Villa Serena Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 723 E 9th Street, Long Beach, California 90813
- CMS Provider Number
- 055329
- Inspections on file
- 28
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Villa Serena Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, muscle wasting, and diabetes was found with a skin tear and new skin discoloration after an incident with another resident. Nursing staff notified the physician and updated the care plan but did not initiate a formal change of condition process or conduct a pain assessment as required by facility policy. This resulted in the resident not being properly monitored for changes in condition.
A resident with COPD, ESRD, CHF, and Type II Diabetes Mellitus was neglected by LTC facility staff, leading to their death. Despite being informed of the resident's breathing difficulties, the LVN failed to assess or monitor vital signs, and the RN did not notify the physician or ensure the resident wore a LifeVest. When the resident became unresponsive, proper CPR procedures were not followed, violating facility policies and resulting in the resident's death.
A resident with a Full Code status was found unresponsive, and the facility failed to provide timely CPR. The LVN did not announce a Code Blue or perform CPR, and CNAs stopped chest compressions before paramedics arrived. The facility's failure to follow its CPR policy resulted in a delay in life-saving measures, leading to the resident's death.
The facility did not implement its Water Management Plan, failing to complete a necessary water management assessment to prevent the growth of bacteria, including Legionella. The Infection Prevention Nurse confirmed the assessment was not done, and the facility's policy required following CDC guidance and contracting experts for plan development.
The facility failed to document COVID-19 vaccination status for all employees, including physicians and consultants, potentially placing staff and residents at risk. The Infection Prevention Nurse was unaware of the requirement to obtain this information. The facility's policy required education and offering of vaccinations to all staff and consultants.
The facility failed to meet the required minimum square footage per resident in 17 out of 19 rooms, with rooms having two, three, and six beds not meeting the regulatory standards. Despite a waiver indicating ample space, the survey found rooms like Room 2 with six beds at 470 sq. ft. and Room 3 with six beds at 426 sq. ft. did not meet the minimum requirements. No adverse effects on nursing care or resident comfort were observed during the survey.
A resident at moderate risk for skin injury developed multiple pressure injuries due to the facility's failure to implement care plan interventions and adhere to wound management policies. The resident, with a history of dementia and diabetes, required substantial assistance but was not regularly repositioned, leading to preventable pressure injuries.
A facility failed to provide appropriate dialysis care for a resident with ESRD. The resident missed two dialysis sessions, and the facility did not notify the physician, assess the resident, monitor for complications, or educate the resident on the risks. Additionally, the facility did not complete necessary documentation before a previous dialysis session, impacting continuity of care.
The facility failed to obtain informed consent for psychotropic medications for a resident with decision-making capacity, did not conduct required Gradual Dose Reductions (GDR) for two residents, and inadequately monitored another resident for lithium toxicity. Additionally, there was a delay in addressing a therapeutic duplication of BPH medications for a resident, despite a pharmacist's recommendation.
A resident with breast cancer experienced medication administration errors when an LVN failed to use gloves while handling Anastrozole and did not remove a lidocaine patch as scheduled. This resulted in a medication error rate of 7.69 percent, contrary to the facility's policy and the Director of Nursing's expectations.
The facility failed to store medications securely and maintain the medication refrigerator within the proper temperature range. A resident was observed self-administering and storing medications at their bedside, confirmed by an LVN, while an RN Supervisor stated these should be in the medication cart. Additionally, the medication refrigerator was found to be at 48°F, outside the acceptable range.
The facility failed to follow dietary guidelines during lunch preparation, serving residents on a pureed diet less fish than required and substituting peas for green beans for those on a renal diet. Additionally, fortified diets were not prepared or served to residents needing increased caloric intake. These deficiencies were confirmed through interviews with staff and a review of facility policies.
The facility failed to maintain safe food storage and dishwashing practices. Unlabeled and uncovered frozen food items were found in the freezer, and a dietary aide did not wash hands or change gloves between handling soiled and clean dishes. Additionally, the dishwashing machine was initially using an inadequate concentration of chlorine sanitizer, risking foodborne illness for residents.
A facility failed to follow its antibiotic stewardship program by not monitoring a resident's long-term use of Neomycin for hepatic encephalopathy. The IPN did not review the resident's antibiotic use since readmission, and there was no documentation of clinical indication or monitoring for adverse reactions, contrary to the facility's policy.
The facility was found to be non-compliant with federal regulations by housing six residents in rooms two and three, exceeding the maximum of four residents per room. Although there was space for necessary equipment, the arrangement did not meet regulatory standards. A waiver acknowledged the non-compliance but claimed adequate space for care.
The facility did not provide evidence of the Infection Prevention Nurse completing the required 10 hours of annual continuing education in Infection Prevention and Control. The IPN confirmed she had not completed this education since her initial training in 2023, contrary to the guidelines outlined in the California Department of Public Health's All Facilities Letter 20-84.
A resident with intact cognition and independence was observed self-administering medications without an IDT assessment or physician's order, contrary to facility policy. Interviews with staff confirmed the lack of necessary assessments and orders, highlighting a deficiency in ensuring safe self-administration of medications.
A facility failed to update a resident's medical records to include an advance directive, despite the resident's fluctuating decision-making capacity and existing diagnoses of major depressive disorder, dementia, and hypertension. The Social Service Director admitted that although the resident's family was contacted, the advance directive was not obtained and included in the medical record, contrary to facility policy.
The facility failed to reassess the PASRR for two residents with mental health diagnoses, leading to incorrect screenings that did not reflect their conditions. One resident had major depressive disorder, anxiety disorder, and PTSD, while another had bipolar disorder and was on Lithium Carbonate. The PASRR screenings inaccurately indicated no serious mental illness, risking inadequate care.
A resident with insomnia did not receive their prescribed Restoril medication due to a failure in the facility's pharmaceutical services. Despite a new order for a reduced dosage, the medication was not available, as confirmed by a Registered Nurse Supervisor. The facility's policy requires medications to be available the same day they are ordered, which was not adhered to in this case.
A resident with bipolar disorder had a high lithium level lab result that was not communicated to the physician for five days, contrary to facility policy requiring immediate notification of abnormal results.
A resident with complex medical needs was not provided with a peanut butter and jelly sandwich as ordered by their doctor during snack time. Instead, the resident was given yogurt, despite their requests and dietary orders. Interviews with staff revealed a communication breakdown and failure to adhere to dietary orders, resulting in the resident's dissatisfaction and potential nutritional impact.
A resident on a mechanical soft diet received a quesadilla that was not prepared to meet their dietary needs, as it had dry, crispy edges and was not chopped. The resident, who had missing teeth, was unable to eat the meal and expressed dissatisfaction. The dietary staff acknowledged the meal should have been softer and chopped, and the facility's policies on diet preparation were not followed.
The facility failed to revise a resident's care plan to include necessary fall risk interventions and did not involve the resident's Responsible Party (RP) in the care planning process. Despite the resident's history of falls and cognitive impairments, the care plan was not updated following an unwitnessed fall. This oversight was confirmed by multiple staff members, and the facility's policies for fall risk assessment and care planning were not followed.
A resident with a history of multiple falls and severe cognitive impairment was left unsupervised in the dining room, resulting in an unwitnessed fall. Despite the resident's need for constant supervision, the facility lacked a system to designate staff responsibility for supervision, leading to the incident.
The facility failed to ensure there were enough bath and shower towels for 50 residents, leading to hygiene and infection control issues. Multiple staff members confirmed the shortage, and the DON verified the absence of towels, acknowledging the impact on resident care. The Administrator admitted responsibility and stated that more towels would be ordered.
Failure to Initiate Change of Condition and Pain Assessment for Resident with Skin Injuries
Penalty
Summary
The facility failed to initiate a change of condition (COC) process and conduct a pain assessment for a resident who was found with a skin tear and unknown skin discoloration. The resident, who had diagnoses including dementia, muscle wasting, and Type 2 diabetes, was found with a left forearm skin tear and multiple discolorations on the right upper extremity following an incident involving another resident. Documentation showed that while the physician was notified and the care plan updated, a formal COC was not initiated at the time the new skin discoloration was identified, and a pain assessment was not performed when the skin tear was first observed. Interviews with nursing staff and the Director of Nursing (DON) confirmed that a COC should have been initiated when the skin discoloration was first noted, and a pain assessment should have been completed when the skin tear occurred. The facility's policies require that any change from baseline, such as new skin findings, be documented through a COC process, including ongoing monitoring and pain assessment. The lack of timely COC initiation and pain assessment resulted in the resident not being properly monitored for changes in condition, as required by facility policy.
Neglect Leads to Resident's Death Due to Inadequate Monitoring and Emergency Response
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident's death. The resident, who had a history of COPD, ESRD, CHF, and Type II Diabetes Mellitus, was admitted to the facility and was supposed to have vital signs monitored every shift for 72 hours. However, the licensed nurses did not conduct timely assessments or monitor the resident's vital signs when the resident developed breathing difficulties. Despite being informed by a CNA that the resident was gasping for air, the LVN did not assess the resident or take vital signs, leading to the resident becoming unresponsive and eventually being pronounced dead by paramedics. The RN noted that the resident had an out-of-range oxygen saturation level and was weak, but failed to notify the physician or ensure the resident wore a LifeVest, which was crucial given the resident's risk for sudden cardiac arrest. The RN also did not document any vital signs or assessments after the resident's admission, which was a direct violation of the physician's orders. The LVN, upon being informed of the resident's condition, did not perform an assessment or take any vital signs, and when the resident was found unresponsive, the LVN failed to initiate proper CPR procedures or call a Code Blue. Interviews with staff revealed that the LVN did not follow protocol for emergency situations, such as using the crash cart or providing rescue breaths. The facility's policies on abuse prevention, change of condition notification, and CPR were not adhered to, resulting in the neglect of the resident's care needs. The lack of timely assessments and failure to follow emergency procedures directly contributed to the resident's death.
Removal Plan
- The DON provided RN 1 with a one-to-one in-service regarding responsibilities of a licensed nurse when assessment findings are outside the normal range. The in-service emphasized the importance of monitoring and reassessing the resident to determine the effectiveness of interventions and the resident's response to the interventions.
- LVN 1 was sent home on an administrative leave pending the results of the facility's investigation of the allegation.
- The facility has 48 residents in-house. All residents have the potential to be affected by the same deficient practice.
- The DON reviewed changes in condition to ensure that the residents were assessed timely and appropriately. There were four residents with changes in condition. Licensed nurses assessed the residents timely and appropriately.
- The Administrator and Director of Staff Development (DSD) provided an in-service to facility's employees regarding the facility's policy on Abuse and Neglect Prohibition. The in-service emphasized the following: a. Different types of abuse, including neglect. b. The definition and examples of neglect. c. The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- The facility staff were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 6 out of 6. Staff who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- All new hires will be provided with an in-service and post-test by the Director of Staff Development (DSD) regarding the facility's policy on Abuse and Neglect Prohibition. Staff who don't pass will be asked to attend the in-service and take the post-test again. The in-service will address the following: a) Different types of abuse, including neglect; b) The definition and examples of neglect; c) The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- The Administrator or designee will provide Abuse and Neglect Prevention in-service to staff quarterly for 1 year and twice a year thereafter.
- The DON and Nurse Consultant provided an in-service to RNs and LVNs regarding managing changes of condition. The in-service emphasized the following points: a) Conducting timely assessments, including vital signs, of a resident who has a change in condition; b) Notifying the physician of changes in condition; c) Monitoring the resident's condition; d) Reassessing the resident to determine the resident's response and the effectiveness of the interventions.
- The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON will provide training on managing changes in condition for all newly hired licensed nurses.
- The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately.
- The Medical Records Director will audit changes in condition daily, from Monday through Friday, to ensure that the medical provider was notified of changes in condition. Changes in condition that occur on the weekend will be audited the following Monday. Findings will be reported to the DON for follow-up.
- The DSD will report the number of new hires for the month and if the abuse in-service training was provided for them to the Quality Assessment and Assurance Committee during the Quality Assurance Performance improvement meeting monthly for three months.
- The DON will report findings and trends from the change in condition review to the QAA Committee during the QAPI meeting monthly for three months.
- The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months.
Failure to Provide Timely CPR to Full Code Resident
Penalty
Summary
The facility failed to provide timely and appropriate basic life support, including CPR, to a resident with a Full Code status who was found unresponsive. The resident, who had a history of chronic obstructive pulmonary disease, end-stage renal disease, congestive heart failure, and type II diabetes mellitus, was admitted to the facility and later found unresponsive. Despite the resident's Full Code status, indicating a desire for all life-saving measures, the facility staff did not initiate CPR immediately upon discovering the resident's condition. The Licensed Vocational Nurse (LVN) on duty did not announce a Code Blue or provide immediate resuscitation efforts. Instead, the LVN left the resident to call 911, during which time the Certified Nursing Assistants (CNAs) attempted chest compressions without providing rescue breaths or using an Ambu-bag. The facility's policy and procedure for cardiopulmonary resuscitation, which aligns with the American Heart Association guidelines, was not followed, resulting in a delay in life-saving measures. Interviews with staff revealed a lack of coordination and adherence to emergency protocols. The LVN did not perform CPR, and the CNAs stopped chest compressions before the paramedics arrived. The facility's failure to implement its policy and procedure for CPR and Code Blue announcements contributed to the delay in providing necessary life-saving interventions, ultimately resulting in the resident's death.
Removal Plan
- A BLS certified instructor provided BLS training to licensed nurses and CNAs. The training consisted of in person instructions on when to initiate CPR and how to perform the CPR correctly according to the American Heart Association guidelines, and skills demonstration of the proper CPR procedure.
- The DON and the Nurse Consultant conducted a Code Blue drill for nursing staff to simulate a medical emergency. The drill emphasized the staff's responsibility to respond to a medical emergency, the various roles and responsibilities of the staff when responding to a medical emergency, how to operate emergency equipment found in the crash cart, including the Ambu-bag and cardiac board. Nursing staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON and Nurse Consultant will conduct a Code Blue drill for nursing staff quarterly for one year and then annually thereafter.
- The DON and Nurse Consultant provided an in-service to Registered Nurses and LVNs regarding managing changes of condition. The in-service emphasized the following points: Conducting timely assessments, including vital signs, of a resident who has a change in condition; Notifying the physician of changes in condition; Monitoring the resident's condition; Reassessing the resident to determine the resident's response and the effectiveness of the interventions; Initiating CPR promptly when the resident is not breathing and/or does not have a pulse. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave will be provided the in-service and post-test upon their return to work.
- The DON will review changes in condition daily to ensure that prompt resident assessment was conducted in response to the change in condition. Findings will be corrected immediately.
- The DON will report findings and trends from the change in condition review to the Quality Assessment and Assurance Committee during the Quality Assurance Performance improvement meeting monthly for three months.
- The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement its Water Management Plan, which is designed to identify hazardous conditions and minimize the growth and spread of bacteria, including Legionella. During an interview and record review, it was found that there was no documented water management plan, and the Infection Prevention Nurse (IPN) confirmed that the water management assessment had not been completed. The IPN acknowledged the necessity of completing the assessment to prevent microbial growth. Additionally, the facility's policy and procedure on Legionella, implemented in February 2024, indicated that the facility should follow CDC guidance and complete a risk assessment to develop a water management plan. The policy also stated that the facility would contract with experts to assist in this development, considering both internal and external factors that may contribute to Legionella growth.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which could potentially place staff and residents at risk for serious outcomes such as hospitalization due to COVID-19. During an interview and record review with the Infection Prevention Nurse (IPN), it was revealed that the facility's employee records from 2024 to 2025 did not include the COVID-19 immunization status of physicians and consultants. The IPN admitted to not knowing that she was required to obtain this information. Additionally, the facility's policy and procedure on COVID-19 vaccination, implemented in February 2024, indicated that the facility was responsible for educating and offering COVID-19 vaccinations to all facility staff and consultants, which includes all paid and unpaid individuals working in indoor settings where care is provided to residents or who have resident access for any purpose.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident rooms, affecting 17 out of 19 resident rooms. The deficiency was identified during an observation conducted on January 14, 2025, where rooms with two, three, and six beds were found to have inadequate space per resident. Despite the presence of side tables, chairs, and wheelchairs, the rooms did not meet the regulatory requirements of 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The facility had previously submitted a room size waiver in January 2024, indicating that there was ample room to accommodate residents and ensure their health and safety. The survey, conducted from January 13 to January 18, 2025, did not observe any adverse effects related to the adequacy of space for nursing care, comfort, and privacy of the residents. The rooms were noted to have sufficient space to accommodate wheelchairs, beds, and other medical equipment, allowing for mobility and locomotion of residents. However, the square footage in several rooms, such as Room 2 with six beds at 470 square feet and Room 3 with six beds at 426 square feet, did not meet the minimum requirements of 480 square feet for six-bed rooms, 160 square feet for two-bed rooms, and 240 square feet for three-bed rooms.
Failure to Prevent Pressure Injuries in a Resident
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was assessed at moderate risk for skin injury. The resident, who had intact skin upon admission, developed multiple pressure injuries over time, including a Stage II pressure injury on the sacrum, an open area on the buttocks, and another Stage II pressure injury on the coccyx. These injuries were attributed to the facility's failure to implement the resident's care plan intervention to turn and reposition the resident as needed, as well as the failure to adhere to the facility's wound management policy. The resident's medical history included dementia, osteoporosis, type 2 diabetes, and mild protein-calorie malnutrition, which increased their risk for pressure injuries. The Minimum Data Set (MDS) indicated the resident required substantial assistance with daily activities and was dependent on staff for repositioning. Despite these needs, there was no documented evidence that the resident was turned and repositioned regularly, as confirmed by interviews with staff and review of the resident's care records. The facility's policy required minimizing pressure on wounds and notifying the Interdisciplinary Team (IDT) to discuss new interventions for recurring or worsening pressure ulcers. However, the IDT did not meet to discuss new interventions for the resident's recurring pressure ulcers, and there was no documentation of regular repositioning. This lack of adherence to the care plan and facility policies resulted in preventable pressure injuries for the resident.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident missed scheduled dialysis sessions on two consecutive days due to a rescheduling by the dialysis center and a subsequent refusal to attend the makeup session. The facility did not notify the physician of the missed sessions, assess the resident for potential complications, monitor the resident for symptoms such as shortness of breath or respiratory distress, or educate the resident on the risks associated with missing dialysis. Additionally, the facility did not complete the necessary pre-assessment and communication documentation before sending the resident to dialysis on a previous occasion. The Dialysis Transfer Information form, which is used to communicate the resident's status between the facility and the dialysis center, was left incomplete. This lack of documentation and communication could have impacted the continuity of care for the resident.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for Resident 22, who had the capacity to understand and make decisions. Despite this, consents for Seroquel and Mirtazapine were signed by a family member instead of the resident, and no consent was obtained for Ativan. This oversight was confirmed during an interview with an LVN, who acknowledged that the resident should have signed the consents. The facility also did not conduct Gradual Dose Reductions (GDR) for three residents on psychotropic medications. Resident 41, with intact cognition, had not undergone a GDR for Sertraline and Trazadone, which was overdue. Similarly, Resident 18, with mild cognitive impairment, had not had a GDR for Aripiprazole and Mirtazapine since the last evaluation. The Director of Nursing emphasized the importance of monthly GDR attempts to ensure medication appropriateness and effectiveness. Additionally, the facility failed to monitor Resident 44 for signs of lithium toxicity adequately. The MAR indicated signs of toxicity on specific dates, but the symptoms were not detailed, and there was no clarification with the doctor. Furthermore, Resident 42 experienced a therapeutic duplication of BPH medications, which was not addressed promptly despite a pharmacist's recommendation to discontinue one of the medications. This was confirmed by an RN who acknowledged the delay in discontinuing the medication.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to administer medications appropriately for a resident, resulting in a medication error rate of 7.69 percent. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered Anastrozole to a resident without using gloves, despite the medication label indicating that gloves should be used. Additionally, the resident was found with a lidocaine patch still on their chest, which should have been removed the previous night according to the medication order. The LVN acknowledged the oversight and stated that the patch should have been removed as per the instructions. The resident involved was admitted with a diagnosis of malignant neoplasm of the breasts and required substantial assistance with daily activities. The facility's policy on medication administration, effective since 2017, mandates that medications be administered as prescribed and in accordance with good nursing principles. The Director of Nursing confirmed that medications should be administered as ordered, highlighting the deviation from the facility's established procedures in this instance.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that medications for one resident were stored securely and that the medication refrigerator maintained the appropriate temperature range. During an observation, it was noted that the medication refrigerator had a temperature reading of 48 degrees Fahrenheit, which is outside the acceptable range of 30 to 46 degrees. This discrepancy was confirmed by the Director of Staff Development, who acknowledged the improper temperature. Additionally, a resident was observed self-administering medications, including artificial tears, an inhalation aerosol powder, and nasal solutions, and storing them at their bedside in their luggage. This was confirmed by a Licensed Vocational Nurse, who stated that the medications were in the resident's safekeeping. However, a Registered Nurse Supervisor later indicated that these medications should have been stored in the medication cart for safekeeping, highlighting a failure in proper medication storage practices.
Failure to Follow Dietary Guidelines and Fortified Diets
Penalty
Summary
The facility failed to adhere to the prescribed food production recipes and fortified diet guidelines during lunch preparation and tray line observation. Specifically, the cook used a smaller scoop size to serve pureed fish to residents on a pureed diet, resulting in 10 residents receiving 3 ounces instead of the required 4 ounces per menu. Additionally, three residents on a renal diet were served peas instead of the green beans specified in the menu. These actions were confirmed during an interview with the cook and dietary supervisor, where the cook acknowledged the mistake in scoop size and menu adherence. Furthermore, the facility did not prepare or serve fortified diets to residents who required them. During the tray line observation, the dietary aide failed to communicate the fortified diet orders written on the meal tickets, and the cook did not add the necessary additional food items per the fortified menu. This oversight was confirmed during interviews with the cook, dietary aide, and infection prevention nurse, who noted that fortified diets are crucial for residents experiencing weight loss. The facility's policies, including the Menu Planning Policy and Fortification of Food Policy, were not followed. These policies require that all menu changes be documented and that fortified diets be prepared to increase calorie and protein intake for residents in need. The registered dietitian confirmed the importance of fortified diets in preventing weight loss, highlighting the facility's failure to meet the nutritional needs of its residents as per established guidelines.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. One open bag of frozen pepperoni and a large plastic bag of diced chicken were stored in the freezer without an open date or label, and a bag of frozen chicken thighs was stored uncovered, leading to freezer burn. The Dietary Supervisor (DS) acknowledged that the pepperoni and chicken should have been labeled and dated according to facility policy and the U.S. Food and Drug Administration Food Code. In the dishwashing area, a Dietary Aide (DA1) was observed not washing hands and changing gloves after handling soiled dishes and before touching clean dishes. This action was contrary to the facility's handwashing and glove use policies, which require handwashing and glove changes when moving from a contaminated task to a clean one. The DS confirmed that DA1's actions could lead to contamination of clean dishes, potentially causing foodborne illness among residents. Additionally, the dishwashing machine was found to be using an inadequate concentration of chlorine sanitizer, below the recommended 50-100 parts per million (PPM). The DS initially believed the machine was functioning correctly, but upon testing, the sanitizer level was found to be less than 50 PPM. The DS then changed the sanitizer bucket and retested the solution, which eventually showed an effective level of 50 PPM. However, the initial inadequacy in sanitizer concentration meant that dishes were not properly sanitized, posing a risk of foodborne illness to residents.
Failure to Monitor Antibiotic Use in Resident
Penalty
Summary
The facility failed to implement its protocol for an antibiotic stewardship program by not monitoring the side effects and addressing antibiotic use for a resident. The resident was admitted with a diagnosis including hepatic encephalopathy and was prescribed Neomycin Sulfate Oral Tablet, an antibiotic, for this condition. However, the facility's antibiotic stewardship binder did not include documentation of the resident's Neomycin use from November 2024 to January 2025. The Infection Prevention Nurse (IPN) admitted to not reviewing the resident's Neomycin use since the initial readmission and acknowledged the absence of documented evidence for the clinical indication of long-term Neomycin use. Additionally, there was no documented evidence of monitoring for adverse reactions related to the resident's long-term use of Neomycin. The facility's policy and procedure for the Antibiotic Stewardship Program, dated February 2024, emphasized promoting appropriate antibiotic use and reducing adverse events. Despite this, the facility did not adhere to its own policy, as evidenced by the lack of documentation and monitoring for the resident's antibiotic treatment, which could potentially lead to inappropriate antibiotic use and adverse reactions.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with federal regulations by accommodating more than the allowed number of residents in certain rooms. Specifically, during an observation, it was noted that rooms two and three each housed six residents, exceeding the maximum of four residents per room as stipulated by federal guidelines. Despite the presence of space for wheelchairs, beds, and bedside tables, this arrangement did not meet the regulatory requirements. A waiver submitted by the administrator acknowledged that these rooms did not comply with the four-resident limit but claimed that there was sufficient space to provide care without compromising the residents' health and safety.
Infection Prevention Nurse Lacks Required Continuing Education
Penalty
Summary
The facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the Infection Prevention Nurse (IPN). During an interview, the IPN stated she did not complete the required annual 10 hours of continuing education in IPC after her initial training in 2023. A review of the California Department of Public Health All Facilities Letter (AFL) 20-84 indicated that ongoing education in IPC is necessary for infection preventionists to remain informed about new information, trends, and best practices. The AFL specifies that the IP should complete 10 hours of continuing education in IPC annually, and facilities should support IP staff in staying updated through recognized infection prevention and control associations.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to assess a resident's capability to self-administer medications, which is a requirement according to the facility's policy. The resident, who was admitted with diagnoses including allergic rhinitis and asthma, was observed self-administering various medications such as artificial tears, Fluticasone Salmeterol inhalation, Ipratropium Bromide nasal solution, and sodium chloride nasal solution. Despite the resident's intact cognition and independence in self-administering these medications, there was no documented assessment by the IDT or a physician's order permitting the resident to self-administer medications. During interviews, both a Licensed Vocational Nurse and a Registered Nurse Supervisor confirmed that the resident had been self-administering medications without the necessary assessments and orders. The Director of Nursing reiterated that self-administration of medications is only allowed if a physician orders it and the IDT assesses the resident's capability. The facility's policy requires that the results of such assessments be recorded in the resident's medical record, which was not done in this case.
Failure to Document Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect the presence of an advance directive, which is a written statement of a person's wishes regarding medical treatment. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including major depressive disorder, dementia, and hypertension. The resident's history and physical indicated fluctuating capacity to understand and make decisions, while the Minimum Data Set showed intact cognitive skills and varying levels of assistance required for activities of daily living. The Social Service Director (SSD) acknowledged that although the resident's family was contacted about the advance directive upon admission, a copy was not obtained and included in the resident's medical record. The facility's policy requires that a copy of the advance directive be obtained and included in the medical record upon admission. The absence of this documentation had the potential to cause conflict with the resident's healthcare wishes.
Failure to Reassess PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) assessments for two residents, Resident 39 and Resident 44, were reassessed to determine the facility's ability to meet their special needs. Resident 39 was admitted with diagnoses including major depressive disorder, anxiety disorder, and PTSD. Despite these diagnoses, the PASRR Level I screening incorrectly indicated that Resident 39 did not have a serious mental illness. The Minimum Data Set Coordinator (MDSC) acknowledged this discrepancy during an interview, noting that the PASRR is crucial for identifying residents who may require follow-up care. Resident 44 was admitted with diagnoses including bipolar disorder, alcohol abuse, and adult failure to thrive. The PASRR Level I screening for Resident 44 also failed to indicate a serious mental illness, despite the resident's diagnosis of bipolar disorder and treatment with Lithium Carbonate. The MDSC confirmed that the PASRR was not filled out correctly, which could lead to the resident not receiving the necessary care. The facility's policy and procedure for PASRR, dated February 9, 2024, states that all facility applicants should be screened for mental illness and/or intellectual disability. However, the failure to reassess the PASRR for these residents placed them at risk of not receiving the necessary care and services they need, as the screenings did not accurately reflect their mental health conditions.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medication, Restoril, was available as prescribed. The resident, who was admitted with a diagnosis of insomnia, had their Restoril dosage reduced from 30 mg to 15 mg on January 11, 2025. However, during a resident council meeting on January 14, 2025, the resident reported that they had been waiting for their medication for a couple of days. An observation and interview with a Registered Nurse Supervisor confirmed that the medication was not available in the medication cart, despite a new order for the reduced dosage being present in the system. The Director of Nursing acknowledged that ordered medications should be available for residents. The facility's policy and procedure, effective since April 2008, mandates that pharmaceutical services should be reliable and available 24/7, with medication orders being fulfilled on the same day they are placed. This deficiency in pharmaceutical services had the potential to negatively impact the resident's health due to the lack of sleep medication.
Delayed Notification of Abnormal Lab Result
Penalty
Summary
The facility failed to inform the physician about an abnormal laboratory result in a timely manner for a resident, which placed the resident at risk for delayed treatment. The resident, who was admitted with diagnoses including bipolar disorder, alcohol abuse, and adult failure to thrive, had a lithium level blood test ordered and completed. The lab results, indicating a high lithium level, were collected and received on the same day, but the physician was not notified until five days later. Interviews with nursing staff revealed that the facility's policy requires abnormal lab results to be reported to the physician immediately. However, the delay in notifying the physician about the high lithium level was not in accordance with this policy. The facility's policies on laboratory services and the responsibilities of licensed vocational nurses emphasize the importance of timely communication of abnormal test results to the ordering practitioner.
Failure to Provide Ordered Snack to Resident
Penalty
Summary
The facility failed to provide a resident with a peanut butter and jelly sandwich as requested during snack time, which was part of the resident's dietary orders. The resident, who has a history of malignant neoplasm, anemia, and congestive heart failure, was dependent on staff for assistance with eating. Despite the resident's request and the doctor's order for a specific snack, the resident was repeatedly given yogurt instead. Interviews with staff revealed a breakdown in communication and adherence to dietary orders. The Certified Nurse Assistant and Dietary Aide both provided the resident with yogurt, as it was listed on the nourishment list, but failed to provide the peanut butter and jelly sandwich as ordered. The Dietary Supervisor admitted to missing the order, and the Licensed Vocational Nurse acknowledged the oversight in checking the diet against medical records. The Director of Nursing confirmed that there was a communication lapse between the speech therapist, dietary staff, and nursing staff, resulting in the resident not receiving the ordered snack. The facility's policies on food preferences and nourishment were not followed, leading to the resident's dissatisfaction and potential impact on their nutritional intake.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a meal that met the dietary needs of a resident on a mechanical soft diet. The resident, who had been admitted with conditions including chronic obstructive pulmonary disease and dysphagia, received a quesadilla that was not prepared according to their dietary requirements. The quesadilla had dry, crispy edges and was not chopped, making it difficult for the resident, who had missing teeth, to consume. The resident expressed dissatisfaction with the meal, stating it was overcooked and dry, and requested not to receive quesadillas in the future. The dietary staff, including the cook and the registered dietitian, acknowledged that the quesadilla should have been prepared softer and chopped to meet the mechanical soft diet requirements. The cook did not use a standardized recipe, which contributed to the inappropriate texture of the meal. Additionally, the quesadilla was not fortified as required by the resident's diet order, which called for extra caloric content. The facility's policies on mechanical soft diets and menu planning were not followed, leading to the resident's meal dissatisfaction and potential health risks.
Failure to Revise Care Plan and Include Responsible Party
Penalty
Summary
The facility failed to ensure that Resident 2's care plan was revised to include interventions to reduce the resident's fall risk, such as direct line of sight supervision while the resident was awake. Despite the resident's history of falls and cognitive impairments, the care plan was not updated following an unwitnessed fall on 5/14/2024. The IDT meeting held on 5/15/2024 discussed necessary interventions, but these were not incorporated into the care plan. Additionally, the resident's Responsible Party (RP) was not included in the care planning process during the IDT meeting, violating the resident's and RP's rights to be involved in the care planning process. Resident 2 was admitted with diagnoses including overactive bladder and major depressive disorder with severe psychotic symptoms. The Minimum Data Set (MDS) indicated that Resident 2 had severely impaired cognitive skills and required supervision for various activities. Despite these needs, the care plan did not reflect the necessary interventions discussed in the IDT meeting, such as direct line of sight supervision. This oversight was confirmed by the Infection Preventionist Nurse (IPN), Director of Rehabilitation (DOR), and Director of Nursing (DON), who all acknowledged that the care plan was not updated appropriately. The facility's policies and procedures for fall risk assessment, response to falls, and care planning were not followed. The policies indicated that the IDT team should review and modify the care plan as needed and that the resident and their family should be involved in the care planning process. The failure to revise the care plan and include the RP in the IDT meeting led to the resident's unwitnessed fall and could result in further falls and injuries. The DON confirmed that the facility did not notify the RP of the IDT meeting, violating the resident's rights.
Failure to Supervise Resident with History of Falls
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of multiple falls, resulting in an unwitnessed fall. Resident 2, who was admitted with diagnoses including overactive bladder and major depressive disorder with severe psychotic symptoms, had severely impaired cognitive skills and required supervision for various activities, including transfers and ambulation. Despite these needs, Resident 2 was left unsupervised in the dining room by CNA 1, leading to an unwitnessed fall on 5/14/2024. Resident 2's history of falls was well-documented, with multiple incidents occurring between 6/30/2023 and 5/30/2024. The Morse Fall Scale Reports indicated that Resident 2 had falls on 7/21/2023, 9/2023, 5/4/2023, and 5/14/2023. On 5/14/2024, an unidentified resident called for help, stating that Resident 2 was on the floor. The SBAR communication form note confirmed that Resident 2 was found on the floor in a sitting position near her wheelchair, having sustained an unwitnessed fall. Interviews with various staff members, including the Infection Preventionist Nurse, Director of Rehabilitation, Registered Nurse 1, and CNA 1, revealed that Resident 2 required constant supervision due to poor safety awareness and frequent attempts to stand up unattended. However, the facility did not have a system in place to designate which staff member was responsible for supervising Resident 2. This lack of a system led to Resident 2 being left unattended in the dining room, resulting in the unwitnessed fall. The facility's policy on fall risk assessment indicated that the environment should be free of accident hazards and that residents should receive adequate supervision to prevent accidents, which was not adhered to in this case.
Towel Shortage in Facility
Penalty
Summary
The facility failed to ensure there were enough bath and shower towels for 50 out of 50 sampled residents. This deficiency was identified through multiple observations, interviews, and record reviews. Resident 2 reported having to wait until the next day to receive towels for bathing, indicating a towel shortage. Central Supply confirmed the lack of towels and mentioned that it sometimes takes more than a day to replenish the supply. The laundry assistant noted that clean towels are delivered by an external company twice a week, but there were no towels available in the facility at the time of observation. Certified Nursing Assistants (CNAs) also confirmed the shortage, stating they had to use personal cleansing wipes or residents' gowns and sheets for hygiene purposes due to the lack of towels. The Director of Nursing (DON) verified the absence of towels on the linen carts and in the linen room, acknowledging that this issue prevents proper resident care and poses an infection risk. The Administrator admitted responsibility for ensuring an adequate supply of towels and stated that more would be ordered moving forward. The facility's policies and procedures for infection prevention and control, as well as laundry services, were reviewed and found to be inadequate in maintaining sufficient quantities of clean linen to meet residents' needs.
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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