The Village Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 2400 West Acacia Avenue, Hemet, California 92545
- CMS Provider Number
- 555463
- Inspections on file
- 26
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Village Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that a resident admitted for aftercare following a below-knee amputation, who was cognitively intact and planning to return home with home health services, did not have a discharge-related care plan despite documented discharge plans and a physician order specifying the discharge home. Record review showed progress notes and orders outlining the intended discharge, but no corresponding care plan problem, goal, or interventions for discharge planning. Staff interviews, including with the SSA, ADM, and DON, confirmed that social services was responsible for initiating discharge care planning upon admission and that no such care plan had been developed for this resident.
Surveyors identified unsanitary conditions in the kitchen and resident food storage areas, including dust and grime on equipment and surfaces, as well as expired and unlabeled food items in a nurses' station refrigerator. Staff interviews confirmed these issues, and facility policy requires proper labeling, dating, and timely disposal of food to maintain sanitation.
The facility did not ensure that advance directives or DPOA-HC documents were readily available in the medical records for several residents, despite documentation indicating their existence. In one case, a cognitively intact resident was not provided with information or documentation regarding advance directives upon admission. The DON confirmed that these documents should have been present and accessible to staff, in accordance with facility policy.
Surveyors found that a resident's furosemide medication label lacked required holding parameters per physician order, and the pharmacy had not updated the label. Additionally, expired iron tablets, an opened container of Metamucil for a discharged resident, and a contaminated bottle of ProStat were stored in the medication cabinet, contrary to facility policy. The DON confirmed these items should not have been available for use.
Food and Nutrition Services staff did not follow required procedures for cleaning and sanitizing kitchen equipment and food contact surfaces, omitting the rinse step between washing and sanitizing, and failed to use the correct timing when testing sanitizer concentration as per manufacturer guidelines. These deficiencies were confirmed through staff interviews, direct observation, and review of facility policies and FDA Food Code.
Food and Nutrition Services staff did not follow the prescribed diet spreadsheets and menu orders for several residents on therapeutic diets. Two residents with diabetes were served inappropriate desserts, and three residents did not receive gravy with their pot roast as required. The facility lacked documentation of menu changes, and the Registered Dietitian confirmed that the meals served did not match the planned therapeutic diets.
Nine residents on mechanical soft diets were served food that did not meet prescribed texture requirements, including unground meat, large vegetable chunks, and potatoes with skin, despite facility guidelines specifying otherwise. The RD confirmed these deviations from the required diet texture during meal service.
A nurse was observed removing a Metoprolol tablet from a medicine cup with a bare finger and failing to disinfect a BP apparatus and stethoscope before and after use on a resident. These actions did not follow infection prevention protocols, as confirmed by the facility's Infection Preventionist and DON.
A refrigerator condenser unit leak in the kitchen led to water dripping onto food items, as confirmed by the Food Service Director, Maintenance Supervisor, and Registered Dietician. The maintenance issue was not promptly addressed, resulting in water overflow and potential cross-contamination of food, contrary to facility policy requiring safe and operable equipment.
The facility failed to maintain sanitary conditions in the kitchen, with dirty dishes and food debris observed during an unannounced visit. Pest control reports indicated ongoing rodent and insect activity, with recommendations to clean and sanitize areas. The Dietary Supervisor acknowledged the unclean conditions and the lack of consistent cleaning documentation, which could lead to increased pest activity and potential foodborne illnesses.
A facility failed to administer medications and conduct assessments as ordered for three residents. One resident did not receive antibiotics and topical treatments for skin damage, another did not have neurochecks after a fall, and a third did not receive medications for constipation. These lapses in care could have affected the residents' health conditions.
A facility failed to provide adequate pressure ulcer care and monitoring for three residents, leading to delayed wound healing and the development of new pressure injuries. One resident's stage 1 pressure injuries were not properly documented or monitored, resulting in progression to more severe stages. Another resident's non-blanchable redness was not treated promptly, worsening to an unstageable pressure injury. A third resident did not receive consistent wound care as ordered, with missing documentation for pressure injury and catheter care.
A facility failed to report an allegation of physical abuse involving a resident to the CDPH within the required timeframe. The resident, who was cognitively intact, reported being pushed by a CNA, but the facility deemed it a false accusation and did not report it. The DON and ADM were unaware of the allegation, which led to a delayed investigation and potential further exposure to abuse.
A facility failed to investigate an allegation of physical abuse reported by a resident, who claimed a CNA pushed her. Despite the report being discussed in meetings, the DON and Administrator were unaware, and no investigation was conducted. The resident, who was cognitively intact, had a history of making false accusations, but the MDS Coordinator emphasized the need for an investigation to determine the validity of the claim.
The facility failed to provide adequate wound management for four residents, leading to deficiencies in pressure ulcer care. A resident did not receive a comprehensive assessment of a re-opened sacral wound, and there was a lack of documentation regarding the wound's measurements, description, and progression. Another resident's medical records showed a lack of comprehensive assessment for wounds on the bilateral buttocks upon admission and no weekly re-evaluation during a specified week. A third resident did not receive treatment for a stage three pressure ulcer on the left buttock, and there was no comprehensive assessment upon admission. Similarly, a fourth resident's stage four pressure ulcer on the left buttock was not re-evaluated on specified dates, and the TN relied on the wound consultant's assessments instead of conducting their own.
Two residents experienced severe weight loss due to the facility's failure to implement a comprehensive approach to monitor nutritional status. The RD did not follow policies on Nutritional Assessment and Weight Assessment, resulting in unmonitored weight loss and ineffective nutritional interventions. Residents reported dissatisfaction with food and lack of communication about their nutritional care plans.
The facility failed to obtain informed consent for psychotropic medications for four residents, resulting in incomplete or unsigned consent forms. This led to residents or their representatives not being informed of the risks and benefits of the medications. Interviews with the DON and DSD confirmed the deficiencies in the informed consent process.
The facility failed to replace three emergency kits in a timely manner after they were opened, as observed during an inspection. Additionally, discrepancies were found in the documentation of controlled substances for two residents, where medications were signed out on count sheets but not documented on the MAR. Interviews with staff confirmed these issues, and the facility's policies were not followed.
The facility failed to monitor the medication refrigerator temperature twice daily as required, leading to incomplete and missing temperature logs from September 2023 to May 2024. The refrigerator contained critical medications such as vaccines and insulin. The DON confirmed the inconsistency in monitoring, which violated the facility's policy for proper medication storage.
The facility failed to ensure food safety and nutrition services were conducted properly, with issues in documenting cooling processes, calibrating thermometers, and following sanitization guidelines. Tuna salad was found in the danger zone for pathogens, and dishwashers did not follow proper sanitization procedures. Additionally, a cook prepared inappropriate food textures for residents on pureed diets, posing potential health risks.
The facility failed to maintain sanitary food preparation and storage practices, as observed during a survey. The cooling process for tuna salad was not documented, and its temperature was found in the danger zone. A dishwasher worked without covering his mustache, and grime and rust were found on kitchen equipment. Dust and debris were present in various areas, and opened food items were exposed to air in the freezer. Condensation was noted on the ventilation above the dish machine, and microwaves had grime buildup. These conditions posed a risk of cross-contamination and exposure to foodborne pathogens for residents.
The facility failed to develop a comprehensive care plan for two residents prescribed apixaban, a medication to prevent blood clots. Resident 8, with atrial fibrillation, and Resident 12, with acute embolism and thrombosis, had no documented care plans addressing the risk of bleeding. The DON confirmed the absence of care plans, contrary to the facility's policy requiring person-centered care plans with measurable objectives.
A facility failed to ensure adequate monitoring of a resident's use of psychotropic medications, Zoloft and Escitalopram, as required by the manufacturer's guidelines and facility policies. The Consultant Pharmacist did not report the lack of monitoring during the monthly medication regimen reviews, and the Director of Nursing acknowledged the oversight. This deficiency could lead to suboptimal medication use and potential adverse effects.
The facility failed to monitor two residents on Eliquis for side effects like bleeding and bruising. Despite physician orders and facility policy requiring monitoring, there was no documentation of such monitoring for April and May. The DON acknowledged this oversight during interviews and record reviews.
A resident was administered Zoloft and Escitalopram without adequate monitoring, and PRN Xanax was given without a prescriber-documented rationale for extended use. The DON acknowledged the lack of monitoring and indefinite end date for Xanax, contrary to facility policy requiring adequate monitoring for psychotropic medications.
Two residents experienced medication administration errors, resulting in a 19.23% error rate. An LVN administered incorrect forms of aspirin and sennoside to a resident and failed to ensure mouth rinsing after inhaler use. Another resident received medications without clarified doses and strengths. The DON confirmed the need for order clarification, highlighting non-compliance with facility policies.
The facility failed to provide a smooth pureed diet for two residents with physician-prescribed dietary needs. Observations revealed that the pureed broccoli contained fiber and was not smooth, posing risks of choking and aspiration. Interviews with the DON and Food Service Director confirmed the deficiency, highlighting the importance of adhering to dietary requirements for residents with swallowing difficulties.
Two residents did not receive physician-ordered diets, with one not getting large portions and another missing fortified food items. The discrepancies were confirmed by the Food Service Director and DON, highlighting a failure to adhere to dietary orders, potentially affecting the residents' nutritional status.
A facility failed to maintain infection control procedures when an LVN did not disinfect a shared stethoscope between uses on two residents. The LVN acknowledged the oversight, and the facility's policy requires disinfection of reusable items like stethoscopes between residents. Interviews with the IP and DON confirmed the need for disinfection with Sani-Cloth wipes. The residents involved had medical conditions that could be compromised by infection.
Failure to Develop Discharge Care Plan for Resident Returning Home
Penalty
Summary
The deficiency involves the facility’s failure to develop a care plan addressing a resident’s discharge plans. During an unannounced visit, surveyors reviewed the record of a cognitively intact resident admitted for aftercare following a below-knee amputation. The resident’s MDS showed a BIMS score of 15, and progress notes documented discharge plans to home with home health services. A physician’s order specified the last covered date and a planned discharge home on a specific date. Despite these documented discharge plans and orders, the resident’s care plan did not contain any problem, goal, or intervention related to discharge planning or the resident’s return home. Interviews with staff confirmed that a discharge care plan should have been in place. The Social Services Assistant stated that the Social Services Director is responsible for developing a care plan related to discharge plans and acknowledged that a discharge care plan is important to plan where the resident will go and what care and resources are needed before and at discharge. The Administrator stated that discharge care planning should be initiated upon admission, including discharge plans and care needs. The DON confirmed there was no discharge-related care plan for this resident and stated that social services should have initiated one on admission to ensure proper care to reach the discharge goal. A review of the facility’s transfer/discharge policy showed that details of transfers or discharges are to be documented in the medical record and communicated to receiving providers, but there was no corresponding discharge care plan for this resident.
Deficient Food Sanitation and Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen and resident food storage areas. Multiple observations revealed dust accumulation on various kitchen equipment and surfaces, including refrigerator fan covers, walls, and door frames. These findings were confirmed by the Food Server Director, Food Server, and Dietary Supervisor during concurrent interviews, who acknowledged that the dust was present and should have been cleaned. The Registered Dietitian also stated that dust in the kitchen could potentially cause cross-contamination. Further inspection identified grime buildup on the bottom shelves of cold storage and on the inner door gasket of a walk-in refrigerator. The Dietary Supervisor confirmed that the white grime was food residue and the black grime was dirt, both of which had been missed during cleaning. The supervisor acknowledged that such grime could cross-contaminate food and potentially cause food-borne illness. The Registered Dietitian reiterated that kitchen and storage equipment should be free from grime to prevent illness. Additionally, the inspection of the nurse's station refrigerator, which stored residents' food, revealed several undated, expired, or unlabeled food items. The Infection Preventionist confirmed that these items were past their storage dates, should have been labeled, and should have been discarded according to facility policy. The Registered Dietitian stated that expired food should be removed to maintain sanitary conditions and prevent food-borne illness. Facility policy requires that food stored for residents be labeled, dated, and discarded per safe food storage guidelines.
Failure to Maintain and Document Advance Directives
Penalty
Summary
The facility failed to maintain accurate and accessible documentation of residents' advance directives (ADs) for four out of six residents reviewed. For three residents, their ADs or Durable Power of Attorney for Health Care (DPOA-HC) documents were not readily available in either their physical or electronic medical records, despite documentation indicating that these documents existed and were acknowledged by the residents or their representatives. The Director of Nursing (DON) confirmed during interviews that these documents should have been present in the residents' charts and acknowledged that their absence could result in staff not following the residents' documented wishes. Additionally, for one resident, there was no documented evidence that information regarding the formulation of an AD was provided upon admission. The resident was cognitively intact, but neither an AD nor an Advance Directive Acknowledgement Form was found in the resident's records. The DON stated that if an AD was not obtained at admission, follow-up and education regarding ADs should have been conducted and documented, but this was not done in this case. The facility's own policy requires that copies of advance directives be obtained, maintained in a consistent and accessible section of the medical record, and that residents or their representatives be provided with written information about their rights regarding advance directives. The policy also specifies that these documents should be easily retrievable by staff and that residents' wishes should be communicated to direct care staff and physicians. These requirements were not met for the residents identified in the report.
Deficient Medication Labeling and Storage Practices
Penalty
Summary
Surveyors identified deficiencies in the facility's medication labeling and storage practices. During a medication administration observation, a nurse prepared furosemide for a resident with congestive heart failure and atrial fibrillation. The nurse stated that the medication should be held if the resident's systolic blood pressure was below 110 mmHg, as per the physician's order. However, the medication label did not include the required holding parameter, and there was no direction change sticker to indicate this instruction. The Director of Nursing confirmed that the pharmacy should have updated the label to reflect the physician's order. Further inspection of the medication storage area revealed additional issues. Three bottles of iron tablets with expiration dates of April 2025, an opened container of Metamucil labeled for a discharged resident with an expiration date of November 2024, and an open bottle of ProStat with dried liquid residue were found stored in the medication cabinet. These items were readily available for use despite being expired, labeled for a discharged resident, or showing signs of contamination. The Director of Nursing acknowledged that these medications should not have been stored in the cabinet and could potentially be administered in error. A review of the facility's policy indicated that medication labeling must include appropriate instructions and precautions, and only the dispensing pharmacy may alter medication labels. The policy also requires that discontinued, outdated, or deteriorated medications be returned or destroyed according to pharmacy instructions. The facility failed to adhere to these policies, resulting in improper labeling and storage of medications and biologicals.
Failure to Follow Proper Cleaning and Sanitizing Procedures in Food Service
Penalty
Summary
Food and Nutrition Services staff failed to follow proper cleaning and sanitizing procedures for kitchen equipment and food contact surfaces. Observations and interviews revealed that staff used a soap and water solution to clean surfaces and then applied sanitizer, but did not perform a separate rinse step between washing and sanitizing, as required by facility policy and the FDA Food Code. Both staff members interviewed confirmed omitting the rinse step, and the Registered Dietitian verified that the correct procedure should include washing, rinsing, and then sanitizing. Review of facility policy and FDA guidelines confirmed the necessity of the rinse step to ensure effective cleaning and sanitizing. Additionally, staff did not adhere to the manufacturer's guidelines for testing sanitizer concentration. The Kitchen Supervisor and another staff member were observed dipping test strips into the sanitizer for 10 and 15 seconds, respectively, instead of the required 5 seconds per the manufacturer's instructions. The Registered Dietitian confirmed that not following the correct timing could result in inaccurate readings. Facility policy also required staff to follow manufacturer recommendations for such procedures. These failures were identified through direct observation, staff interviews, and review of relevant policies and guidelines.
Failure to Follow Diet Spreadsheets and Menu Orders for Therapeutic Diets
Penalty
Summary
Food and Nutrition Services staff failed to follow the facility's Cook's spreadsheet and diet orders for multiple residents on a controlled carbohydrate (CCHO) diet. During a lunch meal observation, two residents with diabetes mellitus type 2 were served cherry crisp for dessert instead of fruit, as required by the CCHO diet outlined in the facility's diet spreadsheet. The residents' medical records and physician orders confirmed their need for a CCHO diet, and the Registered Dietitian (RD) verified that the correct dessert should have been fruit. There was no documentation or posting regarding any changes to the planned menu, and the facility could not provide a log of such changes. Additionally, three residents did not receive gravy with their pot roast meat, contrary to the instructions on the meal tickets and the diet spreadsheet, which specified that both mechanical soft and pureed diets should include gravy with the pot roast. The RD confirmed that the meals should have included gravy, as indicated in the spreadsheet. The facility's policy and procedure required that diet spreadsheets be followed for regular and therapeutic diet orders, but these were not adhered to during the observed meal service.
Failure to Provide Proper Food Texture for Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the appropriate texture for nine residents who were prescribed a mechanical soft diet. During a lunch observation, residents on this diet received pot roast meat that was not ground or chopped to the required size, but instead contained whole coarse strands approximately one inch in size. The vegetables served were also in large chunks, similar to those provided to residents on a regular diet. The Registered Dietician (RD) confirmed that the meat and vegetables did not meet the texture and consistency requirements for a mechanical soft diet, which should be chopped or ground to half an inch or smaller and vegetables in small chunks. The facility's diet manual and menu spreadsheet both specified these requirements, but they were not followed during the observed meal service. Additionally, residents on a mechanical soft diet were served potatoes with skin, contrary to the facility's diet manual and menu spreadsheet, which indicated that potatoes should be served without skin for this diet type. The RD confirmed that no alternative potatoes were prepared and acknowledged that potato skins should not have been served to these residents. The failure to provide food in the correct texture and form was observed for all nine residents with a mechanical soft ground diet order during the meal service.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow infection prevention and control practices during medication administration. The LVN was observed removing a Metoprolol tablet from a medicine cup using a bare forefinger, rather than using appropriate tools or gloves. Additionally, the LVN did not disinfect the blood pressure (BP) apparatus or stethoscope before or after use on a resident. The BP apparatus was returned to the medication cart without being cleaned, and the stethoscope was placed back around the LVN's neck without disinfection. The resident involved was being assessed for blood pressure prior to medication administration, as the medication was not to be given if the systolic blood pressure was below 110 mmHg. The LVN measured the resident's blood pressure, determined it was too low to administer the medication, and then handled the medication directly with a bare finger. Both the Infection Preventionist and the Director of Nursing confirmed that these actions were not in accordance with facility policy, which requires cleaning and disinfection of reusable resident-care equipment between uses to prevent contamination or cross-contamination.
Failure to Maintain Kitchen Equipment Results in Water Leak and Food Contamination Risk
Penalty
Summary
A deficiency was identified when water was observed dripping from the condenser unit of Refrigerator #3 in the facility's kitchen. The water was collecting in a metal pan placed on the top shelf of the refrigerator, which had filled to the brim and was overflowing onto food items stored on the lower shelves. Both the Food Server Director and the Maintenance Supervisor confirmed that the leak originated from the condenser unit and acknowledged that maintenance should have addressed the issue promptly. The Food Server Director also stated that the water leaking onto the food rendered it unsafe due to possible cross-contamination. Further, the Registered Dietician confirmed that any damaged kitchen equipment should be prioritized for repair to ensure safe and operable use, and that water leaking onto food could cause cross-contamination, potentially leading to food-borne illnesses. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping equipment in a safe and operable manner at all times. The failure to repair the refrigerator's condenser unit resulted in water leaking onto food, creating a risk of contamination.
Sanitation Deficiencies in Kitchen Lead to Potential Health Risks
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an unannounced visit. Stacks of dirty pots, pans, and dishes were found in the three-compartment sink area, with several items still containing food. Additional dirty dishes were noted on a metal shelf across from the sink. Food particles, crumbs, a whole cookie, broken eggshells, a plastic bowl, and various wrappers were found under the stoves and ovens. The Dietary Supervisor (DS) acknowledged the unclean conditions and stated that the kitchen staff did not have time to clean up after breakfast, indicating that the breakfast dishes would be cleaned after lunch. The facility's pest control service reports from November 2024 to January 2025 indicated ongoing rodent and insect activity in the kitchen, with recommendations to clean and sanitize areas with grease build-up and debris. The reports noted mice caught in traps, earwig activity, and gnat presence, with repeated recommendations to clean and sanitize the kitchen area. The facility's cleaning documentation showed multiple instances where cleaning tasks were not documented as completed, suggesting that the kitchen was not being cleaned regularly as required. The DS admitted that the cleaning lists were confusing and that tasks were not consistently documented, which could lead to increased rodent and insect activity and potential foodborne illnesses. The facility's policy on sanitization emphasized maintaining a clean and sanitary food service area, free from garbage and debris, and protected from pests. However, the lack of proper cleaning and documentation indicated a failure to adhere to these standards, posing a risk to the health and safety of the residents.
Failure to Administer Medications and Conduct Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for three residents, leading to deficiencies in their care. Resident D did not receive prescribed antibiotic medication, Bactrim DS, for a urinary tract infection on two occasions due to the medication being unavailable, despite it being accessible in the emergency kit. Additionally, Resident D's topical treatments for moisture-associated skin damage (MASD) were not documented as completed on several dates, indicating a lapse in care. Resident E, who had a history of metabolic encephalopathy and dementia, experienced a fall and sustained a head injury. Despite the physician's order for neurochecks following the fall, there was no documented evidence that these checks were conducted. This lack of documentation suggests that the necessary assessments to monitor Resident E's condition post-fall were not performed, potentially compromising the resident's health and safety. Resident F, diagnosed with Parkinson's dementia and psychosis, suffered from constipation but did not receive the prescribed medications to manage this condition. The medical record indicated that Resident F did not have bowel movements on multiple days, yet the medications such as Milk of Magnesia, bisacodyl suppository, and fleet enema were not administered as ordered. This oversight in medication administration could have exacerbated Resident F's discomfort and health condition.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to ensure accurate skin assessments and wound care treatment for three residents, leading to delayed wound healing and the development of new pressure injuries. Resident A was admitted with multiple stage 1 pressure injuries, which were not properly documented or monitored. The Treatment Nurse failed to document the progression of these injuries, and the Registered Nurse admitted to not finding documentation of monitoring in the progress notes or treatment administration record. This lack of documentation and monitoring resulted in the progression of Resident A's pressure injuries to more severe stages. Resident B was admitted with non-blanchable redness on the buttocks, which should have been identified as a stage one pressure injury. However, treatment was not initiated until seven days after the initial identification. The Treatment Nurse acknowledged that the redness should have been treated immediately and a care plan should have been created. The delay in treatment and lack of immediate care plan development contributed to the worsening of Resident B's condition, with the pressure injury becoming unstageable. Resident C, who had a stage 4 pressure injury, did not receive consistent wound care as ordered. The Treatment Administration Record showed no documentation of completed treatments for the pressure injury, Foley catheter care, or scrotum care on several occasions. The Director of Nursing noted the importance of consistent care for Resident C due to frequent urinary tract infections. The lack of documentation and adherence to treatment orders for Resident C's pressure injury and catheter care further exemplifies the facility's failure to provide adequate care and monitoring for residents with pressure injuries.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident, identified as Resident G, to the California Department of Public Health (CDPH) within the required timeframe. The incident was initially reported by Resident G to a licensed nurse on January 23, 2025, during which she claimed that a Certified Nursing Assistant (CNA) had pushed her. Despite this, the facility's Infection Preventionist (IP) and Director of Medical Records (DOMR) decided not to report the allegation to CDPH, deeming it a false accusation. This decision was made during a stand-up meeting on January 24, 2025, where Resident G's behavioral symptoms and previous false allegations were discussed. The facility's policy mandates immediate reporting of suspected abuse to relevant authorities, which was not adhered to in this case. Resident G, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13, had a history of making false accusations, as noted in her care plan. However, there was no specific care plan addressing the allegation of being pushed by a CNA. During an interview, Resident G recounted an incident where two unfamiliar individuals pulled her out of bed against her will. The Director of Nursing (DON) and Administrator (ADM) were unaware of the abuse allegation and acknowledged that it should have been reported. The facility's failure to report the incident promptly resulted in a delayed investigation by CDPH and potentially exposed Resident G to further abuse.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident, identified as Resident G. The incident was initially reported during a stand-up meeting on January 24, 2025, after Resident G informed a licensed nurse that a CNA had pushed her. Despite the report, the Director of Nursing and the Administrator were not made aware of the allegation, and no investigation was initiated. The facility's policy requires that all allegations of abuse be reported immediately to the administrator and relevant authorities, and that a thorough investigation be conducted. However, this protocol was not followed in this case. Resident G, who was cognitively intact with a BIMS score of 13, had a history of making false accusations, as noted in her care plan. However, the MDS Coordinator did not agree that the allegation of being pushed was false, emphasizing the need for an investigation to determine the validity of the claim. Interviews with the Infection Preventionist and the Director of Medical Records confirmed that the allegation was discussed in meetings, yet no action was taken to investigate the claim. This oversight had the potential to result in further abuse and affect Resident G's emotional and psychosocial well-being.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate wound management for four residents, leading to deficiencies in pressure ulcer care. Resident A did not receive a comprehensive assessment of a re-opened sacral wound, and there was a lack of documentation regarding the wound's measurements, description, and progression. The Treatment Nurse (TN) admitted to not measuring the wounds upon admission and relied on the wound consultant's notes for documentation, which resulted in a delay in identifying the stage four pressure ulcer. Resident B's medical records showed a lack of comprehensive assessment for wounds on the bilateral buttocks upon admission and no weekly re-evaluation during a specified week. The TN did not document the condition of the moisture-associated skin damage (MASD) on the bilateral buttocks, and there was no evidence of a wound assessment conducted by either the TN or the wound consultant during the week of September 18 to 20, 2024. Resident C did not receive treatment for a stage three pressure ulcer on the left buttock, and there was no comprehensive assessment upon admission. The TN failed to document wound measurements and treatment on several occasions. Similarly, Resident D's stage four pressure ulcer on the left buttock was not re-evaluated on specified dates, and the TN relied on the wound consultant's assessments instead of conducting their own. The facility's policies and procedures for wound care and change in resident condition were not followed, contributing to these deficiencies.
Failure to Monitor Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for two residents. The Registered Dietitian (RD) did not follow the facility's policies on Nutritional Assessment and Weight Assessment and Intervention. For one resident, the RD failed to assess nutritional status and monitor the effectiveness of nutritional interventions, resulting in a severe weight loss of 10 pounds (8.8%) in one month. The resident reported disliking the food due to its saltiness and not being aware of the physician's order for snacks between meals. The RD did not document discussions with the resident about their usual body weight, poor appetite, or nutritional interventions. Another resident experienced a severe weight loss of 17 pounds (8.5%) within three weeks. The RD did not assess the resident's nutritional status or monitor the effectiveness of fortified diet interventions. The resident reported a loss of appetite and dissatisfaction with the taste of the food. The RD did not visit the resident to gather nutritional information or discuss the resident's usual body weight, appetite, or nutritional interventions. The RD relied on nursing staff for meal intake information and did not observe the resident's dining experience. The Director of Nursing (DON) acknowledged that the RD did not follow the facility's policies and failed to conduct weight loss assessments, evaluations, and interventions. The DON stated that the RD only interpreted information from electronic medical records instead of visiting the residents to collect nutritional information. The DON noted that the residents' weight loss could have been preventable if the RD had visited them, obtained their usual body weight, and personalized nutritional interventions based on their preferences.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained from residents or their representatives for the use of psychotropic medications. This deficiency was identified for four out of five residents reviewed for unnecessary medications. The informed consent forms were either incomplete or not signed by the resident, their representative, or the physician who obtained the consent. This resulted in the residents or their representatives not being informed of the risks and benefits of the proposed care and treatment regarding the use of psychotropic medications. For Resident 12, the informed consent form for venlafaxine did not indicate the dose and frequency of the medication, and there was no physician's signature. Additionally, there was no documented evidence of informed consent for the use of bupropion. Resident 15's informed consent form lacked the frequency of the medication and the date of the resident's signature. Resident 17's form did not include the dose and frequency for sertraline, nor did it have the physician's signature. Resident 19's medical record lacked documented evidence of informed consent for the use of escitalopram, Zoloft, and Xanax. Interviews with the Director of Nursing and the Director of Staff Development confirmed the deficiencies in the informed consent process. The Director of Nursing acknowledged that the residents should be aware of the psychotropic medications being administered and that the informed consent forms were incomplete. The Director of Staff Development also confirmed the lack of documented informed consent for Resident 12's medications. The facility's policy on requesting, refusing, and discontinuing care or treatment emphasized the importance of informing residents or their representatives about the care to be furnished and the associated risks and benefits.
Failure to Replace Emergency Kits and Document Controlled Medications
Penalty
Summary
The facility failed to ensure that three out of five emergency kits were replaced in a timely manner after being opened. During an inspection, it was observed that the oral medication e-kit and the intramuscular medication e-kit were sealed with yellow locks, indicating they had been opened. The oral medication e-kit had been opened on two occasions, with medications removed on May 15 and May 16, 2024, but had not been replaced. Similarly, the intramuscular e-kit had been opened on April 4 and April 10, 2024, and had not been replaced. The narcotic e-kit was also found to be opened and not replaced since May 15, 2024. Interviews with nursing staff confirmed that the e-kits should have been replaced within 72 hours, but this was not done. The facility also failed to accurately account for controlled substance medications on the Medication Administration Record (MAR) and the Drug Control Receipt Record/Disposition Form for two residents. For one resident, a discrepancy was found where a hydrocodone-acetaminophen tablet was signed out on the count sheet but not documented on the MAR. Similarly, for another resident, multiple instances were found where oxycodone-acetaminophen tablets were signed out on the count sheet but not documented on the MAR. Interviews with nursing staff and the Director of Nursing confirmed these discrepancies and acknowledged the lack of documentation. The facility's policies and procedures for emergency medications and controlled substances were reviewed, indicating that the facility should maintain a supply of medications typically used in emergencies and that documentation should be completed immediately after medication administration. However, the facility failed to adhere to these policies, resulting in the deficiencies observed during the survey.
Medication Refrigerator Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that the temperature in the medication refrigerator was monitored twice daily, as required by the facility's protocol. During an inspection of the medication room, it was observed that the refrigerator contained vaccines, insulin products, a refrigerated emergency kit, and other medications. The Registered Nurse (RN) stated that the temperature was supposed to be checked and documented by the licensed nurse at each shift. However, a review of the temperature logs from September 2023 to May 2024 revealed numerous inconsistencies and missing entries, indicating that the monitoring was not performed as required. Specifically, the temperature logs showed missing recordings on several days across multiple months, including October 2023, December 2023, January 2024, February 2024, and March 2024. The entire log for November 2023 was missing. The Director of Nursing (DON) confirmed these findings, acknowledging that the logs were incomplete and not consistently monitored twice a day. The facility's policy, dated February 2023, required that all medications and biologicals be stored under proper temperature conditions, with nursing staff responsible for maintaining these standards.
Deficiencies in Food Safety and Nutrition Services
Penalty
Summary
The facility failed to ensure that food service employees were adequately trained and followed proper procedures for food safety and nutrition services. On May 20, 2024, a container of tuna salad was found in the walk-in refrigerator with a temperature of 56.7 degrees Fahrenheit, which is within the danger zone for foodborne pathogens. The cooling process for this tuna salad was not documented, and the Prep Cook admitted to forgetting to log it. Interviews with the Food Service Director confirmed that the tuna salad had been in the danger zone for more than four hours, violating the facility's policy on rapid cooling of potentially hazardous foods. Further deficiencies were noted in the staff's ability to demonstrate proper food safety procedures. The Prep Cook and another cook were unable to correctly demonstrate the cooling process for tuna salad, with discrepancies in their understanding of the required time to cool the salad below 41 degrees Fahrenheit. Additionally, a cook was unable to properly calibrate a thermometer, setting it to 36 degrees Fahrenheit instead of the required 32 degrees Fahrenheit. This lack of knowledge could lead to inaccurate temperature readings, further compromising food safety. The facility also failed to ensure that dishwashing staff followed manufacturer guidelines for sanitizing kitchenware. Dishwashers were not immersing kitchenware in sanitizer for the required 60 seconds and were incorrectly using test strips to check sanitizer concentration. Additionally, a cook prepared grainy broccoli for two residents on a physician-prescribed pureed diet, which could pose a choking hazard. These failures in following proper procedures and guidelines had the potential to cause foodborne illness and aspiration risks for residents.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices, as observed during a survey. The cooling process for tuna salad prepared on May 20, 2024, was not monitored, and the temperature of the tuna salad was found to be 56.7 degrees Fahrenheit, which is within the danger zone for food temperature. The prep cook admitted to forgetting to document the cooling process in the cooling log, and the Food Service Director confirmed that the tuna salad had been held in the danger zone for more than four hours, necessitating its disposal. Additionally, the facility did not maintain proper hygiene standards in the kitchen. A dishwasher was observed working without covering his mustache, which posed a risk of hair contamination in food or clean dishes. The can opener base had a buildup of black grime, and rust was found on shelves used for drying and storing kitchenware. Dust and debris were present in various areas of the kitchen, including walls, fans, and shelves, which could lead to cross-contamination. The ice machine's deflector had residue buildup, and the plastic coating on refrigerator shelves was worn off, exposing metal that could rust. Further observations revealed that the vent above the stove was covered with grease and dust, and opened food items in the walk-in freezer were exposed to air, risking freezer burn. Condensation was noted on the ventilation above the dish machine, indicating a malfunction. Two microwaves in the dining room, labeled for resident use, had yellow grime buildup inside. These unsanitary conditions and improper food handling practices had the potential to increase the risk of cross-contamination and exposure to foodborne pathogens for all 37 residents receiving food from the kitchen.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure a comprehensive care plan was initiated for the use of apixaban, a medication that helps prevent blood clots, for two residents. Resident 8, diagnosed with atrial fibrillation, was prescribed Eliquis (apixaban) 5 mg to be taken orally twice a day. Similarly, Resident 12, diagnosed with acute embolism and thrombosis, was prescribed apixaban 2.5 mg for DVT prophylaxis, to be taken orally twice a day. However, upon review of their records, there was no documented evidence of a care plan addressing the risk for bleeding associated with the use of apixaban. During an interview, the DON acknowledged that a care plan should be in place to monitor residents for bleeding when prescribed medication to prevent blood clots. The DON was unable to provide documentation of such a care plan for Residents 8 and 12. The facility's policy, dated December 2016, requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, which was not adhered to in these cases.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for a resident. Specifically, the CP did not report the lack of adequate behavioral and manufacturer's specified monitoring for two psychotropic medications, Zoloft and Escitalopram, administered to the resident. The resident was admitted with a diagnosis of anxiety and was prescribed Escitalopram for depression in February and Zoloft in March. However, there was no documentation of monitoring for side effects or behavioral manifestations as required by the manufacturer's guidelines and the facility's policies. During interviews and record reviews, the Director of Nursing (DON) acknowledged the absence of monitoring for side effects and behavioral changes during the use of these medications. The monthly MRRs for March and April did not include any recommendations from the CP regarding the need for such monitoring. The facility's policy on medication regimen reviews, dated May 2019, mandates a thorough review to prevent, identify, report, and resolve medication-related problems, including inadequate monitoring for adverse consequences. The lack of monitoring could potentially lead to the medication not being optimized for the best possible health outcome and unnecessary or prolonged use, which could result in adverse effects.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that two residents, who were receiving the anticoagulant medication Eliquis (apixaban), were monitored for signs and symptoms of side effects, such as bleeding and bruising. Resident 8 was admitted with a diagnosis of atrial fibrillation and had physician orders to receive Eliquis and be monitored for bleeding. However, there was no documentation of monitoring for bleeding on the Medication Administration Record (MAR) for April and May 2024. The Director of Nursing (DON) acknowledged the lack of documentation during an interview and record review. Similarly, Resident 12, admitted with diagnoses of embolism and deep vein thrombosis, was prescribed apixaban with orders to monitor for bleeding. Like Resident 8, there was no documentation of monitoring for bleeding on the MAR for April and May 2024. The DON confirmed this oversight during a concurrent interview and record review. The facility's policy on anticoagulation therapy, which requires monitoring for adverse drug reactions and signs of bleeding, was not followed, leading to the potential for undetected side effects.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident was receiving Zoloft and Escitalopram for depression, and Xanax as needed for anxiety. However, there was inadequate behavioral and manufacturer-specified monitoring documented for Zoloft and Escitalopram. Additionally, the PRN Xanax was administered without a prescriber-documented rationale and specified duration for extended use beyond 14 days. During interviews and record reviews, the Director of Nursing acknowledged the lack of monitoring for side effects and behavior manifestations for Zoloft and Escitalopram. Furthermore, the PRN Xanax order had an indefinite end date, and there was no documentation by the prescriber for extending its use beyond 14 days. The facility's policy on psychotropic medication management requires adequate monitoring for efficacy and adverse consequences, which was not adhered to in this case.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain medication error rates below 5 percent, resulting in a 19.23 percent error rate during medication administration for two residents. For Resident 138, the Licensed Vocational Nurse (LVN) administered an enteric-coated aspirin tablet instead of the prescribed chewable aspirin tablet, a sennoside tablet instead of the combination sennoside-docusate tablet, and did not ensure the resident rinsed their mouth after using the Trelegy Ellipta inhaler as per physician's orders. These discrepancies were confirmed by the LVN during a review of the medication administration record and physician's orders. For Resident 131, the LVN administered an enteric-coated aspirin and a folic acid tablet without clarifying the missing dose and strength in the physician's orders. The Director of Nursing (DON) confirmed that the orders were incomplete and should have been clarified by the nursing staff. The facility's policies and procedures for administering medications and recording orders emphasize the importance of following prescriber orders and ensuring all medication details are specified, which were not adhered to in these instances.
Failure to Provide Appropriate Pureed Diet Texture
Penalty
Summary
The facility failed to provide the appropriate food texture for two residents who had a physician-prescribed pureed diet. During an observation and interview, it was noted that the pureed broccoli prepared by a staff member contained fiber and did not achieve the required smooth consistency. A test tray evaluation confirmed that the pureed broccoli had grainy strands and was not smooth, as expected for a pureed diet. The Food Service Director acknowledged that the pureed broccoli was not smooth and contained small pieces, which did not meet the dietary requirements for residents on a pureed diet. Interviews with the Director of Nursing and the Food Service Director highlighted the risks associated with not providing a smooth pureed diet, including choking, aspiration, and decreased meal intake. The facility's documents and the residents' physician's orders confirmed the need for a pureed diet, emphasizing the importance of a smooth, pudding-like consistency to accommodate residents with difficulty swallowing or chewing. The failure to adhere to these dietary requirements placed the residents at risk and did not comply with the prescribed therapeutic diets.
Failure to Follow Physician-Ordered Diets for Residents
Penalty
Summary
The facility failed to adhere to physician-ordered dietary requirements for two residents, leading to potential nutritional deficiencies. Resident 12, who was prescribed large portions due to weight loss, did not receive the correct portion size during a lunch meal. The meal tray ticket incorrectly indicated a regular portion instead of the large portion ordered by the physician. This discrepancy was confirmed by both the Food Service Director and the Director of Nursing, who acknowledged that the resident did not receive the prescribed diet, placing them at risk of not gaining weight. Similarly, Resident 15, who was on a fortified diet to help gain weight, did not receive the fortified food items as ordered by the physician. The meal tray ticket for this resident also indicated a regular diet instead of the fortified diet. The Cook stated that no fortified food items were prepared because there was a misunderstanding about the current dietary needs of the residents. Both the Food Service Director and the Director of Nursing confirmed that the resident did not receive the fortified diet, which was intended to provide additional calories. The facility's policies and procedures, including those for physician orders and therapeutic diets, were reviewed and found to be in place to support the residents' treatment and care plans. However, the failure to follow these orders resulted in the residents not receiving the necessary dietary interventions as prescribed, potentially impacting their nutritional status and overall health.
Infection Control Deficiency: Failure to Disinfect Shared Stethoscope
Penalty
Summary
The facility failed to implement and maintain proper infection control procedures when a Licensed Vocational Nurse (LVN 1) did not disinfect a shared stethoscope between uses on two medically compromised residents. On May 21, 2024, LVN 1 was observed using a stethoscope to check Resident 181's blood pressure without cleaning the stethoscope between residents. During an interview, LVN 1 acknowledged the failure to clean the stethoscope and stated that it should be cleaned before and after each use. The facility's policy, revised in 2022, requires that resident-care equipment, including reusable items like stethoscopes, be cleaned and disinfected according to CDC recommendations between residents. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the stethoscope should have been disinfected with Sani-Cloth wipes after each use. Resident 181 was admitted with a fracture to the left femur, and Resident 138 had a right artificial hip joint, both conditions that could be compromised by infection.
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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