, 2025, without reviewing the resident's history, past evaluations, or other pertinent information from staff, concluding that the resident was not at risk for elopement. Additionally, the Social Services Assistant completed the Quarterly Minimum Data Set Section E-Behavior assessment on January 7, 2025, without checking the Medication Administration Record for January 2025, which documented episodes of anxiety and paranoia. The facility's policy on Behavioral Health Services requires a comprehensive assessment process, including obtaining history from medical records and other sources, which was not followed in this case.
Failure to Implement Behavioral Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement the interventions outlined in the behavioral care plan for a resident diagnosed with unspecified dementia, leading to increased episodes of aggression, anxiety, and paranoia. The resident, who had a history of being a danger to self and others, was admitted to the facility with a care plan that included providing reassurance, redirection, administering anti-anxiety medication as needed, and consulting with a psychiatrist for medication adjustments. However, during the review of the Medication Administration Record (MAR) for February 2025, it was found that the resident experienced multiple episodes of anxiety and paranoia over two days, but there was no documented evidence of non-pharmacological interventions being provided or the administration of prescribed anti-anxiety medication. Interviews with facility staff revealed that although the resident's behavior was monitored and documented, the staff did not contact the physician or psychiatrist to report the increased behavioral episodes. Additionally, the staff did not document the non-pharmacological interventions that were reportedly used to calm the resident. The Psychiatry Practitioner confirmed not receiving any communication from the facility regarding the resident's increased behavioral episodes, which could have led to a medication adjustment. The facility's policy and procedure on care plan documentation emphasize the responsibility of nursing services to coordinate care among all disciplines, which was not adhered to in this case.
Improper Storage and Maintenance Issues in Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two shower rooms, which had the potential to negatively impact residents. During an observation and interview with the Health Information Manager (HIM 1), it was noted that eight clean/unused razors were improperly stored on top of a dirty sharps container in shower room one, located in the south wing of the facility. Similarly, seven clean/unused razors were found on top of a dirty sharps container in shower room two, also located in the south wing. HIM 1 acknowledged that these razors should have been stored at the nurse's station inside a cabinet. Additionally, both shower rooms in the south and central wings had broken floor tiles, which HIM 1 confirmed. The facility's policy on maintaining a safe, clean, and comfortable environment, dated June 2023, requires proper labeling and storage of personal ADL supplies and prompt reporting of maintenance issues, which was not adhered to in this instance.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen staff did not maintain clean food preparation equipment, as evidenced by dried liquid spills, food debris, and trash on the floor of the walk-in freezer. Additionally, clean scoops and serving utensils were stored in a container with spilled food, crumbs, and grime, and the can opener was covered with built-up food debris and grime. The Manager of Dietary acknowledged these issues, attributing them to short staffing, which hindered proper cleaning. The facility also failed to date and label leftover food items, as observed in the walk-in refrigerator, where undated and unlabeled containers of various food items were found. The Manager of Dietary admitted that it was challenging to ensure staff consistently dated and labeled leftover food items. The Registered Dietitian and Executive Director both expressed expectations for proper labeling and dating to maintain food quality and safety. Furthermore, the facility did not follow safe food handling practices. Raw chicken was observed thawing at room temperature, contrary to the policy of thawing under refrigeration or running water. Additionally, a staff member handled ready-to-eat food without gloves and engaged in inappropriate behavior by throwing lettuce. Hair restraint policies were also not followed, as several staff members were observed without proper hairnets or beard nets. The Manager of Dietary and Registered Dietitian acknowledged these lapses, emphasizing the importance of adhering to sanitary standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, affecting all 171 residents. Observations revealed that the trash and recycle dumpster lids were open, with trash overflowing and debris scattered around the base of the dumpsters. This was contrary to the facility's policy, which required dumpsters to be kept closed and free of litter. The Manager of Dietary acknowledged the issue and stated that maintenance would be notified to clean the area. However, subsequent observations showed that the problem persisted, with dumpster lids remaining open and trash continuing to overflow. Interviews with facility staff, including the Manager of Dietary, Supervisor of Maintenance, Registered Dietitian, Director of Nursing, and Executive Director, confirmed that the expectation was for dumpsters to be closed and the surrounding area to be clean. The Executive Director noted the challenge of maintaining the area due to the dumpsters being located on the street, where people often opened them to search for food and recyclables. Despite daily cleaning efforts by the maintenance staff, the issue of trash overflow and open dumpster lids remained unresolved, posing potential infection control and rodent infestation risks.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, identified as Resident #118, during four separate incidents. Resident #118, who was admitted to the facility with a medical history of dementia, psychosis, and anxiety disorder, exhibited severe cognitive impairment with a BIMS score of 6. Despite the resident's care plan indicating a need for monitoring due to episodes of physical aggression, the facility did not effectively prevent altercations. The incidents involved Resident #118 striking another resident with a coffee cup, smacking a resident, and pushing a resident against a wall. The facility's policy on abuse prevention required monitoring and intervention for residents with behaviors that could lead to conflict. However, Resident #118's care plan interventions, such as keeping residents apart and providing one-to-one supervision, were not adequately implemented. During the incidents, staff failed to prevent Resident #118 from engaging in physical altercations, despite being aware of the resident's aggressive tendencies. The facility's response included contacting law enforcement and revising the care plan, but these measures were reactive rather than preventive. Interviews with staff and residents' responsible parties revealed that the facility was aware of Resident #118's aggressive behavior but did not successfully mitigate the risk of further incidents. Staff interventions were not timely or effective in preventing the altercations, and the facility's efforts to find alternative placement for Resident #118 were unsuccessful. The deficiency highlights a failure in the facility's duty to protect residents from abuse and ensure their safety, as required by their own policies and regulatory standards.
Inaccurate PASRR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Level I PASRR screenings for residents with mental disorders or intellectual disabilities, affecting three residents. Resident #129 was admitted with diagnoses of unspecified psychosis and depression, but their PASRR Level I screening, completed by a hospital, inaccurately indicated no serious mental illness. The Director of Nursing (DON) acknowledged the error, noting that the screening should have triggered a serious mental illness due to the resident's diagnoses. No additional screenings were conducted for this resident. Resident #26 was admitted with diagnoses of paranoid schizophrenia and anxiety disorder. However, their PASRR Level I screening also inaccurately indicated no serious mental illness. The DON recognized the inaccuracy and stated that schizophrenia should have triggered a serious mental illness. The facility staff, including the DON, were responsible for reviewing the screenings for accuracy, but no new screenings were submitted for this resident. Resident #103 was admitted with diagnoses of psychosis and depression. Their PASRR Level I screening, completed by a hospital, indicated an exempted hospital discharge for a short stay. However, the resident remained in the facility beyond the 30-day exemption period, requiring a new Level I PASRR screening, which was not submitted. The DON confirmed the need for a new screening after the exemption period to determine if the resident triggered for a serious mental illness.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Specifically, staff pureed plain beef instead of beef stew, mixed breadcrumbs in water in place of sliced bread to make pureed bread, and served applesauce in place of pureed baked apple slices to residents on a pureed diet. This practice had the potential to affect 22 residents who received pureed diets. The facility's policy required that therapeutic diets be prepared and served as planned, with recipes available for use. However, during observations and interviews, it was found that staff did not follow these recipes. For instance, [NAME] #6 pureed plain beef stew meat instead of the scratch-prepared beef stew, citing difficulties in pureeing vegetables. Additionally, breadcrumbs were used instead of sliced bread to make pureed bread, and applesauce was used instead of pureed baked apple slices, as staff believed these substitutions were easier and more consistent. The Manager of Dietary acknowledged the struggle with staff following the menu and recipes, noting that staff felt overwhelmed and opted for easier methods. The Registered Dietitian confirmed that staff had been trained to follow recipes and should consult her before making substitutions. The Executive Director emphasized the importance of following the diet spreadsheet to ensure proper nutrition and flavor for residents on pureed diets.
Failure to Obtain Physician Order for Psychological Services
Penalty
Summary
The facility failed to obtain a physician order before providing psychological services to a resident. During a record review and interview with the Health Information Manager, it was confirmed that the resident received psychological services from November 2023 to July 2024 without a physician's order. The Director of Nursing also confirmed the absence of documentation for a physician's order for these services. The facility's policy requires a medical doctor's order for providing or arranging counseling services, which was not adhered to in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for wound care treatment for a resident with a pressure ulcer in the sacral region. The resident had multiple diagnoses, including an unstageable pressure ulcer, Type Two Diabetes, and mobility issues, which could complicate wound healing. The physician had ordered the application of Hydrogel to the sacrum every day and evening shift, following cleansing with normal saline and covering with a dry dressing. However, the Treatment Administration Record (TAR) showed missing entries for the evening shifts on two specific dates, indicating that the treatment was not documented as administered. During a review of the facility's policy on wound treatment management, it was noted that the policy required treatments to be provided in accordance with physician orders, including the method of cleansing, type of dressing, and frequency of dressing change. The Health Information Manager confirmed the missing entries and acknowledged that the facility could not provide records to show that the physician's orders were followed on the specified dates. This oversight had the potential to lead to complications for the resident, such as increased pain and wound infections.
Failure to Reorder Medication Timely
Penalty
Summary
The facility failed to reorder medication from the pharmacy according to their policy and procedure for one resident, leading to a potential health risk. Resident 1, who was admitted with a diagnosis of seizures and had an intact cognitive status, missed doses of her antiseizure medication, Lacosamide, for two days. This occurred because the medication was not available, as confirmed by the medication nurse. The facility's policy required medication to be reordered five to seven days in advance, but this was not adhered to, resulting in the missed doses. Interviews with staff revealed a lack of a clear process for ordering and tracking medication refills. The RN mentioned that while refill requests could be sent electronically, there was no alert system to track the order status, and staff relied on verbal endorsements during shift reports. The Licensed Nurse indicated that there were no clear instructions on who was responsible for ordering and tracking medications, which could lead to oversight. The Assistant Director of Nursing confirmed the policy of ordering medications in advance, but this was not followed, as evidenced by the Medication Administration Record and nurse progress notes indicating the missed doses and the delay in pharmacy delivery.
Failure to Maintain Resident Room and Restroom
Penalty
Summary
The facility failed to maintain a resident's room and restroom in a clean and homelike manner, which had the potential to negatively impact residents. During an observation and interview with the Maintenance Director, it was noted that the wall in the resident's room was in disrepair, with large scrapes and missing paint. Additionally, the hand sanitizing dispenser in the resident's restroom was missing a front cover. The Maintenance Director acknowledged that these issues had not been reported by staff nor were they listed on the maintenance log as items needing attention. The facility's policy requires all personnel to report broken or malfunctioning equipment immediately, but this protocol was not followed in this instance.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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