Almond Vista Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 2030 Evergreen Avenue, Modesto, California 95350
- CMS Provider Number
- 555118
- Inspections on file
- 30
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Almond Vista Healthcare during CMS and state inspections, most recent first.
A resident with a recent right foot arthrodesis and intact cognition had orders to keep a sterile post-op dressing clean and dry. During a shower, a CNA placed a plastic bag over the foot, but water entered, leaving the dressing soaked; the resident reported the wet dressing remained for several days and was not changed or reinforced by nursing staff. At a follow-up visit, the podiatrist documented soiled, malodorous dressings, erythema, warmth, maceration, and some dehiscence, diagnosed cellulitis, and prescribed oral antibiotics, which were entered as facility orders. Subsequent interviews and record review with an LVN, the treatment nurse, and the DON confirmed there was no comprehensive care plan addressing the foot infection, cellulitis, or antibiotic therapy, despite facility policy requiring person-centered care plans to be developed and revised with changes in condition.
A cognitively intact post‑operative resident with diabetes and recent right foot arthrodesis had a physician order for a sterile surgical dressing to be kept clean and dry, with instructions to notify the physician if there was a problem with the bandage. During a shower, staff used a plastic trash bag and tape to protect the dressing, but water entered the bag, leaving several inches of water and a wet dressing. The resident reported the wet dressing to nursing staff, yet it was not changed or reinforced and remained in place for several days until a podiatry follow‑up, where the dressing was found soiled and malodorous with skin maceration, erythema, warmth, and some dehiscence, and cellulitis was diagnosed and treated with oral abx. There was no documentation that the physician was notified when the dressing became wet, no order to monitor the dressing’s condition, and no care plan addressing the cellulitis or abx use, despite job descriptions and a wound care policy requiring adherence to physician orders and professional standards of nursing practice.
Two residents did not have their care plans updated or revised after significant changes in condition, including post-surgical care for a hip procedure and wound care following a fall with laceration. Staff were unclear on wound care, bathing instructions, and weight-bearing status due to missing information in the care plans, despite physician orders being present elsewhere in the record. The interdisciplinary team did not review or update the care plans as required by facility policy.
A resident at high risk for falls suffered a broken hip after the facility failed to implement a physician-ordered intervention of placing a floor mat beside her bed. Despite a history of falls and severe cognitive impairment, the nursing staff did not follow the care plan, leading to the resident's fall and subsequent hospitalization. The resident's condition worsened, resulting in decreased mobility and placement on hospice care.
A resident with known swallowing difficulties and cognitive impairments was not provided adequate supervision during meals, leading to a choking incident. The resident was admitted with a history of dysphagia and required strict aspiration precautions, but the facility failed to develop a care plan for supervision. The resident choked during dinner, was diagnosed with respiratory failure and aspiration pneumonia, and subsequently died. The facility's SLP did not review hospital evaluations indicating the need for supervision, and the DON acknowledged the lack of a care plan.
The facility did not create and implement a comprehensive Facility Assessment to determine necessary resources for resident care. The 'SNF/NF Capabilities List' from July 2021 was not comprehensive, and the 'Facility Assessment Tool' was updated only after surveyors arrived. The Administrator confirmed the lack of annual assessments for 2020-2023, indicating insufficient planning for resident needs.
The facility did not have a Quality Assurance Performance Improvement (QAPI) plan in place, as required by their policy. This deficiency was confirmed through interviews and document reviews, with the Administrator acknowledging the absence of the plan. The lack of a QAPI plan had the potential to impact all 161 residents in the facility.
The QAPI committee failed to ensure required members attended quarterly meetings, potentially affecting all 161 residents. Facility policies lacked attendance expectations. The Administrator confirmed that meetings should include an Administrator, DON, IP, and MD. However, the MD missed meetings in the third and fourth quarters of 2023, and both the IP and MD were absent in the first quarter of 2024.
The facility failed to provide timely written transfer notices to residents or their representatives before or after hospital transfers. Four residents were transferred without receiving the required documentation, and the Ombudsman was not notified in some cases. Staff interviews revealed a lack of process for issuing written notices during emergent hospitalizations.
The facility failed to provide bed hold notices to five residents transferred to the hospital in emergencies, as required by policy. Despite the facility's guidelines, residents with conditions like sepsis, altered mental status, and catheter issues did not receive written notifications within 24 hours of their transfers. Interviews and record reviews confirmed the absence of these notices, highlighting a significant oversight in the facility's adherence to its bed hold policy.
The facility failed to complete bed hold audits as part of their performance improvement project, potentially affecting residents sent to the hospital. The QAPI Program policy required performance improvement projects, but the facility lacked a QAPI Plan. The DON confirmed a PIP for bed hold notifications, but audits were not conducted. The ADON assumed Medical Records was responsible, and the MRD confirmed incomplete audits. The Administrator was aware of the incomplete audits.
The facility failed to properly issue the SNFABN to two residents who completed therapy or skilled nursing services. The notices lacked clear explanations for Medicare's non-coverage and contained incorrect financial liability dates. Both residents confirmed understanding the notices and chose not to continue therapy. The Social Services Director misunderstood the form's requirements.
Two residents in a facility were improperly subjected to physical restraints without medical orders. One resident was positioned in bed to prevent getting out, with the bed's head down and foot elevated, which staff admitted was to prevent falls. Another resident had a sock and bandage on his hand, restricting movement, with no documented reason or physician's order. Both cases violated the facility's restraint policy, which requires restraints only for medical symptoms and not for staff convenience.
A facility failed to complete a required PASARR Level II assessment for a resident with schizoaffective and bipolar disorders. Despite a positive Level I screening, the facility did not resubmit the screening after the initial Level II evaluation could not be conducted. Interviews revealed a lack of process for ensuring follow-ups, and observations showed the resident exhibiting behaviors consistent with her care plan issues.
The facility failed to include a resident's code status in the baseline care plan, despite having a POLST and DNR order, and did not document the use of side rails for another resident with systemic lupus erythematosus and systemic sclerosis. The omissions were confirmed by the MDS Director and DON.
A resident admitted with COVID-19, type two diabetes, and acute kidney failure did not receive timely care for constipation, going ten days without a bowel movement. The facility delayed initiating the bowel protocol, which should have started after three days, and failed to create a care plan for the issue. Alerts in the EMR were not acted upon, and no constipation policy was provided during the survey.
A resident admitted with COVID-19, diabetes, and acute kidney failure did not receive adequate hydration due to the facility's failure to timely assess fluid needs and monitor intake. Despite being prescribed IV fluids, the care plan set an inadequate fluid intake goal, and health shakes were not documented as consumed. Staff interviews confirmed the delay in nutritional assessment and incorrect care plan goals, contrary to the facility's hydration policy.
A resident received Ativan, an antianxiety medication, on a PRN basis for more than 14 days without a physician's rationale for extending its use and without a specified stop date. The facility's policy requires PRN orders for psychotropic medications to be limited to 14 days unless a physician documents the rationale for extending the use. Interviews with the ADON and DON confirmed the oversight, which increased the risk of adverse reactions.
The facility failed to ensure proper infection control during catheter care for two residents. An LVN did not change gloves appropriately while providing suprapubic catheter care, risking cross-contamination. Another resident's urinary collection bag was found on the floor without a dignity bag, contrary to facility policy, increasing infection risk. These deficiencies were confirmed by staff, including the DON.
Failure to Care Plan for Post-Operative Foot Cellulitis and Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered, comprehensive care plan for a resident who developed cellulitis of a right foot surgical wound and was started on antibiotics. The resident had undergone right foot surgery involving arthrodesis of the 2nd, 3rd, and 4th toes and had orders for the sterile surgical bandages to be kept clean and dry with no bandage change needed, and to notify the physician’s office if there was a problem with the bandage. The resident was cognitively intact per a BIMS score of 15/15 and reported that about a week and a half after surgery, a CNA placed a clear plastic trash bag over the right foot and secured it with tape for a shower, but the tape slid down, allowing water to enter the bag and soak the dressing. The resident stated that after the shower there were about three inches of water in the bag, the dressing was wet, and the nurses did not change or reinforce the wet dressing. The resident reported that the wet dressing remained in place for four to five days until a post-operative visit with the podiatrist. At that visit, the podiatrist documented that the dressings were soiled and malodorous, with some wound dehiscence proximally to the 2nd toe incision, erythema and increased warmth to the dorsal midfoot, and skin maceration. The podiatrist assessed cellulitis and prescribed oral antibiotics. The facility’s Order Summary Report reflected an order for Amoxicillin-Pot Clavulanate 875-125 mg to be given every 12 hours for 14 days for bacterial infection, with the DON and treatment nurse confirming that the antibiotics were started after the post-operative appointment for a bacterial infection/cellulitis of the surgical wound. Despite the new diagnosis of cellulitis and the initiation of antibiotic therapy, interviews and record reviews with the LVN, treatment nurse, and DON showed there was no care plan addressing the resident’s foot infection, cellulitis, or antibiotic use. Both the LVN and treatment nurse were unable to locate any care plan related to the infection or antibiotic treatment, and the DON confirmed that no care plan had been entered for cellulitis or antibiotic use, despite the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives, time frames, and interventions that reflect current standards of practice and are revised as residents’ conditions change. The surveyors concluded that the facility failed to ensure a person-centered comprehensive care plan was implemented for this resident, which had the potential for the resident’s needs to go unmet.
Failure to Maintain and Monitor Post‑Operative Surgical Dressing per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards of practice for a post‑operative resident whose surgical dressing was ordered to be kept clean and dry, with instructions to notify the physician if there was a problem with the bandage. The resident, cognitively intact per a BIMS score of 15/15, had undergone right foot surgery involving arthrodesis of the 2nd, 3rd, and 4th toes and had comorbidities including type 2 diabetes mellitus, orthopedic aftercare needs, and osteoarthritis. The physician’s post‑operative order directed that the sterile surgical bandages be kept clean and dry, that no bandage change was needed, and that the office be notified if there was a problem with the bandage. There was no order in the record to monitor the dressing for cleanliness or dryness, and the DON later stated there was no policy and procedure available for following physician orders or professional standards of practice. The resident reported that approximately a week and a half after surgery, a CNA prepared him for a shower by placing a clear plastic trash bag over his right foot and securing it with tape to keep the dressing dry. During the shower, the tape slid down his leg, allowing water to enter the bag. After the shower, when the resident removed his foot from the bag, he observed about three inches of water in the bottom of the bag and noted that his dressing was wet. The resident stated he notified the nurses that his dressing was wet, but the nurses did not change or reinforce the dressing, and he kept the wet dressing in place for four to five days until his post‑operative visit with the podiatrist. CNA 1 confirmed that the process used to keep a dressing dry during showers was to place a plastic trash bag around the foot and secure it with tape. At the podiatry follow‑up visit, the podiatrist documented that the resident reported he had wet his dressings in the shower the prior Wednesday and did not think they needed to be changed or that it was a serious matter. The podiatrist’s exam noted that the dressings were soiled and malodorous, with some dehiscence proximally to the 2nd toe incision, erythema and increased warmth to the dorsal midfoot, and skin maceration. The podiatrist assessed cellulitis and prescribed oral antibiotics, which were later approved by the attending physician and started at the facility. The treatment nurse and DON both stated that, based on the order to keep the dressing clean and dry, nursing staff should have contacted the physician if the dressing became wet, and the DON acknowledged there were no nurses’ notes indicating whether the bandage became wet during showers and no care plan addressing the cellulitis or antibiotic use. The facility’s LVN and DON job descriptions required adherence to professional standards of nursing practice and physician orders, and the wound care policy referenced reporting information in accordance with facility policy and professional standards of practice, but these standards were not followed when the resident’s wet, soiled surgical dressing was not addressed or reported as ordered. A subsequent office visit note from the podiatrist documented that the resident reported the forefoot dressing had come off and the foot was soaked in water for an unknown period, with persistent swelling and burning between the lesser toes, and that he was taking the prescribed antibiotic. The DON stated she did not have documentation that the dressing became wet in the facility shower and that the resident sometimes refused to allow staff to check his dressing, but also stated that the expectation was for staff to keep extremity dressings dry during showers using plastic wrap secured with tape and to call the physician if the dressing became wet. The professional reference reviewed by surveyors indicated that nurses cannot arbitrarily decide which physician orders to follow and that failing to carry out orders can be grounds for discipline and may be deemed neglect, underscoring that the failure to keep the surgical dressing dry and to notify the physician when it became wet did not meet professional standards of practice.
Failure to Update and Implement Person-Centered Care Plans After Change in Condition
Penalty
Summary
The facility failed to review, revise, and implement person-centered comprehensive care plans for two residents following significant changes in their conditions. For one resident who underwent a left hip hemiarthroplasty, the care plan did not specify the frequency of dressing changes, instructions for bathing with respect to the surgical site, or clarify the resident's weight-bearing status. Interviews with staff revealed a lack of awareness regarding the resident's surgical history and uncertainty about wound care and mobility instructions, despite existing physician orders. The care plan lacked clear guidance, and staff were unable to reference it for necessary care details. Another resident experienced a fall resulting in a laceration above the left eyebrow, which required repair with sutures. The care plan for this resident did not include instructions for wound care of the laceration, even though physician orders specified the wound care regimen and suture removal timeline. Staff interviews and record reviews confirmed that the care plan was not updated to reflect these new care needs after the resident returned from the hospital. Both the Director of Nursing and the Administrator acknowledged that the interdisciplinary team did not update the care plans after the residents returned from the hospital, as required by facility policy. The policy mandates that care plans be reviewed and revised after significant changes in a resident's condition or after hospital readmission. The lack of updated, accessible care plans meant that staff could not easily determine or implement the required care for these residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a resident, who was assessed as a high risk for falls, was free from accident hazards. The resident had a history of falls and a physician's order for a floor mat to prevent injury in the event of a fall. However, the nursing staff did not implement the care plan intervention for the use of the floor mat, which was not placed beside the resident's bed. This oversight led to the resident experiencing a fall from her bed, resulting in a broken left hip and severe pain, necessitating hospitalization and administration of fentanyl for pain management. The resident, who had severe cognitive impairment and was non-ambulatory, attempted to get out of bed unassisted, leading to the fall. The resident's care plan had been revised multiple times to include the use of floor mats, but these were not in place at the time of the fall. Interviews with staff revealed that the floor mats had been removed at some point, and there was no clear understanding among the staff as to why they were not replaced. The Director of Nursing confirmed that the order for the floor mats was never discontinued, indicating a lapse in following the care plan. The resident's condition was further complicated by her medical history, which included senile degeneration of the brain, syncope, and dysarthria. The fall resulted in a significant decline in the resident's mobility and comfort, as she was no longer able to turn herself in bed and was placed on hospice care. The facility's failure to adhere to the care plan and ensure the presence of fall mats directly contributed to the resident's injury and subsequent decline in health.
Failure to Provide Supervision During Meals Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with known swallowing difficulties and cognitive impairments, leading to a choking incident. The resident was admitted from an acute care hospital with a history of dysphagia and required strict aspiration precautions, including supervision during meals. However, the facility did not develop a care plan to address the need for supervision, and the resident was allowed to feed himself unsupervised. On the day of the incident, the resident choked during dinner and was found unresponsive by a CNA. Despite immediate intervention with the Heimlich maneuver and CPR, the resident was transported to an acute care hospital where he was diagnosed with respiratory failure, aspiration pneumonia, severe protein-calorie malnutrition, and chronic kidney disease. The resident subsequently passed away due to these conditions. Interviews with facility staff revealed that the facility's SLP did not obtain or review the hospital's SLP evaluations and recommendations, which indicated the need for supervision during meals. The Director of Nursing acknowledged that a care plan was not developed to address the resident's specific needs during meals, and the Administrator confirmed that the aspiration could have been avoided with proper supervision. The facility's policy required comprehensive, person-centered care plans, which were not implemented in this case.
Failure to Implement Comprehensive Facility Assessment
Penalty
Summary
The facility failed to create and implement a comprehensive Facility Assessment to determine the necessary resources to meet the needs of its residents. The review of the 'SNF/NF Capabilities List' dated July 2021 revealed it was not a comprehensive Facility Assessment. Additionally, the 'Facility Assessment Tool' provided by the facility was updated on July 30, 2024, after the surveyors had already entered the facility. During an interview, the Administrator confirmed that the current Facility Assessment was created after the surveyors' arrival. Furthermore, the Administrator was unable to provide annual Facility Assessments for the years 2020, 2021, 2022, and 2023, indicating a lack of ongoing assessment and planning to ensure resident needs are met.
Absence of QAPI Plan in Facility
Penalty
Summary
The facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) plan, which is essential for driving quality assurance measures. This deficiency was identified through interviews, facility document reviews, and policy reviews. The facility's policy, revised in April 2014, outlined the need for a QAPI plan to guide quality efforts and support QAPI implementation. However, upon review, it was found that the facility did not have a QAPI plan in place. During an interview, the Administrator confirmed the absence of a QAPI plan, which had the potential to affect all 161 residents currently living in the facility.
QAPI Committee Attendance Deficiency
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to ensure the required members attended the quarterly meetings, which had the potential to affect all 161 residents. The facility's policies on QAPI, revised in 2014 and 2020, did not include expectations for attendance at these meetings. During an interview, the Administrator confirmed that the QAPI meetings were held quarterly and should include an Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Medical Director (MD). However, it was confirmed that the MD did not attend the QAPI meetings for the third and fourth quarters of 2023, and neither the IP nor the MD attended the meeting for the first quarter of 2024, despite their required presence.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives before or immediately following transfers to the hospital. This deficiency was identified in four out of five residents reviewed for hospitalization. Resident 99, who was unimpaired in cognition, was transferred to the hospital due to severe infection without receiving a written discharge notice. Although the resident was notified in person, the section for the resident or representative's signature on the notice was left blank. Interviews with staff revealed that there was no process in place for providing written notices for emergent hospitalizations, and the Director of Nursing confirmed that the resident's family was only notified via phone call. Resident 126 was sent to the hospital due to unresponsiveness, but there was no evidence of a written transfer notice provided to the resident or their representative. The Director of Nursing confirmed the absence of a written notice for this hospitalization. Similarly, Resident 68 was transferred to the emergency department for a foley catheter evaluation without any documentation of a transfer/discharge notice being provided to the resident, representative, or Ombudsman. The Director of Nursing confirmed the lack of notification for this resident's hospitalization. Resident 102 was transferred to the emergency department for symptoms including diarrhea and high blood pressure, yet no documentation was found indicating a transfer/discharge notice was provided to the resident or representative. The Director of Nursing confirmed that the required notifications were not made. The facility's policy requires that residents and their representatives receive written notice of transfer or discharge as soon as practicable, and a copy of the notice should be sent to the Ombudsman. However, this policy was not followed in the cases reviewed.
Failure to Provide Bed Hold Notices After Emergency Transfers
Penalty
Summary
The facility failed to provide bed hold notices to five residents who were transferred to the hospital in emergency situations. This deficiency was identified through interviews, record reviews, and policy reviews. The residents involved were R99, R126, R151, R68, and R102, all of whom were transferred to the hospital for various medical reasons, including sepsis, altered mental status, lethargy, catheter issues, and myocardial infarction. Despite the facility's policy requiring written bed hold notices within 24 hours of an emergency transfer, none of these residents received such notices. Resident R99, who was her own responsible party, was transferred to the hospital due to sepsis and septic shock. She confirmed during an interview that she did not receive a bed hold notice at the time of her hospitalization. Similarly, R126 was transferred for altered mental status, and the facility's records showed no evidence of a bed hold notice being issued. The Director of Nursing confirmed the absence of bed hold notices for these residents during interviews. Other residents, including R151, R68, and R102, also did not receive bed hold notices following their hospital transfers. R151 was sent to the emergency department for lethargy and agitation but did not return to the facility. R68 and R102 were hospitalized for catheter issues and gastrointestinal symptoms, respectively, yet neither received the required bed hold notifications. The facility's policy, revised in October 2022, mandates that residents or their representatives receive written information about bed hold policies at least twice, including within 24 hours of an emergency transfer, which was not adhered to in these cases.
Failure to Complete Bed Hold Audits
Penalty
Summary
The facility failed to ensure that bed hold audits were completed as part of their performance improvement project (PIP), which had the potential to affect residents who were emergently sent out to the hospital. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy required performance improvement projects to be initiated when problems were identified, with systematic actions targeted at the root causes of identified problems. However, the facility did not have a QAPI Plan in place, and the bed hold notifications were not being issued to residents or their responsible parties in advance of transfers or within 24 hours if emergent. The Director of Nursing (DON) confirmed that a PIP was in place for ensuring bed hold notifications, but audits were not conducted as required. The Assistant Director of Nursing (ADON) was aware of the PIP but did not conduct audits, assuming it was the responsibility of Medical Records. The Medical Records Director (MRD) began conducting bed hold audits in May 2024 but confirmed that the audits were incomplete. The Administrator was aware that the bed hold audits had not been completed per the facility's current PIP.
Improper Issuance of SNFABN to Medicare Beneficiaries
Penalty
Summary
The facility failed to correctly issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to Medicare Part A beneficiaries, specifically for two residents who had completed therapy or skilled nursing services. For one resident, the SNFABN was issued with an incorrect financial liability start date and lacked a clear explanation of why Medicare would not cover the continued stay. The estimated cost section was filled out, but the reason for Medicare's potential non-payment was not sufficiently detailed to enable the resident to understand the denial. The resident confirmed signing the SNFABN and chose not to continue therapy. For the second resident, the SNFABN was issued with a financial responsibility start date that was incorrect by a year, and the estimated cost was listed as $0.00. The reason Medicare may not pay was similarly vague, lacking a specific explanation of why the resident's medical needs did not meet Medicare coverage guidelines. The resident confirmed understanding the SNFABN and opted not to continue therapy. The Social Services Director was unaware that the SNFABN should provide information related to the end of skilled services, indicating a misunderstanding of the form's completion requirements.
Improper Use of Physical Restraints on Residents
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, which were not ordered for medical treatment. The first resident, R78, was positioned in bed in a manner that prevented him from getting out of bed, which was used as a fall intervention. The bed was positioned with the head down and the foot elevated, with a foam wedge and blanket creating a barrier. Despite R78's requests to sit up and get out of bed, staff members continued to reposition him into a lying position, citing fall risk as the reason for the bed's positioning. This method was not documented in the care plan and was acknowledged by staff and the Director of Nursing as potentially functioning as a restraint. The second resident, R203, was observed with a bandage and sock combination on his left hand and forearm, which he could not remove. This was not ordered by a physician and was not documented in the care plan. Staff members were unaware of the reason for the application, and it was suggested that it might have been used to prevent the resident from accessing his incontinence brief. The Director of Nursing confirmed that such a combination could function as a restraint and should have been accompanied by a physician's order, assessment, and care plan. The facility's policy on the use of restraints specifies that restraints should only be used to treat medical symptoms and not for staff convenience or fall prevention. The policy also states that any device that restricts a resident's ability to change position or place is considered a restraint. In both cases, the use of positioning and the sock/bandage combination were not in compliance with the facility's policy, as they were used without proper documentation, orders, or assessments, and restricted the residents' mobility.
Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a resident, identified as R95, received a Level II assessment as required by the Pre-Admission Screening and Resident Review (PASARR) program. R95, who was admitted and re-admitted to the facility, had primary medical diagnoses of schizoaffective disorder and bipolar disorder. The resident's admission Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic medications. Despite a positive Level I PASARR screening indicating the need for a Level II evaluation, the facility did not resubmit the screening after the initial Level II evaluation could not be conducted due to the resident's inability to participate. The report highlights that the facility did not have a process in place to ensure follow-ups for PASARR screenings were completed. Interviews with the Social Services Director (SSD), Director of Nursing (DON), and Admissions Director (AD) revealed that the facility was not notified of the screening results unless direct contact was made, and the determination letter was not followed up. The PASRR Manager confirmed that the Level I screening was submitted, but the follow-up Level II evaluation was not completed because the available staff could not answer the necessary questions. Observations of R95 showed the resident exhibiting behaviors such as yelling and demanding attention, which were consistent with the issues noted in her care plan. The facility's policy required all new admissions to be screened for mental disorders, and if a Level I screen indicated potential issues, a Level II evaluation should be conducted. However, the facility failed to adhere to this policy, resulting in the deficiency noted in the report.
Deficiencies in Baseline Care Plans for Code Status and Side Rail Use
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed to include the code status for a resident admitted with diagnoses of secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall, who was receiving hospice services. The resident had completed a POLST indicating a preference for no resuscitation, and a physician order for DNR was documented. However, the care plan did not reflect these advance directives or the resident's code status, which was confirmed by the MDS Director during an interview. Additionally, the facility did not include the use of side rails in the baseline care plan for another resident diagnosed with systemic lupus erythematosus and systemic sclerosis. Observations revealed that the resident used bilateral 1/4 side rails for repositioning, and a physician order indicated their use as an enabler for bed mobility. Despite this, the baseline care plan lacked documentation of the side rails being used for positioning, as confirmed by the Director of Nursing.
Failure to Initiate Timely Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide timely care for constipation for Resident 204, who was admitted with diagnoses including COVID-19, type two diabetes mellitus, and acute kidney failure. Despite being cognitively intact and continent of bowel upon admission, Resident 204 did not have a bowel movement for ten days. The bowel protocol, which included administering milk of magnesia (MOM) after three days without a bowel movement, was not initiated until the fifth day. This delay in initiating the bowel protocol was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the protocol should have been started on the third day. The facility's electronic medical record (EMR) system flagged the need to initiate the bowel protocol after three days without a bowel movement, but the floor nurses did not act on these alerts for two days. Additionally, there was no care plan initiated to address the resident's constipation, and the DON confirmed that an episodic care plan should have been opened. The facility did not provide a constipation/bowel policy upon request during the survey, indicating a lack of documented procedures to guide staff in managing such issues.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for one resident, identified as R204, who was at risk for dehydration and weight loss. R204 was admitted with diagnoses including COVID-19, type two diabetes mellitus, and acute kidney failure. Despite being prescribed intravenous fluids twice within the first ten days of admission due to poor nutritional and fluid intake, R204's fluid requirements were not assessed timely. The care plan goal for fluid intake was set at 1000 cc per day, which was inadequate compared to the 2400 ml per day calculated by the Registered Dietitian (RD) on 07/31/24. The facility's records revealed inconsistencies in monitoring and documenting R204's fluid intake. The Medication Administration Record (MAR) showed varying daily fluid intake levels, with several days falling significantly below the required 2400 ml. Additionally, health shakes ordered to supplement R204's nutrition were not documented as administered or consumed, and the facility did not record supplements given with meals. The RD acknowledged the delay in completing R204's nutritional assessment and the inadequacy of the care plan's fluid intake goal. Interviews with facility staff, including the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and the RD, confirmed the lack of timely assessment and monitoring of R204's hydration status. The RD stated that the provision of IV fluids should have triggered a high nutritional/dehydration risk assessment, which was not completed in a timely manner. The Director of Nursing (DON) verified that the care plan goal for fluid intake was incorrect and should have been aligned with the RD's assessment. The facility's policy on hydration and prevention of dehydration was not adhered to, as the dietitian did not assess R204's hydration needs within the standard timeframe.
Failure to Renew PRN Antianxiety Medication Order
Penalty
Summary
The facility failed to ensure that a resident did not receive an as-needed antianxiety medication, Ativan, for more than fourteen days without a physician's rationale for extending the use and without a specified stop date. The resident, who was admitted with diagnoses including major depressive disorder, psychotic disorder with delusions, and anxiety disorder, was prescribed Ativan on a PRN basis. The order did not include a stop date, and the medication was administered beyond the 14-day period without documentation for its continued use. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the PRN Ativan should have been renewed after 14 days, and there was no documentation of a physician's rationale for extending its use. The facility's policy on psychotropic medication use requires that PRN orders for such medications are limited to 14 days unless a physician documents the rationale for extending the use. The failure to adhere to this policy increased the risk of adverse reactions to medications that may not be needed to treat a clinical condition.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during catheter care for two residents. For one resident, a Licensed Vocational Nurse (LVN) did not change gloves appropriately while providing suprapubic catheter care. The LVN cleaned the catheter and then proceeded to rinse and pat it dry without changing gloves, which is a necessary step to prevent cross-contamination. This oversight was confirmed by the LVN, the Director of Nursing (DON), and the Infection Preventionist (IP), all acknowledging that gloves should be changed when transitioning from a dirty to a clean area. In another instance, a resident's urinary collection bag was observed on the floor without a dignity bag, contrary to the facility's policy. The resident, who had severe cognitive impairment and an indwelling catheter, was found with the collection bag on the floor, which poses a risk for infection. This was confirmed by another LVN and the DON, who stated that the expectation is for urinary collection bags to be kept off the floor and in a dignity bag to prevent infection. The facility's policy on catheter care explicitly states that catheter tubing and drainage bags should be kept off the floor to avoid urinary tract infections.
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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