Arlington Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 3688 Nye Avenue, Riverside, California 92505
- CMS Provider Number
- 056485
- Inspections on file
- 47
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Arlington Gardens Care Center during CMS and state inspections, most recent first.
A deficiency was identified when an LVN prepared and administered medications to a resident but failed to document the administration in the eMAR, resulting in an inaccurate medication record. Facility policy requires the nurse who administers medications to record this in the eMAR at the time of administration.
A resident with dementia and dysphagia, requiring constant supervision and a pureed diet, was discharged to an unlicensed room and board without caregivers or knowledge of her medical needs. The facility did not verify the receiving environment's ability to meet the resident's care requirements, and the placement agency did not assess the resident or confirm the suitability of the new setting. The resident's significant needs were not communicated or addressed, resulting in an unsafe discharge.
A resident with severe cognitive impairment was discharged without proper documentation of the Notice of Proposed Discharge, including inaccurate signatures and lack of clear notification to the responsible party. Additionally, after a witnessed fall, the LVN did not accurately document the time or details of family notification, and the required information was missing from the medical record.
A resident with dementia, hypertension, and acute kidney failure was found with excessively long fingernails and expressed a desire to have them trimmed. The treatment nurse and CNA did not provide the required nail care during routine care, despite facility policy mandating daily cleaning and regular trimming. The DON confirmed that nail care should have been addressed by staff.
A resident with a history of dementia, hypertension, and acute kidney failure was found to have long, painful toenails and had not received ongoing podiatry care despite previous diagnoses of onychomycosis, dystrophic nails, and paronychia. Nursing staff acknowledged responsibility for nail care and the need to notify podiatry, but there was no evidence of follow-up, resulting in the resident's toenails remaining untrimmed and painful.
A resident with significant neurological and medical conditions experienced four unwitnessed falls within a week due to the facility's failure to provide adequate supervision and timely interventions. Despite being identified as a fall risk and having several interventions in place, the resident continued to fall, and requests for increased monitoring and a sitter were not implemented until after multiple incidents. The DON acknowledged that the supervision provided was insufficient to prevent these repeated falls.
The facility did not provide the required transfer/discharge notice to the LTC Ombudsman at the same time as to two residents and their representatives. For both a resident with a pelvic fracture discharged to hospice and another with coronary artery disease discharged home, the Ombudsman was notified a day after the residents or their representatives received notice, contrary to facility policy.
The facility failed to follow its infection control policy for N95 mask usage. Two CNAs wore N95 masks over surgical masks, compromising the seal. An agency CNA, not fit tested, cared for a COVID-19 positive resident. The facility did not verify fit testing with the agency, contrary to policy requirements.
The facility failed to ensure accurate PASRR Level I screenings for three residents. One resident's screening was not resubmitted after a 30-day exemption expired, another's screening inaccurately reported no serious mental disorder, and a third's screening was not updated after a short-term exemption. The DON was responsible for ensuring the accuracy and timeliness of these screenings.
A facility failed to complete a quarterly MDS assessment on time for a resident with encephalopathy. The MDS, with an ARD in mid-June, was not signed by the RN until early July, exceeding the 14-day completion requirement. Interviews revealed that staff were not adhering to the timeline, with the DON expecting the MDS Nurse to ensure timely submissions.
A facility failed to ensure the accuracy of the MDS for a resident, resulting in a documented discrepancy regarding the resident's discharge location. The MDS inaccurately stated the resident was discharged to a hospital, while progress notes and the discharge summary indicated a discharge to home. Interviews with staff confirmed the expectation for MDS accuracy, and the error was acknowledged by the MDS Nurse.
A resident with a known allergy to hydrocodone was administered Norco due to a failure in documenting the allergy upon admission. This led to behavioral changes in the resident, as noted by a family member. The oversight was acknowledged by the DON, but the cause of the error was unclear.
A resident with severe cognitive impairment eloped from a facility during a heat wave, leading to an emergency room visit. The resident, who had a history of stroke and muscle weakness, was not initially identified as an elopement risk. Despite being seen in the facility earlier, the resident was found wandering outside by police and taken to the hospital. Staff interviews revealed no prior indication of elopement risk, and the facility's security footage showed the resident exiting and re-entering the building twice.
A facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69%. During a medication pass, an LVN administered the wrong type of multivitamin and an incorrect dose of docusate sodium to a resident with multiple sclerosis and immunodeficiency. The LVN admitted to the errors, and both the DON and Administrator emphasized the importance of correct medication administration.
The facility failed to make survey results accessible to residents and family members as required by policy. A resident noted the survey binder was previously available but had not been seen for two years. Observations and staff interviews confirmed the binder was not at the designated location. It was eventually found in the DON's office, contrary to expectations.
The facility did not post daily direct care staffing information as required by its policy, potentially affecting all 98 residents. During an observation, the surveyor could not find the posting, and interviews revealed that a CNA and the Administrator were unaware of the requirement. The DON acknowledged the oversight, stating the information should have been posted daily.
A resident with multiple health conditions was discharged to an incorrect facility due to the failure of the Social Service Director and Case Manager to confirm the discharge address with the family. The resident, who required maximum assistance and lacked decision-making capacity, was returned to the nursing facility after the error was discovered.
A facility failed to update the transfer and discharge notice for a resident's responsible party and the Ombudsman, leading to the resident being found outside a board and care facility that had not agreed to admit him. The resident was subsequently taken to the hospital.
A resident was discharged to a Board and Care that had not accepted him, then transferred to another Board and Care that was unaware of his arrival, resulting in the resident being found outside and subsequently admitted to a hospital.
The facility failed to inform a resident's representative of the findings of an investigation related to an incident during a doctor's appointment, despite the resident being transferred to a hospital. The DON conducted an investigation but did not recall informing the family member of the results, violating the facility's grievance policy.
The facility failed to provide NOPDs and notify the Ombudsman for three residents who were transferred or discharged. Interviews with the SSD and DON confirmed that the NOPDs were not properly handled, and the facility's documentation showed non-compliance with its policy.
The facility failed to ensure that a resident had the call light button within reach. During an unannounced visit, it was observed that the call light button was on the floor, out of the resident's reach. The resident, who had severe cognitive impairment and muscle weakness, confirmed that the call light was usually near him. Both the LVN and DON acknowledged that the call light should be within the resident's reach.
The facility failed to schedule follow-up appointments with a cardiologist and pulmonologist for a resident with significant medical conditions, despite physician orders. Interviews revealed a lack of communication and urgency among staff, and the facility's policy on referrals was not followed, resulting in delayed medical follow-ups.
Failure to Document Medication Administration in eMAR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN 2) prepared and administered some of a resident's medications but did not sign the electronic Medication Administration Record (eMAR) to document the administration. On the day in question, LVN 2 assisted another nurse (LVN 1) with the 9 a.m. medication pass for a resident who had moderate cognitive impairment and multiple diagnoses, including diabetes mellitus. LVN 2 prepared prescription and over-the-counter medications, placed them in a medicine cup, and administered them to the resident. However, there was no documentation in the eMAR reflecting that LVN 2 had administered these medications. Facility policy and statements from the Director of Nursing confirmed that the standard practice requires the nurse who prepares and administers medications to document the administration in the eMAR at the time the medication is given. The failure to document the medication administration resulted in an inaccurate medication record for the resident. The facility's own policies specify that only the licensed or legally authorized personnel who prepare a medication may administer it and must record the administration on the resident's MAR.
Failure to Ensure Safe and Appropriate Discharge for High-Needs Resident
Penalty
Summary
A facility failed to ensure a safe and appropriate discharge for a resident with dementia and dysphagia who required constant supervision and a pureed diet. The resident was discharged to an unlicensed room and board facility that did not provide caregivers or understand the resident's medical and dietary needs. The facility did not verify whether the receiving environment could meet the resident's care requirements, and there was no documentation that the facility communicated with the receiving location to confirm its suitability. The resident's care plans indicated significant needs, including 1:1 supervision for elopement risk, assistance with all activities of daily living, and a specialized diet due to swallowing difficulties. Despite these documented needs, the discharge process relied on a placement agency that did not assess the resident in person or ensure the receiving facility was licensed or capable of providing the required care. The Social Services Director admitted to not verifying the receiving facility's ability to meet the resident's needs and assumed that such facilities would not accept residents they could not care for. Upon arrival at the unlicensed room and board, the owner was unaware of the resident's dietary restrictions and did not provide 24-hour care or supervision. The resident did not have family support or in-home services at the new location. Within a week, the resident was transferred to a hospital due to concerns about care. The facility did not have a specific policy or procedure for managing safe discharges, and the only relevant policy referenced the need to consider the resident's needs, choices, and best interests when determining transfer locations.
Removal Plan
- The Social Service Director (SSD) and the Case Manager (CM)/Discharge Planner (DCP) reviewed residents scheduled for possible discharge to ensure that each resident was appropriately assessed for discharge placement and that the receiving facility will be able to meet the residents' needs.
- The SSD and CM/DCP reviewed residents who were discharged and ensured that each resident was safely discharged and the receiving facility was able to meet the residents' needs.
- The Director of Nursing (DON) conducted an in-service to the SSD and CM/CDP regarding appropriate discharge placement to ensure that residents are discharged to a safe location that can meet their needs.
- The receiving facility will send a representative to assess the resident's current condition and plan of care, which includes evaluation of diet, medications, functional abilities (such as transfers, bed mobility, and ambulation), and cognitive status.
- A checklist was created to identify the residents' needs and will be used to verify and acknowledge that they can manage the care of the resident.
- The SSD will continue to conduct admission assessments with initial plans for discharge in collaboration with IDT and during their stay at the facility and coordinate with the resident or the responsible party for changes in the discharge plans and provide assistance as needed.
- The SSD and CM/DCP will continue to conduct post discharge follow-up to ensure safe discharge.
- The SSD will report the number of discharges to different levels of care and report concerns as presented by residents or the responsible party on post discharge follow-up during quarterly QAA meetings. The QAA will monitor compliance and trends and provide recommendations during the meeting.
Failure to Maintain Accurate Clinical Records and Notification Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score indicating severe impairment, was issued a Notice of Proposed Discharge (NOPD) on the same day as discharge. The NOPD was signed by both the resident and her responsible party (RP), despite the RP not being present at the facility on that day. Interviews confirmed that the RP did not sign the document and would not have used the signature shown. The Social Service Director (SSD) and Director of Nursing (DON) acknowledged that the RP was not present and that the documentation did not accurately reflect the method of notification or the actual signature process. Additionally, the facility did not accurately document the time of family notification following a witnessed fall involving the same resident. The SBAR Communication Form indicated that the resident's daughter was notified at midnight, but the DON stated this was likely incorrect, and the Licensed Vocational Nurse (LVN) could not recall the exact time of the incident or the calls made. The LVN admitted to not updating the documentation to reflect the actual time of notification and was unsure if the calls were documented in the progress notes. There was no other documentation to support the timing or occurrence of family notification. Facility policies required that all services, changes in condition, and notifications be documented completely and accurately in the resident's medical record. The failures in documentation and record-keeping resulted in the resident and her family not being able to exercise their right to appeal the discharge and had the potential to prevent the family from making informed decisions or being present during a crisis.
Failure to Provide Ongoing Nail Care for Resident
Penalty
Summary
A resident with diagnoses including dementia, hypertension, and acute kidney failure was observed to have long fingernails on her right hand during a complaint investigation. The resident, who was alert and oriented at the time of observation, expressed a desire to have her fingernails cut. Measurements taken by the treatment nurse showed fingernail lengths ranging from 1.6 cm to 1.9 cm. The treatment nurse acknowledged that it was the responsibility of both the treatment nurse and the certified nurse assistant to provide nail care, and that the resident's long fingernails should have been addressed during routine care. A review of the resident's medical record indicated she had no decision-making capacity, and the facility's policy required daily cleaning and regular trimming of fingernails by CNAs, treatment nurses, or licensed nurses. The Director of Nursing confirmed that nail care should have been provided during routine care. The facility's policy also stated that proper nail care helps prevent skin problems and injuries. The failure to provide ongoing grooming services, specifically nail care, resulted in the resident having excessively long fingernails.
Failure to Provide Ongoing Foot Care and Podiatry Services
Penalty
Summary
A resident was observed with long, curved toenails on both feet, with measurements indicating significant overgrowth. The resident reported experiencing painful toenails. During an interview and observation, the Treatment Nurse confirmed the responsibility for toenail care lies with the nursing staff, including CNAs and licensed nurses, and acknowledged that podiatry should have been notified about the resident's condition. The resident's medical record showed a history of dementia, hypertension, and acute kidney failure, and documented a previous podiatry visit diagnosing onychomycosis, dystrophic nails, and paronychia with painful nail borders. However, there was no evidence of ongoing podiatry care after the last documented visit. The Director of Nursing stated that facility policy requires regular nail care by nursing staff and that podiatry services should have been scheduled for the resident. The facility's policy emphasizes daily cleaning and regular trimming of nails to prevent skin problems and injuries. Despite these policies, the resident did not receive appropriate foot care, and there was no documentation of podiatry follow-up after the initial assessment, resulting in the resident having long, painful toenails.
Failure to Provide Adequate Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who experienced four unwitnessed falls within a seven-day period. The resident, who had diagnoses including hemiplegia, hemipheresis, diabetes mellitus, and Parkinson's disease, was identified as being at risk for falls upon admission. Despite this, the resident continued to fall multiple times, with each incident documented in the medical record. After the first and second falls, interventions such as keeping the bed in a low position, using side rails, bed and wheelchair alarms, floor mats, and every two-hour monitoring were implemented. However, these measures did not prevent subsequent falls. The Director of Nursing confirmed that after the second fall, the resident's family requested a sitter and for the resident to be moved closer to the nursing station, but these requests were not fulfilled due to room availability and a desire to avoid restrictive measures. The DON acknowledged that monitoring every two hours was not a sufficient intervention for this resident and that more frequent rounding and a sitter should have been provided prior to the fourth fall. The facility's own policy required staff and physicians to identify and implement pertinent interventions to prevent subsequent falls, but the lack of timely and adequate supervision contributed to the repeated incidents.
Failure to Timely Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to provide the required proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was given to the resident and/or their representative for two sampled residents. For one resident with a history of pelvic fracture who was being discharged to board and care on hospice, the notice was signed by the resident and given to the family member, but the Ombudsman was not notified until the following day. Similarly, for another resident with coronary artery disease and a history of coronary artery bypass grafting, the discharge notice was provided to the resident's representative, but the Ombudsman received the notice a day later. Interviews and record reviews confirmed that the facility's Director of Social Services typically sent the notice to the Ombudsman on the day of discharge, rather than concurrently with the notice to the resident or representative. The facility's policy requires that the Ombudsman be notified at the same time as the resident and representative. This lapse resulted in the Ombudsman not being informed in a timely manner, as required by policy and regulation.
Improper Use of N95 Masks and Lack of Fit Testing
Penalty
Summary
The facility failed to adhere to its infection control policy regarding the proper use of N95 masks, as observed during a survey. Two CNAs were found wearing an N95 mask over a surgical mask, which is against the facility's guidelines. This practice can compromise the seal of the N95 mask, reducing its effectiveness. One CNA admitted to alternating between the N95 and surgical mask depending on their location, while the other CNA, who was an agency staff member, was not aware of the proper use of N95 masks and had not undergone a fit test. Additionally, the facility did not verify whether the agency staff had been fit tested for the N95 mask before assigning them to care for a COVID-19 positive resident. The Director of Nursing and the Infection Control Nurse acknowledged these lapses, noting that the facility should have confirmed the fit testing status with the agency. The facility's policy requires fit testing and training on respirator use before initial assignment, which was not followed in this instance.
Inaccurate PASRR Screenings for Three Residents
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) Level I screenings for three residents. Resident #3 was admitted with a history of dementia, bipolar disorder, major depressive disorder, and schizophrenia. The Level I PASRR screening was initially exempt due to a short-term stay expectation, but it was not resubmitted after the resident remained in the facility beyond 30 days. Both the Administrator and the Director of Nursing (DON) acknowledged that the screening should have been resubmitted timely. Resident #18 was admitted with diagnoses of unspecified psychosis and major depressive disorder. However, the Level I PASRR screening incorrectly indicated that the resident did not have a serious mental disorder, resulting in a negative screening outcome. The DON admitted that the screening was inaccurate and should have included the resident's diagnoses. The responsibility for ensuring accurate PASRR screenings was attributed to the DON, who was also responsible for revising any inaccurate screenings. Resident #59 was admitted with a history of anxiety disorder and major depressive disorder. The initial Level I PASRR screening was negative due to a 30-day exempted hospital discharge. However, the screening was not resubmitted after the resident stayed beyond 30 days. The Administrator and the DON both confirmed that the DON was responsible for ensuring the accuracy and timeliness of PASRR screenings, and the failure to resubmit the screening was acknowledged as an oversight.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a quarterly Minimum Data Set (MDS) assessment for a resident with a diagnosis of encephalopathy. The facility's policy on resident assessments, revised in October 2023, specifies that non-comprehensive MDS assessments, including quarterly assessments, must be completed within 14 days after the Assessment Reference Date (ARD). However, the quarterly MDS for the resident, with an ARD of June 14, 2024, was not completed on time. The section for the Signature of the RN Assessment Coordinator Verifying Assessment Completion was left blank, indicating the assessment was incomplete. Interviews with facility staff revealed a lack of adherence to the required timeline for MDS completion. The MDS Nurse stated that the assessment should have been completed within 14 days from the ARD, but it was not signed by the RN until July 10, 2024, well past the deadline. The Director of Nursing was unsure of the exact timeline for MDS completion but expected the MDS Nurse to ensure timely submission. This oversight resulted in the resident's quarterly MDS not being completed within the required timeframe, as per the facility's policy and CMS guidelines.
Inaccurate MDS Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The facility's policy requires that all individuals who complete any portion of the MDS sign the document to attest to its accuracy and that the information in the MDS should consistently reflect the progress notes, care plans, and resident observations. However, for one resident, the discharge MDS inaccurately documented that the resident was discharged to a short-term general hospital, while the progress notes and discharge summary indicated that the resident was discharged home with a family member. Interviews with facility staff, including the Administrator, MDS Nurse, and Director of Nursing (DON), revealed an expectation for the MDS to be accurate. The MDS Nurse acknowledged the mistake in documenting the discharge location and stated that the MDS should have reflected the resident's discharge to home. The DON also emphasized the importance of reviewing progress notes to ensure MDS accuracy. This discrepancy between the MDS and other documentation led to the identified deficiency.
Failure to Document Medication Allergy
Penalty
Summary
The facility failed to document a known medication allergy for a resident, leading to the administration of a medication that the resident was allergic to. The resident, who had a medical history including a fracture, joint replacement surgery, and dementia, was admitted to the facility with a documented allergy to hydrocodone. Despite this, the resident's Order Summary Report did not list any known allergies, and the resident was prescribed Norco, a medication containing hydrocodone, for pain management. The resident received Norco multiple times over several days, resulting in behavioral changes such as increased aggression and uncooperativeness, as noted by a family member. Interviews with facility staff revealed that the allergy information was supposed to be entered into the resident's chart by the unit supervisor upon admission, but this step was missed. The Director of Nursing acknowledged the oversight but could not explain how the allergy documentation was overlooked.
Resident Elopement During Heat Wave
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #91, who eloped from the facility during an excessive heat wave. Resident #91, who had a history of cerebral infarction, muscle weakness, and difficulty walking, was admitted to the facility for short-term care. The resident had a severe cognitive impairment with a BIMS score of 3, indicating a high level of cognitive dysfunction. Despite this, initial assessments did not identify the resident as an elopement risk, and the care plan was not updated to reflect any potential wandering behavior until after the incident. On the day of the incident, Resident #91 was last seen in the facility at around 10:30 AM. The resident's spouse reported them missing around 11:50 AM, prompting a search by the facility staff. The resident was found by a police officer wandering outside in 95-degree weather and was subsequently taken to the emergency department for evaluation. The facility's security footage later revealed that Resident #91 had exited and re-entered the building twice that morning, although the exact doors used were not captured on camera. Interviews with facility staff indicated that while Resident #91 was known to walk around the building, there was no prior indication or report of them attempting to leave the premises. The Director of Nursing and other staff members were unaware of any elopement risk associated with Resident #91, and the family had not communicated any concerns about wandering behavior. The facility's failure to identify and monitor the resident's elopement risk contributed to the incident, resulting in the resident's exposure to hazardous conditions outside the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69%. This deficiency was identified during a medication administration observation involving a resident with a medical history of multiple sclerosis and immunodeficiency. The resident's care plan included interventions for constipation and malnutrition, requiring specific medications to be administered as per physician orders. However, during the medication pass, a Licensed Vocational Nurse (LVN) administered the wrong type of multivitamin and an incorrect dose of docusate sodium to the resident. The LVN prepared and administered a multivitamin without minerals instead of the prescribed multivitamin with minerals, and only gave 100 mg of docusate sodium instead of the ordered 200 mg. The LVN acknowledged the errors during interviews, attributing the mistakes to nervousness. The Director of Nursing (DON) and the Administrator both stated their expectations for medications to be administered correctly according to physician orders, emphasizing the importance of verifying the five rights of medication administration.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were accessible to residents and family members, as required by their policy. The policy, dated March 2017, stated that survey reports and plans of correction should be readily available in a binder located in the resident's day room. However, during an interview, a resident revealed that the survey binder, which was previously available at the front entrance, had been moved and was no longer accessible. The resident had not seen the binder for two years. Observations confirmed that the binder was not at the receptionist desk, where signage indicated it should be. Further interviews with facility staff, including the receptionist, HR Payroll, and the Director of Nursing (DON), revealed that none of them were aware of the binder's location. The receptionist, who had been at the facility for a year, had never seen the binder. The HR Payroll and DON were also unable to locate it initially. Eventually, the binder was found in the DON's office, contrary to the expected location. The Administrator acknowledged that the binder had been removed from the receptionist area after an incident, but expected it to be accessible to residents and family members.
Failure to Post Daily Direct Care Staffing Information
Penalty
Summary
The facility failed to ensure the daily direct care staffing information was posted, which had the potential to affect all 98 residents residing in the facility. The facility's policy, revised in July 2016, required the posting of the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. During an observation, the surveyor was unable to locate the daily direct care staff posting. Interviews revealed that a Certified Nurse Aide (CNA) was unaware of the requirement for a daily staff posting, and the Administrator did not know it was required. The Director of Nursing (DON) acknowledged the oversight and stated that the staffing information should have been posted daily.
Failure to Confirm Discharge Address Leads to Incorrect Transfer
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident when the discharge location was not confirmed with the family before transferring the resident. The resident, who had multiple diagnoses including acute respiratory failure, Type 2 diabetes, chronic kidney disease, and hypertension, was discharged without the capacity to understand and make decisions. The resident required maximum assistance with activities of daily living. The discharge was initially planned for May 29, 2024, to the family member's home, but the address was not confirmed, leading to the resident being taken to an incorrect facility instead. The Social Service Director (SSD) and the Case Manager (CM) were responsible for confirming the resident's address, but the address was not verified between May 22 and May 29, 2024. The SSD only confirmed the correct address with the family after the transportation company reported an insufficient address. The resident was returned to the skilled nursing facility for the night after the family member requested the discharge be postponed. The facility's policy required written notification of the discharge location, but this was not adequately followed, resulting in the resident being taken to the wrong address.
Failure to Update Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide an updated notice of transfer and discharge for a resident's responsible party and the Long-term Care Ombudsman, indicating changes to the discharge location. The Social Service Director (SSD) initially arranged for the resident to be discharged to a board and care facility (Board and Care 1), but upon arrival, the facility refused to accept the resident because he was male. The SSD then arranged for the resident to be admitted to another board and care facility (Board and Care 2) without notifying the resident's family or the Ombudsman of the change. The resident was later found outside Board and Care 2, and the staff there called 911 as they were unaware of the resident's arrival and had not agreed to admit him. Interviews with the SSD, facility administrator, hospital social worker, and Board and Care 2's house manager confirmed the sequence of events. The facility's policy requires that any changes to the discharge location be communicated to the resident, their representative, and the Ombudsman. However, this protocol was not followed, leading to the resident being found outside the second board and care facility and subsequently taken to the hospital. The failure to update the notice of transfer and discharge had the potential to compromise the resident's safety and well-being.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident when the resident was discharged to a Board and Care that had not accepted the resident for admission. The resident was then transferred to another Board and Care that was unaware of the resident's arrival. This resulted in the resident being found outside the second Board and Care and subsequently being transferred to a general acute care hospital. The Social Service Director (SSD) received a call from the transporter on the day of discharge, informing her that the first Board and Care refused to accept the resident because he was male. The SSD then called other Board and Care facilities in the area and spoke with an employee at a second Board and Care, who agreed to admit the resident over the phone. The SSD emailed the necessary paperwork and provided the new address to the transporter. However, the next day, the SSD was informed by a hospital social worker that the resident had been found outside the second Board and Care and was admitted to the hospital. Interviews with the facility administrator and the hospital's social worker confirmed the events. The administrator acknowledged that the discharge did not follow the normal protocol. The House Manager of the second Board and Care stated that they had no prior knowledge of the resident's arrival and called 911 when they found him outside their facility. The facility's policy and procedure for discharge planning were reviewed, indicating that the resident and their family should be involved in the discharge planning process and informed of the final plan, which was not followed in this case.
Failure to Inform Resident's Representative of Investigation Findings
Penalty
Summary
The facility failed to ensure that Resident 1's representative was informed of the findings of an investigation related to an incident that occurred while the resident was at a doctor's appointment. Resident 1 experienced a change of condition during the appointment and was subsequently transferred to an acute care hospital. Despite the Director of Nursing (DON) conducting an investigation, including checking the resident's vital signs and attempting to contact the doctor's office and the transporter, the DON did not recall if the family member was informed of the investigation results. Resident 1 had a medical history that included hemiplegia, hemiparesis following a stroke, atrial fibrillation, benign prostatic hyperplasia, urinary tract infection, and obstructive and reflux uropathy. The facility's policy required that grievances be investigated and that the findings be communicated to the resident or their representative within five working days. However, this policy was not followed, leading to the deficiency noted in the report.
Failure to Provide Transfer/Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to initiate and provide notices of proposed transfer/discharge (NOPD) to three residents and/or their responsible parties, and also failed to notify the Long-Term Care Ombudsman of these transfers/discharges. Resident 4, who had a history of stroke, diabetes mellitus type 2, and heart failure, was transferred to the hospital for shortness of breath without an NOPD being initiated or the Ombudsman being notified. Resident 5, with diagnoses including heart failure, atrial fibrillation, and hyperlipidemia, was discharged home with an incomplete NOPD and no notification to the Ombudsman. Resident 7, diagnosed with epilepsy, hypertension, and osteoporosis, was discharged home without an NOPD being initiated or the Ombudsman being notified. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that the NOPDs were not properly handled. The SSD admitted that the NOPD for Resident 4 was not initiated and that the Ombudsman was not notified. For Resident 5, the SSD acknowledged that the NOPD was incomplete and the Ombudsman was not informed. Similarly, for Resident 7, the SSD confirmed that the NOPD was not initiated and the Ombudsman was not notified. The SSD also mentioned that she sends NOPDs to the Ombudsman weekly, but did not send any on April 12, 2024, because she had sent some on April 9, 2024. The DON confirmed that the NOPDs should have been completed and sent to the Ombudsman immediately after the residents left the facility. A review of the facility's policy and procedure titled Transfer or Discharge Notice indicated that the resident and representative should be notified in writing of the transfer or discharge, and a copy of the notice should be sent to the Ombudsman at the same time. However, the facility's documentation showed that Residents 4 and 5 were not included in the NOPDs faxed to the Ombudsman on April 9, 2024, indicating a failure to follow the established policy and procedure.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident 9 had the call light button within his reach. During an unannounced visit, it was observed that Resident 9's call light button was on the floor, out of his reach. Resident 9, who was lying in bed, alert, and conversant, confirmed that his call light was usually near him. The Licensed Vocational Nurse (LVN) also acknowledged that the call light button should be within Resident 9's reach and that he would not be able to ask for help if it was on the floor. Resident 9 was admitted to the facility with diagnoses including dementia, hypertension, diabetes mellitus, and muscle weakness. The Minimum Data Set (MDS) dated April 13, 2024, indicated that Resident 9 had severe cognitive impairment. The care plan dated April 9, 2024, specified that the call light should be within Resident 9's reach due to his musculoskeletal issues and mobility limitations. The Director of Nursing (DON) confirmed that Resident 9 would not be able to ask for help when his call light was on the floor. The facility's policy and procedure titled 'Answering the Call Light' also indicated that the call light should be within easy reach of the resident.
Failure to Schedule Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to ensure that follow-up appointments with a cardiologist and pulmonologist were scheduled for Resident 8, who had significant medical conditions including myocardial infarction, heart failure, atrial fibrillation, and acute respiratory failure. Despite having physician orders dated March 30, 2024, for follow-up appointments within one to two weeks, these appointments were not scheduled. Resident 8 expressed concerns about her cardiology appointment and had not received any updates from the Social Service Designee (SSD) or Case Manager (CM), who were responsible for scheduling these appointments. Interviews with the Licensed Vocational Nurse (LVN), SSD, CM, and Director of Nursing (DON) revealed a lack of communication and urgency in scheduling the necessary follow-up appointments. The LVN was unaware of whether the appointments had been scheduled, and the SSD admitted to not sending multiple referrals or making additional phone calls to secure the appointments. The CM also failed to document her attempts to schedule the pulmonology appointment and did not notify the physician about the scheduling difficulties. The facility's policy on referrals and consults, dated December 2008, requires social services or designees to coordinate resident referrals based on physician orders and to document these referrals in the resident's medical record. However, this policy was not followed, as evidenced by the lack of scheduled appointments and documentation for Resident 8. The DON acknowledged the importance of the cardiology appointment, given Resident 8's use of a cardiac life vest, but stated that the facility's policy did not specify a timeframe for scheduling appointments, leading to a delay in necessary medical follow-ups.
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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