Adventist Health Sonora - D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Sonora, California.
- Location
- 179 South Fairview Lane, Sonora, California 95370
- CMS Provider Number
- 555209
- Inspections on file
- 22
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Adventist Health Sonora - D/p Snf during CMS and state inspections, most recent first.
Two residents with dementia and significant cognitive impairment were seated near the nursing station when one, who had documented aggressive behaviors and was on quetiapine for vascular dementia, suddenly rose, approached the other, and struck her in the face with a fist while yelling that she was "the devil." The assaulted resident sustained a cut, bleeding, swollen, and bruised upper lip, reported pain, and later described ongoing fear and nervousness that she might be hit again. Staff and the DON acknowledged that this unprovoked, resident-to-resident altercation met the facility’s own policy definition of physical abuse, and behavior monitoring records showed multiple aggressive episodes for the aggressor without clear documentation of targets or types of aggression, evidencing a failure to protect the victim’s right to be free from abuse.
Several residents were prescribed PRN lorazepam without required stop dates or documented clinical justifications for continued use. Facility leadership and the Medical Director confirmed that orders were open-ended and lacked appropriate physician progress notes, contrary to regulatory requirements for psychotropic medication management.
Surveyors found that food items, including a container of cooking wine and several containers of Tahini paste, were stored past their use-by dates or without proper labeling, and that multiple kitchen cutting boards had deep grooves and stains. The DNS and Registered Dieticians confirmed these practices did not meet professional standards and could result in unsafe food handling.
The facility did not implement its QAPI program to monitor or address PRN psychotropic medication use lacking stop dates or documented rationales, as required by a previous plan of correction. Both the DON and ADM confirmed that these measures were not added to QAPI, and the issue was not addressed, resulting in ongoing deficiencies in documentation and oversight for residents receiving PRN psychotropic medications.
Multiple infection control lapses were observed, including dirty shared bathrooms, improper storage of a used feeding tube syringe by an LPN, and failure by an LPN to perform hand hygiene before and after administering medications to several residents. Staff acknowledged these actions did not meet facility policy or infection prevention standards.
A resident with chewing and swallowing difficulties repeatedly requested to speak with the dietician about her preference for gluten-free gravy with meals, but her requests were not honored or followed up on. Despite documentation of her dietary needs and preferences, there was no direct communication from the dietician, resulting in the resident's concerns about her meals remaining unaddressed.
A resident experienced a delay in receiving an x-ray for a hand injury, with the diagnostic imaging not performed until five days after the initial incident. Despite ongoing pain and swelling, administrative and communication issues between nursing staff and the physician led to the delay, resulting in a late diagnosis of a finger fracture.
The facility failed to ensure safe and sanitary food practices for 59 residents by allowing expired pancake mix and unclean double ovens to be available for use. The expired food and unclean ovens posed risks of foodborne illnesses and cross-contamination.
The facility failed to develop complete baseline care plans within 48 hours of admission for three residents, leading to potential risks for their safety and well-being. The care plans did not address all identified problems, interventions, or goals as required by the facility's policy.
The facility failed to ensure adequate supervision and functioning of safety devices for residents at risk of elopement and other hazards. Wander guards for two residents were not monitored for functionality, the wander guard system at the front gate was non-functional, and the system was not checked monthly. Additionally, residents were left unsupervised in the dining room, posing safety risks.
The facility failed to ensure safe medication monitoring practices for residents on cardiac and blood pressure medications, as well as high-risk blood thinners. Vital signs were not regularly monitored or documented, and no hold parameters were provided for medications. The facility's policies were outdated and not consistently followed, posing a risk to resident safety.
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents. One resident was given quetiapine without proper root cause analysis, and two residents received inappropriate dosage ranges. Additionally, PRN lorazepam was renewed without clinical justification for two residents, leading to unsafe medication practices.
The facility failed to maintain a resident's dignity by not covering their urinary catheter bag in the dining room. The exposed bag was confirmed by an LPN and the DON emphasized the importance of covering such bags for privacy. Facility policies also indicated the need for covering catheter bags to ensure resident dignity.
The facility failed to provide a home-like environment for two residents when their personal items were displayed on each other's side of the room, causing discomfort and confusion. This misplacement was confirmed by staff and acknowledged by the DON as potentially leading to misidentification and incorrect care.
The facility failed to provide a written Notice of Transfer or Discharge to a resident, their representative, and the LTC Ombudsman when the resident was transferred to the ER for severe pain. Interviews confirmed that the facility did not notify the LTC Ombudsman of transfers with an expected return, contrary to policy.
The facility failed to ensure two residents had access to their hearing aids and did not assist in arranging audiologist services. One resident's hearing aids were sent home by a CNA without informing a licensed nurse, and the resident has not worn them since. Another resident, who had previously worn hearing aids, did not receive assistance in obtaining new ones after they were stolen at another facility. The DON confirmed that proper protocols were not followed, potentially impacting the residents' communication and dignity.
The facility failed to provide restorative services for a resident referred to the RNA program by the PT Department. Despite the recommendation, the referral was not relayed, resulting in the resident not receiving necessary services. The resident expressed frustration over not receiving PT, and the RNA could not officially add the resident to the program without the PT referral.
The facility failed to provide proper respiratory care for two residents by not posting oxygen safety signage, not labeling oxygen tubing, and not changing the tubing within the required seven days. This placed the residents at risk for injury and infection.
The facility failed to provide PT as ordered by the physician for a resident with a history of falling, stroke, pain in the left hip, and muscle weakness. Despite being in the facility for two weeks, the resident had not received the initial PT assessment, which was supposed to occur within one week. This failure resulted in the potential for the resident not attaining and maintaining their highest possible level of physical and functional well-being.
The facility failed to ensure safe infection prevention practices, including a nurse carrying a stock bottle of test strips into an isolation room without cleaning it, a resident's urinal not being labeled, and a urinary bag hanging on another resident's walker. These actions could contribute to the spread of infection.
Failure to Protect Resident From Peer Physical Abuse Resulting in Facial Injury and Fear
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with vascular dementia, who had been receiving quetiapine 50 mg three times daily for behaviors including aggression and wandering, was seated near the nursing station on the day of the incident. Progress notes from the prior day documented that this resident became aggressive with staff when they attempted to provide standby assistance during ambulation, but did not document aggression toward other residents. On the day of the event, staff observed this resident rise from a chair by the nursing station, approach another resident who was also seated there, stand in front of the second resident, and unexpectedly strike the second resident in the face with a fist while repeatedly yelling that the other resident was “the devil.” The resident who was struck had diagnoses including depression, dementia, and anxiety, and was severely cognitively impaired per a BIMS score of 03. Immediately after the assault, this resident appeared shocked and quiet, with a facial expression of disbelief, and reported being hit in the face while pointing to the left mouth region. Assessment revealed a cut and bleeding upper lip at the left corner of the mouth, with slight swelling, bruising, and small dots of blood noted on a washcloth. The injured resident later stated that the blow was forceful, caused pain, and resulted in visible blood from the lip injury. The facility’s own documentation characterized this event as the resident becoming a victim of unprovoked and unexpected physical abuse from a peer resident. Interviews with staff and leadership confirmed that the facility recognized the event as abuse under its Abuse and Neglect Prevention and Investigation policy, which defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, including abuse by other residents. The DON acknowledged that the altercation between the two residents met the policy definition of physical abuse and that an injury occurred as a result of the aggressive act. Staff reported that the aggressive resident had been suspicious and paranoid that day but had not previously been physically aggressive toward other residents, and they expressed surprise at the assault. The injured resident later reported ongoing fear and nervousness that the aggressive resident might hit her again, and the DON stated she had not been aware of this continuing emotional distress. The facility’s monitoring documentation showed multiple episodes of aggressive behavior for the aggressive resident around the time of the incident, but it did not specify whether the aggression was directed toward staff or other residents or describe the type of aggression, contributing to the deficiency in protecting residents from abuse. The facility’s policy on Abuse and Neglect Prevention and Investigation, dated 5/7/25, states that residents have the right to be free from verbal, sexual, physical, and mental abuse, and that abuse or neglect of residents by anyone, including other residents, is not condoned. Despite this policy, the aggressive resident was able to physically assault the other resident at the nursing station, resulting in a bleeding lip, swelling, bruising, and pain, as well as fear and anxiety for the victim. The DON confirmed that, by the facility’s own policy definition, the incident constituted physical abuse of one resident by another, demonstrating that the facility failed to ensure the victim’s right to be free from physical abuse was protected.
Failure to Ensure Safe Use and Monitoring of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for five residents who were prescribed PRN lorazepam. Physician orders for these residents did not include required stop dates, resulting in open-ended prescriptions. Additionally, there was no documented clinical justification or rationale in the physician progress notes for the continued use of PRN lorazepam for any of the residents reviewed. The Director of Nursing (DON) and the Administrative Director (ADM) both acknowledged during interviews that the facility was not following regulations regarding PRN psychotropic medications, specifically the requirement for a stop date after 14 days or a documented physician justification for continued use. The review of medical records and medication administration histories for the affected residents showed that lorazepam was ordered on a PRN basis without an end date, and the necessary documentation to justify ongoing use was absent. The DON confirmed these findings during concurrent interviews and record reviews, noting that the orders lacked both stop dates and physician progress notes providing rationale for continued administration. The Medical Director (MD) also acknowledged that the current process involved extending PRN psychotropic orders without documenting a clinical justification in the progress notes, believing that nurse documentation and his signature on the extension sufficed. Facility policies reviewed indicated that chemical restraints, such as psychotropic medications, should only be used when required to treat a resident's symptoms and that the Medical Director is responsible for ensuring compliance with care policies. Despite these policies, the facility's practices did not align with regulatory requirements, as evidenced by the lack of stop dates and clinical justifications for PRN lorazepam orders for the sampled residents.
Deficient Food Storage, Labeling, and Equipment Sanitation
Penalty
Summary
Surveyors observed that the facility failed to store and prepare food in accordance with professional standards for food service, affecting 57 residents who consumed facility-prepared meals. During a kitchen tour, a one-gallon container of cooking wine was found on a dry storage shelf with a use-by date that had already passed. The Director of Nutrition Services (DNS) confirmed that storing food items past their use-by date was not acceptable and acknowledged the potential for contamination if such items were used. Registered Dieticians also affirmed that expired food could spoil and become harmful if consumed. Additionally, four containers of Tahini paste were found in the dry storage room without any manufacturer expiration dates, received dates, open dates, or use-by dates. The DNS confirmed that undated food items did not meet facility standards and stated that the absence of proper labeling could result in the use of food outside safe consumption parameters. The facility's policy and the FDA Food Code both require proper labeling and dating of food items to ensure safety and quality. Surveyors also noted that seven kitchen cutting boards, stored in a clean storage rack, had deep grooves and visible stains. The DNS and Registered Dieticians confirmed that such conditions could harbor bacteria and did not meet sanitation standards. Facility policy and the FDA Food Code require that food-contact surfaces be smooth, free of cracks, and maintained in good repair to prevent contamination. These observations were confirmed through interviews and review of facility policies and federal guidelines.
Failure to Address PRN Psychotropic Medication Use in QAPI Program
Penalty
Summary
The facility failed to utilize its Quality Assurance Performance Improvement (QAPI) program to address the use of PRN psychotropic medications for its residents. Specifically, the facility did not collect data or identify corrective measures for PRN psychotropic medication use that lacked a stop date or a documented rationale for ongoing use in the affected residents' medical records. This deficiency was identified for a census of 57 residents, and the lack of documentation and justification for ongoing PRN psychotropic medication use was confirmed during interviews and record reviews with the Director of Nursing (DON) and the Administrative Director (ADM). The DON confirmed that although the previous survey's plan of correction required PRN psychotropic medication use to be monitored through the QAPI program and reviewed monthly by the pharmacist, these measures were not implemented. The DON and ADM both acknowledged that the corrective actions were not added to the QAPI program as required, and the issue was not addressed due to the committee's focus on other areas. The facility's policy required all deficiencies from previous surveys to be added to QAPI, but this was not followed, resulting in the recurrence of the problem.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement effective infection prevention and control measures for its residents, as evidenced by multiple observations and staff interviews. Shared bathrooms used by several residents were found to have dirty toilets and, in one case, a dirty sink. Staff, including a licensed nurse and the Director of Environmental Services, acknowledged that the presence of moldy rings and unclean surfaces indicated the bathrooms had not been cleaned as expected. Facility policy required daily cleaning and disinfection of resident bathrooms, but observations and staff statements confirmed that this standard was not consistently met. In another instance, a licensed nurse did not properly store a used feeding tube syringe for a resident receiving enteral nutrition. After use, the syringe was washed in a shared bathroom sink and left exposed in an open bin on the resident's side table, rather than being placed back in its original packaging or a sealed bag as required by facility policy. Staff interviews confirmed that the syringe should have been stored in a manner that protected it from environmental contamination between uses, in accordance with infection control protocols. Additionally, a licensed nurse was observed failing to perform hand hygiene before and after administering medications to multiple residents during a medication pass. The nurse did not use hand sanitizer or wash hands between resident contacts, despite facility policy and staff expectations that hand hygiene be performed to prevent cross-contamination. The nurse acknowledged this lapse and stated a preference for handwashing over hand sanitizer, but only washed hands once during the observed medication administration for several residents. The Director of Nursing and Infection Preventionists confirmed that proper hand hygiene was expected at all times during medication administration.
Failure to Honor Resident's Right to Communicate Dietary Preferences
Penalty
Summary
Resident 5's right to a dignified existence and self-determination was not honored when her repeated requests to speak with the dietician regarding her dietary preferences were not addressed. Documentation from Resident Council meetings on three separate occasions showed that Resident 5 asked to see the dietician, but the requests were either referred to other staff or noted as sent to a supervisor, with no evidence that the resident was actually able to communicate with the dietician. During an interview, Resident 5 expressed dissatisfaction with her meals, specifically noting that the meats were very dry and that she preferred to have gravy served separately with each meal, a preference that was not accommodated or discussed with her. Record review indicated that Resident 5 had a history of chewing and swallowing difficulties, requiring a mechanical soft, gluten-free diet, and that her preference for gluten-free gravy was documented. The dietician acknowledged being aware of the request and attempting to find a suitable gravy option, but admitted to not following up or communicating directly with Resident 5 after the initial documentation. This lack of follow-up and communication resulted in Resident 5's dietary preferences not being addressed and her requests not being honored.
Delayed Radiology Services Result in Late Fracture Diagnosis
Penalty
Summary
A resident sustained an injury to the left hand and fourth finger, resulting in swelling, bruising, and pain. Initial orders for ice and splint were obtained, but an x-ray order was not received until three days after the injury. Despite the presence of pain and swelling, the x-ray was not performed until five days after the injury occurred. Documentation shows that the resident continued to experience symptoms, and nursing staff provided pain management and immobilization while awaiting further diagnostic evaluation. Attempts to obtain the x-ray were delayed due to issues with the order not being properly entered or signed by the physician, and the hospital's radiology department did not accept the initial order. The resident was transported to the hospital as an outpatient, but the x-ray could not be completed due to these administrative issues. It was only after further communication between nursing staff and the physician that a new order was obtained, and the resident was sent to the emergency department for the x-ray. Interviews with facility leadership, including the Interim Director of Nursing, Administrative Director, and Director of Nursing, confirmed that the delay in obtaining the x-ray did not meet their expectations for care. The physician acknowledged that he did not consider the injury serious enough to warrant immediate action and expected nursing staff to notify him if the order was not carried out. The delay in providing radiology services resulted in a late diagnosis of a finger fracture, as confirmed by the emergency department's final report.
Expired Food and Unclean Ovens in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food practices for 59 residents by allowing expired food and unclean kitchen equipment to be available for use. During an initial tour of the kitchen, a half-filled pancake mix container was found to be expired, and the Production Supervisor (PS) confirmed that expired food should be discarded to prevent foodborne illnesses. The facility's policy on food storage mandates that all stored food must be properly labeled and dated, and the use-by date should not exceed the manufacturer's recommendation. However, this policy was not followed, posing a risk to the residents' health. Additionally, the double ovens in the kitchen were found to be unclean with cooked-on grease. The PS acknowledged that the ovens were not cleaned to the facility's standards and stated that they were cleaned only as needed, while the Lead Food Services Associate (LFSA) mentioned that the ovens were cleaned weekly. The facility's policy on oven sanitation requires daily cleaning and weekly deep cleaning to prevent fires and odor development. The failure to maintain clean ovens posed a risk of cross-contamination and foodborne illness for the residents.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop baseline care plans for three residents (Resident 309, Resident 310, and Resident 311) within 48 hours of their admission. These care plans were supposed to address resident-specific care needs based on their admission documentation, which indicated potential health care problem areas. However, the care plans created did not include all identified problem areas, interventions, or goals, leading to incomplete and ineffective care planning for these residents. Resident 309 was admitted with multiple health issues, including a speech impairment, vision impairment, hearing impairment, falls in the past thirty days, unsteady gait, ambulation deficit, transfer deficit, weakness, and required assistive devices. Despite these issues being noted in the admission documentation, the initial care plan only mentioned hearing impairment and a urinary foley catheter without listing any interventions or goals. The Minimum Data Set Coordinator (MDSC) and the Administrative Director of Post-Acute Services (AD) confirmed that the care plan was incomplete and did not meet the facility's expectations. Similarly, Resident 310 was admitted with diagnoses including cerebral infarction, unspecified musculoskeletal symptoms, GERD, diabetes, hyperlipidemia, and CVA. The only care plan created for Resident 310 upon admission was for psychotropic medication, and no care plans were made for the other diagnoses within 48 hours. Resident 311, admitted with diastolic heart failure, acute respiratory failure, urinary tract infection, and pain, also had an incomplete care plan that did not address all identified problems, interventions, or goals. The AD confirmed that the care plans for these residents were not completed as required by the facility's policy and procedure, leading to potential risks for the residents' safety and well-being.
Failure to Ensure Adequate Supervision and Functioning Safety Devices
Penalty
Summary
The facility failed to ensure adequate supervision and functioning of safety devices for residents at risk of elopement and other hazards. Specifically, the wander guards for two residents were not monitored for functionality, and the wander guard system at the front gate in Unit 7 was not operational. Additionally, the facility did not check the wander guard system monthly as required, and there was no staff present in the dining room during lunch, posing a risk of choking and other safety hazards for residents. Resident 20, who had a history of dementia and elopement attempts, had a wander guard that was not regularly checked for functionality. Interviews with staff revealed that there was no consistent monitoring of the wander guards, and the Treatment Administration Record did not include instructions for checking the wander guard. Similarly, Resident 40, also diagnosed with dementia, had a wander guard that was not checked for battery functionality on a specified date, as confirmed by the Infection Preventionist and other staff members. The wander guard system at the front gate in Unit 7 was found to be non-functional during testing, and there was no designated person responsible for ensuring its operation. Additionally, the system was not checked monthly as required, with the last inspection being overdue. Furthermore, during an observation, several residents were left unsupervised in the dining room, leading to a situation where one resident's urinary catheter bag was improperly placed on another resident's walker, highlighting the lack of adequate supervision and potential safety risks.
Failure to Ensure Safe Medication Monitoring Practices
Penalty
Summary
The facility failed to ensure safe medication monitoring practices for residents, particularly those on cardiac and blood pressure medications. Resident 28, Resident 11, and Resident 2 were all prescribed medications that could affect their heart rate and blood pressure, but there were no hold parameters or regular monitoring instructions in place. For instance, Resident 28's MAR indicated medications like Carvedilol, Spironolactone, and Furosemide, but only required blood pressure checks once a week, with no slots for documenting heart rate or blood pressure. Historical records showed instances of heart rates below 60 BPM, but no nursing interventions were documented. Similar issues were found with Resident 11 and Resident 2, where vital signs were not regularly monitored or documented, and no hold parameters were provided for their medications. Interviews with nursing staff and the DON revealed a reliance on outdated guidelines and a lack of specific orders from doctors for vital sign monitoring. Additionally, the facility failed to provide adequate monitoring parameters for high-risk medications. Resident 28 was prescribed Apixaban, a blood thinner with a high risk of adverse effects, but the MAR did not include any monitoring parameters to assess or prevent the risk of bleeding. The care plan for Resident 28 mentioned the potential for adverse side effects but only included general instructions to provide medication per orders and assess for adverse effects. Interviews with the DON and the facility's consultant pharmacist indicated that monitoring for blood thinners was done on a case-by-case basis, without standardized protocols. The facility's policies on medication administration and vital sign monitoring were found to be inadequate and not consistently followed. The policy on medication administration did not elaborate on the need for vital sign monitoring without a doctor's order, and the vital sign policy was outdated and not reflective of current practices. The DON acknowledged the need for updated policies and mentioned plans to incorporate monitoring parameters for high-risk drugs with a new electronic medical record system. However, at the time of the survey, these deficiencies in medication monitoring and documentation posed a risk to resident safety.
Failure to Ensure Safe Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents. Resident 209 was administered quetiapine for behaviors such as resistance to care and intrusiveness without a clear root cause analysis or evidence that these behaviors posed harm to the resident or others. The resident's discomfort during care activities, such as bathing, was not adequately addressed through non-pharmacological interventions. Additionally, the facility did not properly document the reasons for the resident's resistance to care or explore alternative methods to meet the resident's needs before resorting to medication. The Director of Nursing acknowledged that the behavior monitoring could have been worded differently and that residents have the right to refuse care. The facility also failed to ensure that the psychotropic drug dosage ranges for Residents 209 and 20 were appropriate for elderly residents with dementia. The consent forms for these medications included dosage ranges that were not tailored to the specific needs of elderly dementia patients. The residents' representatives were not adequately informed about the medication use and dosage ranges. The Director of Nursing admitted that the facility's process for determining dosage ranges was based on a drug reference book and not on age-appropriate guidelines. This oversight led to the administration of potentially inappropriate dosages of quetiapine to these residents. Furthermore, the facility did not provide clinical justification for the prolonged use of PRN lorazepam for Residents 209 and 1. Resident 209's lorazepam was renewed for six months without documentation of non-drug approaches or a clear clinical need. Similarly, Resident 1 was administered lorazepam twice daily along with multiple opioid medications, without proper documentation of the risks and benefits. The facility's Consultant Pharmacist noted the need for a gradual dose reduction, but there was no response from the medical doctor. The facility's policy on psychopharmacologic drug use was not adequately followed, leading to unsafe medication practices and potential harm to the residents.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure Resident 309's right to a dignified existence was honored when the resident's urinary catheter bag was exposed and not placed in a dignity bag while in the dining room. During an observation, it was noted that Resident 309's urinary catheter bag was hanging on a walker and visible to others. Licensed Nurse 7 confirmed that the urinary bag was not in a dignity bag and acknowledged that it should have been covered for privacy. The Director of Nursing also emphasized the importance of covering urinary bags to maintain residents' dignity and privacy. The facility's policies on urinary catheters and resident rights were reviewed and indicated that catheter bags should be covered for privacy and dignity. The Resident Bill of Rights also stated that residents have the right to be treated with respect and dignity, including privacy in the care of personal needs. Despite these policies, the facility did not adhere to them in the case of Resident 309, leading to a deficiency in maintaining the resident's dignity.
Failure to Provide a Home-Like Environment
Penalty
Summary
The facility failed to provide a home-like environment for two residents, Resident 47 and Resident 57, when their personal items were displayed on each other's side of the room. Resident 47, who has dementia, had her roommate's family photos and a birthday poster displayed on her side of the room, while Resident 57's side had items belonging to Resident 47. This situation caused discomfort and confusion for both residents, as evidenced by their statements during interviews. Resident 47 expressed frustration with having to adjust to her roommate's family pictures around her, and Resident 57 was unsure why she had been moved and noted a lack of space for her belongings. The issue was confirmed by a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN), who acknowledged that the residents' belongings were not correctly placed. The Director of Nurses (DON) also confirmed that the misplacement of personal items could lead to misidentification and incorrect care. The facility's policy emphasizes the importance of a safe, functional, and supportive environment that preserves dignity and contributes to a positive self-image, which was not upheld in this instance.
Failure to Notify Resident, Representative, and Ombudsman of Transfer
Penalty
Summary
The facility failed to provide a copy of the written Notice of Transfer or Discharge to the appropriate parties for a resident when the resident, their representative, and the LTC Ombudsman were not notified in writing of the resident's transfer to the emergency room. The resident was transferred to the ER for intractable pain in the left lower abdomen and nausea. Despite the resident initially refusing the transfer, they were eventually sent to the ER due to severe pain. The facility's records did not show that the resident or their representative received a written notice of the transfer, nor was the LTC Ombudsman notified. Interviews with the Admission Coordinator and Medical Records staff confirmed that the facility did not notify the LTC Ombudsman of transfers when a return was expected, which was against the facility's policy. The Director of Nursing also acknowledged that residents and their representatives were not given written notices of transfers and that the LTC Ombudsman should have been notified of all transfers. The facility's policy required informing the resident, family, or representative of the transfer and providing a copy of the Transfer Notice to them and the LTC Ombudsman.
Failure to Ensure Access to Hearing Aids and Audiologist Services
Penalty
Summary
The facility failed to ensure residents had access to their bilateral hearing aids and did not assist in arranging for audiologist referral consult services for two residents. For Resident 311, a CNA asked the resident's wife to take the hearing aids home, and the resident has not worn them since. The CNA did not inform a licensed nurse about the resident's refusal to wear the hearing aids or the decision to send them home. The resident's wife confirmed that the hearing aids helped the resident hear better and expressed a desire for the resident to wear them. The licensed nurse was unaware of the resident's hearing issues and stated that the CNA was responsible for assisting with hearing aids. The Director of Nursing (DON) stated that the protocol was not followed, which could delay proper care and negatively affect the resident's communication and dignity. For Resident 309, the facility did not assist or refer for follow-up auditory services to obtain new hearing aids. The resident's admission assessment indicated hearing impairment, but the initial care plan did not include interventions or goals for this issue. The resident and a family member both stated that the resident had previously worn hearing aids, which were stolen at another facility, and that the facility staff had promised to help obtain new ones. The licensed nurse was aware of the resident's hearing impairment but did not notify other staff. The resident expressed frustration about not being able to hear and stated that the facility had not discussed obtaining new hearing aids with him. The DON confirmed that the care plan should have included follow-up appointments and interventions for the resident's hearing problem. These failures had the potential to impede the residents' ability to maintain or achieve independent functioning, dignity, and well-being due to inadequate hearing during conversations. The DON emphasized that the proper protocol was not followed, which could delay appropriate care and negatively impact the residents' communication abilities and overall socialization.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services for Resident 310, who was referred to the Restorative Nursing Aide (RNA) program by the Physical Therapy (PT) Department on 4/23/24. Despite the recommendation, the referral was not relayed to the skilled nursing facility, resulting in Resident 310 not receiving the necessary restorative services. This oversight was confirmed during interviews and record reviews, where it was found that the RNA binder did not contain the PT referral for Resident 310, and the RNA had not received any paperwork or recommendations for the resident's care. Resident 310, who was admitted to the facility with diagnoses including cerebral infarction due to embolism and unspecified musculoskeletal symptoms, expressed frustration over not receiving the promised physical therapy. The resident had been waiting for PT services since admission and had repeatedly asked staff about it. Despite the RNA's efforts to walk and provide stretch exercises for Resident 310, the resident could not be officially added to the RNA program without the PT referral. Interviews with the Physical Therapist Lead (PTL) and the Administrative Director of Post-Acute Services (AD) revealed that the PT assessment and RNA referral were completed on 4/23/24, but the referral was not transmitted to the RNA binder. The PTL was unaware that Resident 310 was not receiving RNA services and stated that the PT orders and RNA referral should have been included in the RNA binder. The facility's policy indicated that restorative care should be provided to meet each resident's individual needs, but this was not followed in Resident 310's case.
Failure to Ensure Proper Respiratory Care and Oxygen Tubing Management
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two residents. For Resident 311, there was no oxygen safety signage posted outside the room, despite the resident receiving oxygen therapy for acute respiratory failure with hypoxia. This was confirmed by Licensed Nurse 8 and the Director of Nursing, who acknowledged the risk of injury or explosion due to the absence of the signage. Additionally, the facility did not label or change the oxygen tubing within the required seven days for both Resident 311 and Resident 48. Resident 311's oxygen tubing was not labeled with the date of application, and it was confirmed by both Licensed Nurse 8 and the Infection Preventionist that the tubing should be labeled and changed weekly to prevent infection. Similarly, Resident 48's oxygen tubing was found to be outdated and partially lying on the floor, which was confirmed by the Lead Charge Nurse and the Infection Preventionist, who stated that the tubing should be changed immediately if it touches the floor. The Director of Nursing confirmed that the facility's expectation was for oxygen orders to be followed and for the tubing to be labeled with the start date of application. The failure to label and change the oxygen tubing as required placed the residents at risk for infection, as confirmed by the Infection Preventionist and the Director of Nursing.
Failure to Provide Timely Physical Therapy Services
Penalty
Summary
The facility failed to provide Physical Therapy (PT) as ordered by the physician for Resident 309. The physician had ordered PT on 4/26/24, but the services had not been provided by the PT department. Resident 309, who had a history of falling, stroke, pain in the left hip, and muscle weakness, was admitted to the facility and was supposed to receive PT. However, during interviews, both Resident 309 and a family member confirmed that PT had not been initiated. The Physical Therapist Lead (PTL) acknowledged that she had not been able to perform the initial PT assessment for Resident 309, despite the resident being in the facility for two weeks. The PTL stated that the time frame for PT to assess a resident was one week, but this was not met in Resident 309's case. The facility's policy indicated that residents should receive care to achieve and maintain their highest practicable level of physical independence. Licensed Nurse 8 confirmed awareness of the need for PT but stated that they were waiting for the PT assessment before starting Restorative Nurse Aide (RNA) services. The Administrative Director (AD) also stated that the expectation was for a resident to be seen by a Physical Therapist within a week of a doctor's order. The failure to provide timely PT services resulted in the potential for Resident 309 not attaining and maintaining their highest possible level of physical and functional well-being.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to ensure safe infection prevention practices for a census of 60 residents. Licensed Nurse (LN) 8 carried a stock bottle of test strips into an isolation room without cleaning or sanitizing it before and after use. During a medication administration observation, LN 8 placed the supplies, including the test strip bottle, on a bedside counter in an isolation room. When the test strip bottle fell on the floor, LN 8 picked it up and put it in her pants pocket until she exited the room, without cleaning and sanitizing it. The Infection Prevention nurse confirmed that the whole bottle of test strips should not have been taken into the isolation room and that reusable items should be cleaned and sanitized. The facility's policy did not address how to handle the use of test strips or if the test strip bottle should have been cleaned/disinfected if taken inside a resident's room and/or an isolation room. Resident 309's urinal was not labeled with the resident's name or another identifier, and the urinary bag was hanging on another resident's walker. Resident 309, who had a urinary foley catheter, stated that he emptied his urinary catheter bag himself into the urinal and left it hanging off the footboard for staff to empty. The Infection Prevention nurse was not aware that Resident 309 emptied his own urinal and confirmed that the urinal did not have the resident's name or another identifier. The Certified Nurse Assistant (CNA) and LN 8 confirmed that urinals should be labeled with the resident's name and that the urinal was changed weekly or monthly. The risk of not labeling the urinal was that another resident or staff member could accidentally use it, leading to cross-contamination and infection. During an observation, Resident 309's urinary bag was found hanging on another resident's walker while Resident 309 was eating lunch in the dining room. LN 7 confirmed that the urinary bag should not have been placed on another resident's walker due to infection control issues. The Director of Nursing (DON) stated that it was not a clean practice and placed the other resident at risk for a fall. The facility's policy indicated that standard precautions should be followed at all times to reduce the risk of transmission of infectious agents.
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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