Arbor Hills Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mesa, California.
- Location
- 7800 Parkway Drive, La Mesa, California 91942
- CMS Provider Number
- 055114
- Inspections on file
- 27
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Arbor Hills Nursing Center during CMS and state inspections, most recent first.
A resident with a history of Major Depressive Disorder and documented aggressive and elopement behaviors was not referred to psychiatry, despite multiple incidents and staff observations. Facility staff did not communicate or document these behaviors according to policy, and the care plan did not reflect the resident's behavioral issues.
A resident with hemiplegia and high fall risk experienced a fall resulting in a traumatic hematoma due to a CNA providing care alone, contrary to the care plan requiring two-person assistance. The facility's policy on ADLs was not followed, as confirmed by staff interviews and record reviews.
A resident with osteoporosis experienced a decline in range of motion in his hands, affecting his ability to perform daily activities. Despite observations and interviews indicating the resident's limitations, the facility failed to implement a care plan or provide necessary rehabilitation services. Staff members did not report the resident's condition changes, and quarterly rehab screens were not conducted, leading to a lack of appropriate interventions.
The facility failed to provide palatable and properly prepared meals, leading to resident dissatisfaction. Observations revealed issues with food temperature, taste, and presentation, with residents frequently receiving cold and unappealing meals. The Dietary Supervisor and Registered Dietician acknowledged these issues, noting the absence of a formal process for tracking test trays and the need for improved meal presentation. The facility's policy required poorly prepared food to be improved or replaced, but this was not consistently followed.
A resident with a history of heart failure and minimal cognitive deficits was served meals that did not align with their preferences, such as spicy food and gravy, despite these dislikes being documented. The Dietary Supervisor and Registered Dietician acknowledged the oversight, which could lead to poor meal intake and weight loss. The facility lacked a policy for menus, contributing to the deficiency.
The facility failed to maintain food safety and sanitation standards in dietary services. Observations included cereal containers on the floor, a dented can of tomato paste, and food boxes stacked too close to fire sprinklers. Additionally, food seasonings lacked opened dates, a dishwashing machine lacked a proper air gap, and a sanitation bucket was improperly placed on a food preparation table, all contrary to facility policies.
A facility failed to follow the care plan for a diabetic resident, leading to hospitalization. The resident, with a history of gangrene, was not wearing shoes as required by the care plan, resulting in foot abrasions and swelling. The omission of this intervention from the revised care plan contributed to the deficiency.
The facility failed to create and implement specific care plans for two residents, one with limited range of motion and another with PTSD. A resident with osteoporosis showed a decline in hand mobility, requiring assistance with meals, but lacked a care plan addressing this issue. Another resident with PTSD had no care plan for managing triggers, risking retraumatization. Staff acknowledged these needs, but failed to document or address them adequately, contrary to facility policies on trauma-informed care.
A resident with protein-calorie malnutrition experienced an unplanned weight loss of 18.3 pounds in one month, but the facility failed to update the resident's nutritional care plan. The RD acknowledged the oversight, and the DON expected the care plan to be updated, as per facility policy.
A resident's pain medication order was not properly clarified, lacking specific parameters and frequency, which could lead to overmedication. Staff interviews confirmed the order was incomplete and should have been clarified with the physician. The facility's policy did not provide guidance on this issue.
A facility failed to provide trauma-informed care to a resident with PTSD, as staff were unaware of the resident's diagnosis and triggers. The resident, a military veteran, identified wartime battle-related events as a trigger. The Director of Nursing emphasized the importance of staff awareness to prevent psychological distress, highlighting a deficiency in the facility's implementation of its trauma-informed care policy.
A facility failed to reconcile controlled medications with the MAR for a resident, leading to a potential risk of drug diversion. The resident had an order for Norco, but the MAR was blank for a dose signed out in the Controlled Drug Record. Interviews with staff confirmed the missing documentation, and the DON acknowledged the discrepancy, highlighting a failure to adhere to the facility's policy on controlled substances.
A resident prescribed Trazodone for depression with sleep disturbances was inaccurately monitored, with records showing disturbances during day and evening shifts, contrary to staff reports of nighttime disturbances. This discrepancy risked unnecessary medication due to inaccurate data used for medication evaluation.
The facility failed to properly dispose of garbage and refuse, as observed when a Dietary Aide transported a lidless trash barrel to the garbage area. One dumpster had an unsecured lid, and another was overflowing, preventing proper closure. The Dietary Supervisor confirmed the importance of securing dumpsters to prevent pest attraction, as per facility policy and FDA guidelines.
A resident with protein-calorie malnutrition and type 2 diabetes experienced significant weight loss, which was not documented in a timely manner in the EHR. The IDT note was entered late, and an SBAR Communication Form was not completed, delaying communication of the resident's condition to healthcare providers. Staff interviews confirmed the documentation should have been done promptly, as per facility policy.
The facility failed to ensure that three residents fully understood the arbitration agreements they signed. One resident with severe cognitive deficits signed without capacity, another had a family member sign without being the responsible party, and a third resident did not receive a copy to review. The facility lacked documentation and a policy for arbitration agreements.
The QAA Committee failed to address food complaints raised by residents and noted by surveyors, focusing instead on other issues like falls and diabetic care. The DON admitted that food-related concerns from resident council meetings were not discussed in QAPI meetings, leading to unresolved issues affecting residents' quality of life.
The facility failed to follow infection control procedures when a CNA did not wear PPE while assisting a resident on EBP, and an LN did not perform hand hygiene consistently after glove removal. The LN also wore bandages that could harbor bacteria, contrary to facility policy.
A facility failed to complete an Admission Comprehensive Assessment for a resident within the required 14 days due to the departure of the MDS Nurse and a delay in hiring a replacement. The resident, admitted with falls and fractures, was not fully assessed, and CMS was not informed of their health status. Interviews revealed a lack of awareness and assumptions about the completion of assessments by the ADON, DON, and Administrator.
A resident did not receive a prescribed blood thinner for 12 days due to the facility's failure to clarify a physician's order. The process involved documenting the order in a Transportation Log and discussing it at a Stand Up meeting, but the note was not properly followed up. Interviews revealed a lack of documentation and discussion, leading to a delay in medication administration.
A resident with limited English proficiency did not receive adequate communication support in their native Arabic dialect, as the facility failed to implement its language access policy. Staff used hand gestures and Google Translate instead of trained interpreters or telephone services, and relied on a family member for translation. Interviews revealed a lack of staff training and awareness about available translation services.
The facility failed to implement their infection control program when two CNAs did not wear proper full PPE while providing care to COVID-positive residents, and one CNA improperly discarded a used N95 mask. Both CNAs admitted to not wearing face shields or goggles, and a Licensed Nurse confirmed the expectation for proper PPE use and disposal.
Failure to Refer Resident with Behavioral Issues for Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure proper communication and referral for behavioral health services for a resident with a history of Major Depressive Disorder and documented behavioral manifestations. Despite multiple documented incidents of the resident attempting to elope and displaying aggressive behaviors towards staff and other residents, there was no evidence that these behaviors were communicated to the appropriate staff or that a referral to psychiatry was made, as required by facility policy. The resident's care plan did not reflect these behavioral issues, and social services notes lacked documentation of referrals or communication with the charge nurse regarding the incidents. Interviews with facility staff, including the Social Services Director and Assistant Director of Nursing, confirmed that the process for referring residents with behavioral issues to psychiatric evaluation was not followed. The Social Services Director was unaware of the resident's behaviors in February and acknowledged the absence of a paper trail or intervention following the early identification of behavioral issues. The facility's policy required close monitoring, assessment, and interdisciplinary communication for residents exhibiting behavioral difficulties, but these steps were not documented or implemented for this resident.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to Resident 1's care plan, which required two-person assistance during care activities. Despite this requirement, a certified nurse assistant (CNA) provided care alone, leading to a witnessed fall. Resident 1, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia following a stroke, was at high risk for falls as indicated by multiple evaluations. On the night of the incident, while the CNA was turning Resident 1 to the left side during care, the resident rolled out of bed, resulting in a traumatic hematoma on the forehead. Interviews and record reviews confirmed that Resident 1 was dependent on assistance for most activities of daily living (ADLs) and required two-person assistance for bed mobility, transfer, and toileting hygiene. The Director of Nursing (DON) and other staff members acknowledged that the care plan was not followed, as the CNA did not seek additional help. The facility's policy on ADLs emphasized providing care to maintain or improve residents' abilities, which was not adhered to in this case.
Failure to Address Decline in Resident's Range of Motion
Penalty
Summary
The facility failed to identify and address a decline in range of motion (ROM) for a resident, referred to as Resident 27, who was admitted with a diagnosis of osteoporosis. During an initial tour, it was observed that Resident 27 had difficulty fully extending and straightening his fingers, which affected his ability to perform daily activities such as cutting food and using utensils. Despite these limitations, there was no care plan in place to address the resident's hand condition, and no orders for rehabilitation or restorative nursing assistance were found in his records. Interviews with various staff members, including certified nurse assistants (CNAs) and licensed nurses (LNs), revealed that the resident's condition had not been reported or addressed appropriately. CNA 1, who had known the resident for a long time, acknowledged the resident's difficulty in opening his hands and the need for assistance during meals. However, the change in the resident's condition was not reported to a licensed nurse, as confirmed by interviews with other CNAs and LNs. The Director of Rehabilitation and the Minimum Data Set Nurse (MDSN) were also unaware of the resident's hand limitations, and quarterly rehab screens for the resident were not found. The occupational therapy evaluation conducted on 11/1/24 confirmed that Resident 27's hand joints were fixed in a flexed position, causing pain during passive ROM and preventing active ROM. The evaluation indicated that the resident's functional abilities were limited due to contractures, and the therapy would focus on preventing further flexion. The facility's policy on resident mobility and ROM, dated July 2017, stated that residents should not experience an avoidable reduction in ROM and should receive treatment to prevent further decrease, which was not adhered to in this case.
Deficiency in Food Quality and Presentation
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during multiple dining observations. Residents consistently reported dissatisfaction with the taste, temperature, and presentation of the food. Complaints included cold food, lack of flavor, and unappealing presentation. Some residents reported receiving the same meals repeatedly, such as scrambled eggs for breakfast, and others noted that the food was sometimes too spicy or salty, contrary to their preferences. These issues were documented during dining observations and resident council meetings over several months. During interviews, both the Dietary Supervisor (DS) and Registered Dietician (RD) acknowledged the issues with food quality and presentation. The DS admitted that there was no formal process to track test trays and that the pureed meals needed to be more appealing. The RD mentioned that while they follow recipes, there is room for improvement in taste and presentation without altering the menus significantly. Both the DS and RD recognized that the late delivery of meals could affect food quality and residents' appetites, potentially leading to decreased meal intake and weight loss. The facility's policy on food storage and preparation indicated that poorly prepared food should not be served and should be improved or replaced. However, the facility did not provide a specific policy for test trays or meal rounds. The lack of adherence to these policies and procedures contributed to the deficiency, as evidenced by the repeated resident complaints and observations of unappetizing and improperly prepared meals.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, leading to a potential risk of poor meal intake and weight loss. The resident, who had a history of heart failure and minimal cognitive deficits, was observed receiving meals that did not align with their stated preferences. On two separate occasions, the resident was served food that was either spicy or included gravy, both of which were against their documented dislikes. The menu ticket for the resident did not indicate the need for chopped meats, yet the resident received chopped chicken, and their dislike for gravy was not honored. Interviews with the Dietary Supervisor and Registered Dietician revealed that the resident's preferences were not followed, which could lead to the resident becoming upset and potentially losing weight due to poor meal intake. The facility did not provide a policy and procedure for menus, indicating a lack of structured guidance in ensuring resident preferences are consistently met. This oversight in accommodating the resident's dietary preferences was identified through observations, interviews, and record reviews.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as observed during a kitchen tour. Two individual-sized cereal containers were found on the floor of the dry pantry storage, contrary to the facility's policy that requires food to be stored at least six inches off the floor to prevent contamination and pest infestation. Additionally, a large dented can of tomato paste was stored with other canned goods, posing a risk of botulism, which is against the facility's policy that prohibits the use of dented cans. Further observations revealed that multiple brown boxes containing food were stacked above the red line in the dry storage food pantry, which is a fire hazard as it interferes with the fire sprinkler's efficiency. The facility's policy and the California Building Code require that storage be maintained at least 18 inches below sprinkler head deflectors. Moreover, five food seasonings were found without an opened date, which is against the facility's policy that requires labeling and dating to ensure the efficiency and taste of the seasonings over time. The facility also failed to ensure proper plumbing and sanitation practices. The low-temperature dishwashing machine lacked a proper air gap system, which is necessary to prevent backflow of contaminated fluids, as per the facility's policy and the Federal FDA Food Code. Additionally, a red sanitation bucket was placed on a food production table, risking cross-contamination with food, which violates the facility's policy against using cleaning products in food preparation areas.
Failure to Implement Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate interventions according to the comprehensive care plan for a resident with diabetes, leading to a deficiency. Resident 42, who had a history of diabetes and gangrene on the left second toe, was admitted to the facility with severe cognitive deficits. Despite the care plan indicating the need for diabetic shoes on both lower extremities, this intervention was omitted in the revised care plan initiated on 10/26/24. As a result, the resident was found with abrasions on the left great toe and left third toe, and was not wearing shoes while in a wheelchair, which was against the care plan's requirements. The lack of adherence to the care plan led to Resident 42 being hospitalized due to swelling in the left foot, potentially exacerbated by the abrasions. The Director of Nursing acknowledged that the plan of care required the resident to wear shoes to provide foot protection and prevent complications. The facility's policy on foot care, which emphasizes preventing complications from medical conditions, was not followed, as there was no documentation indicating that the diabetic shoes were monitored or applied.
Failure to Implement Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement resident-specific care plans for two residents, leading to deficiencies in addressing their medical needs. Resident 27, who was admitted with osteoporosis, exhibited a decline in the range of motion in his hands, which was not addressed in his care plan. Despite observations and interviews indicating that Resident 27 had difficulty using his hands, requiring assistance with meals, and showing signs of hand contractures, there was no care plan in place to manage or mitigate these issues. The facility's staff, including CNAs and a licensed nurse, acknowledged the resident's condition but failed to report or document it adequately, resulting in a lack of appropriate interventions. Similarly, Resident 294, diagnosed with PTSD, did not have a care plan that addressed his specific triggers, which could potentially retraumatize him. The Social Services Director and the Director of Nursing both recognized the importance of identifying and managing PTSD triggers to prevent psychological distress, yet the care plan lacked these critical interventions. The facility's policies emphasized the need for trauma-informed care and individualized care plans, but these were not effectively implemented for Resident 294, leaving him vulnerable to distressing situations.
Failure to Update Nutritional Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised and updated for a resident reviewed for nutrition. The resident, who was admitted with a diagnosis of protein-calorie malnutrition, experienced a significant, unplanned weight loss of 18.3 pounds in one month. Despite this, the resident's nutritional care plan was not updated to reflect the recent weight loss, as acknowledged by the Registered Dietitian during an interview. The Director of Nursing stated that it was her expectation for the care plan to be updated, especially given the resident's risk for weight loss. The facility's policy on weight assessment and intervention, as well as comprehensive person-centered care plans, requires that care plans address identified causes of weight loss and be revised as the resident's condition changes. However, a review of the resident's care plan indicated no revisions or interventions related to the weight loss.
Failure to Clarify Pain Medication Order
Penalty
Summary
The facility failed to ensure that a resident's pain medication order was properly clarified to include necessary parameters and frequency of administration. Resident 86, who was admitted with a diagnosis including post laminectomy, had an order for Norco Oral Tablet 5-325 mg to be given twice daily as needed for pain management. However, the order lacked specific instructions regarding the frequency and pain level parameters, which are essential for safe administration. This oversight was identified during a review of the resident's Medication Administration Record (MAR). Interviews with facility staff, including the Infection Preventionist (IP), a Licensed Nurse (LN 2), and the Director of Nursing (DON), revealed a consensus that the pain medication order was incomplete and should have been clarified with the prescribing physician. The staff acknowledged that the absence of specific parameters could lead to the risk of the resident being overmedicated. The facility's policy on pain management did not provide guidance on clarifying such orders, contributing to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to Resident 294, who was diagnosed with PTSD, depression, and alcohol use. The resident, a military veteran who had been stationed in Iraq, identified wartime battle-related events as a trigger for his PTSD. Despite this, interviews with CNAs 21 and 22 revealed that they were unaware of Resident 294's PTSD diagnosis and his specific triggers. This lack of awareness among the staff could potentially lead to re-traumatization of the resident. The Director of Nursing acknowledged the importance of staff being informed about Resident 294's PTSD diagnosis to avoid causing psychological distress. The facility's policy on Trauma-Informed and Culturally Competent Care, revised in August 2022, emphasizes the need to minimize triggers and re-traumatization for trauma survivors. However, the failure to communicate Resident 294's PTSD diagnosis and triggers to the staff indicates a deficiency in implementing this policy effectively.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to ensure that controlled medications were properly reconciled with the Medication Administration Record (MAR) for one resident, leading to a potential risk of drug diversion. Resident 86, who was admitted to the facility, had an order for Norco Oral Tablet 5-325 mg to be administered twice daily for pain management. The order was initially set to be discontinued on 10/23/2024 and then restarted with a new order on 10/24/2024. However, the MAR indicated that the only medication given on 10/24/2024 was at 8:27 P.M., despite a dose being signed out at 9:00 A.M. on the Controlled Drug Record. During interviews, Licensed Nurse 2 (LN 2) confirmed that the MAR was blank for the 9:00 A.M. dose on 10/24/2024, and there was no documentation to verify that the medication was given to Resident 86. The Director of Nursing (DON) acknowledged the missing dose and emphasized that all doses must be accounted for and justified in the records. The facility's policy on controlled substances requires nursing staff to count controlled medication inventory at the end of each shift and reconcile any discrepancies, which was not adhered to in this instance.
Inaccurate Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to accurately monitor a resident who was prescribed Trazodone HCL for Major Depressive Disorder with sleep disturbances. The monitoring records inaccurately documented the resident as having sleep disturbances during the day and evening shifts, while no disturbances were recorded during the night shift. However, interviews with staff and the resident's roommate indicated that the resident was actually awake and active during the day and experienced sleep disturbances at night. This discrepancy in monitoring led to the potential risk of the resident receiving unnecessary psychotropic medication due to inaccurate data being used for medication evaluation and potential gradual dose reductions. The resident, who was admitted with a diagnosis of dementia and depression, was on behavioral monitoring for sleep disturbances related to the use of Trazodone. Interviews with CNAs and LNs revealed that the monitoring records were not reflective of the resident's actual sleep patterns, as the resident was reported to be awake at night and not during the day. The inaccurate monitoring records could mislead physicians and pharmacists in evaluating the effectiveness of the medication and determining the need for dose adjustments, thereby putting the resident at risk of unnecessary medication administration.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that outdoor garbage and refuse were properly disposed of, leading to a potential unsafe environment. During an observation and interview with the Dietary Supervisor, it was noted that a Dietary Aide was transporting a kitchen trash barrel without a lid to the facility's garbage area. The facility had three dumpsters located outside the kitchen by the parking lot. The first dumpster was observed with one of its two lids not securely closed, and the third dumpster was overflowing with trash bags, preventing the lids from being fully closed and secured. The Dietary Supervisor acknowledged that the kitchen trash barrel should have had a lid while being transported and that the dumpsters should not be overflowing, as this prevents them from being securely closed. The facility's policy on garbage and refuse disposal, dated November 2017, requires that garbage and refuse containers be maintained in good condition and that waste be properly contained with lids covered. The 2022 FDA Food Code also mandates that outside receptacles for refuse and recyclables have tight-fitting lids. The failure to adhere to these guidelines could attract pests and pose a problem for the facility.
Failure to Timely Document Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's significant weight loss was properly documented in a timely manner in the electronic health record (EHR). Resident 15, who was admitted with diagnoses including protein-calorie malnutrition and type 2 diabetes, experienced an unplanned weight loss of 18.3 pounds in one month. The Interdisciplinary (IDT) Note regarding this weight loss was entered as a late entry on 10/29/24, despite the effective date being 10/4/24. This delay in documentation meant that the resident's condition was not communicated promptly to all healthcare providers, potentially impacting the resident's care. Interviews with facility staff, including the Registered Dietitian (RD), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that the IDT note should have been entered immediately following the IDT meeting. The ADON also noted that an SBAR Communication Form should have been completed due to the change in the resident's condition. The facility's policy on changes in a resident's condition or status, dated February 2021, requires timely documentation of such changes. The failure to document promptly was acknowledged by the staff, highlighting a lapse in following the facility's documentation policy.
Failure to Ensure Residents' Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents fully understood the arbitration agreement they entered into. Resident 68, who had severe cognitive deficits due to dementia, signed an arbitration agreement despite lacking the capacity to understand or make decisions. The Admission Coordinator and Admissions Director acknowledged that the resident's conservator should have been notified, but there was no documentation to support that this occurred. The Director of Nursing confirmed that the resident's cognitive impairments were evident from the initial assessment, and the facility did not provide a policy and procedure for arbitration agreements. Resident 72's arbitration agreement was signed by a family member who was not the responsible party or legal representative. The resident, who had minimal cognitive deficits, stated that the agreement was never explained to him, and he was not given a copy to review. The Admissions Coordinator and Admissions Director confirmed that there was no documented evidence that the agreement was explained or that a copy was provided to the resident. Resident 34, who had no cognitive deficits, signed an arbitration agreement without fully understanding its implications. The resident was not given a copy of the agreement to review, which would have allowed her to cancel it within 30 days if desired. The Admissions Coordinator and Admissions Director confirmed the lack of documentation regarding the explanation of the agreement or the provision of a duplicate copy. The facility did not provide a policy and procedure for arbitration agreements.
QAA Committee Fails to Address Food Complaints
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and address quality deficiencies related to food complaints raised by residents during council meetings and noted by surveyors during a recertification survey. The Director of Nurses (DON) acknowledged that while the QAPI meetings focused on issues such as falls, diabetic care, inaccurate hospital orders, unsafe discharges, and weight loss, they did not address the food-related concerns reported in resident council meetings from May to September 2024. The facility's policy and procedure for Quality Assessment & Assurance mandates the committee to coordinate and evaluate activities under the QAPI program, including developing and implementing plans of action to correct identified quality deficiencies. However, the food issues were not brought up in the QAPI meetings, resulting in unresolved issues affecting the residents' quality of life.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control procedures in two observed instances. In the first instance, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while assisting a resident on Enhanced Barrier Precautions (EBP) with a transfer. The CNA acknowledged the oversight and recognized the potential risk of spreading infections. The Infection Preventionist and Director of Nursing confirmed that staff had been trained on EBP requirements, and the facility's policy clearly outlined the need for gowns and gloves during high-contact activities. In the second instance, a Licensed Nurse (LN) did not consistently perform hand hygiene after removing gloves while preparing medications for a resident on EBP. The LN had adhesive bandages on her hands, which were not removed, potentially harboring bacteria. The Infection Preventionist and Director of Nursing emphasized the importance of hand hygiene and the inappropriateness of using bandages that could become wet and carry infections. The facility's hand hygiene policy required hand washing immediately after glove removal, which was not followed in this case.
Failure to Complete Admission Comprehensive Assessment
Penalty
Summary
The facility failed to complete an Admission Comprehensive Assessment for a resident according to the Minimum Data Set (MDS), a requirement by CMS. The resident was admitted with diagnoses including falls and fractures of the left femur. Upon review, it was found that the comprehensive assessment was still in progress and had not been completed within the mandated 14 days after admission. This oversight was attributed to the departure of the facility's Minimum Data Set Nurse (MDSN), who left on November 20, 2024, and the subsequent delay in hiring a replacement. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator (ADM) revealed a lack of awareness and assumption that the assessments were completed. The ADON acknowledged the overdue status of the assessment and the potential impact on CMS's awareness of the resident's health status. The DON was unaware of the incomplete assessment, and the ADM assumed all assessments were completed after the MDSN's departure. This failure resulted in the resident not being fully assessed for potential health issues and CMS not being informed of the resident's current health status.
Failure to Clarify Physician's Order for Blood Thinner
Penalty
Summary
The facility failed to clarify a physician's order for a blood thinner medication for a resident, resulting in the resident not receiving the medication for 12 days. The resident was admitted with a diagnosis of atherosclerosis of the coronary artery bypass graft. The Director of Nursing (DON) explained that the process for handling new prescriptions involved documenting the order in a Transportation Log book and discussing it at the next Stand Up meeting. However, a note regarding the need to follow up with a neurologist about the blood thinner was written in the log but not signed or timed, and no progress note was found indicating any discussion with the neurologist. Interviews with the DON and Licensed Nurses (LNs) revealed that the note should have been discussed during a Stand Up meeting, but there was no record of such a discussion. The charge nurse, who was responsible for following up on the medication order, did not recall discussing the blood thinner during the meeting. As a result, the resident did not receive the medication until 12 days after the initial note was written, potentially putting the resident at risk for complications. The facility was unable to provide a policy regarding the process for following physician's orders for medications.
Failure to Provide Adequate Language Services for Resident
Penalty
Summary
The facility failed to provide adequate communication in the native language of a resident, who speaks an Arabic dialect, as required by their own policy. The facility's policy on translation and interpretation services was not implemented effectively. Staff members resorted to using hand gestures and Google Translate, which were not in accordance with the facility's communication policy. Additionally, the facility relied on a family member to translate, which could lead to inconsistent and inaccurate communication. The facility's policy outlined several methods for providing competent oral translation, including using trained staff interpreters, contracted interpreter services, and telephone interpretation services, none of which were utilized for this resident. Interviews with staff revealed a lack of awareness and training regarding the use of translation services. The Social Services Director, who speaks Arabic, was the only staff member available to assist, but only during day shifts. A Certified Nursing Assistant and a Licensed Nurse admitted to not using the language line and were unaware of its availability. The Director of Nursing claimed that staff were trained to use the language line, but documentation showed that the CNA and LN involved did not receive such training. Furthermore, there was no evidence provided to confirm the use of telephonic translation services for the resident during the investigation.
Failure to Implement Infection Control Program
Penalty
Summary
The facility failed to implement their infection control program when two staff members did not wear proper full personal protective equipment (PPE) while providing care to residents who tested positive for COVID-19. Specifically, two Certified Nursing Assistants (CNAs) were observed inside a COVID-positive resident's room without wearing face shields or goggles, despite a poster on the wall indicating that full PPE, including face shields or goggles, was required. Additionally, one CNA improperly discarded a used N95 mask by placing it on top of the PPE cart instead of disposing of it properly. Both CNAs admitted to not wearing face shields or goggles while providing care, with one CNA stating that there were no available face shields in the PPE cart at the time. During interviews, both CNAs confirmed that they were designated to provide care to COVID-positive residents and acknowledged the importance of wearing full PPE, including face shields, to protect against splashes and prevent the spread of infection. A Licensed Nurse (LN) also confirmed that the expectation was for staff to discard used N95 masks properly and to wear full PPE while providing care to COVID-positive residents. The failure to adhere to these infection control protocols had the potential to contaminate supplies and spread infection among staff and residents.
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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