Asbury Park Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 2257 Fair Oaks Blvd., Sacramento, California 95825
- CMS Provider Number
- 555673
- Inspections on file
- 51
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Asbury Park Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as flies were observed in the rooms of two residents whose sliding doors were open and lacked screens. Staff and maintenance confirmed that most sliding doors in the building had no screens, and the DON acknowledged concerns about flies, expecting staff to keep doors closed until screens were installed. Pest control service records were reviewed, but the fly issue persisted.
A resident with muscle atrophy and incontinence was left in a soiled brief for an extended period, despite expressing discomfort and using the call light. Staff, including CNAs and the DON, acknowledged the importance of timely changing to prevent dignity issues, but failed to act promptly. The facility's dignity policy, which emphasizes prompt response to toileting needs, was not followed.
Three residents were not protected from peer abuse, including physical altercations and racial slurs. One resident with cognitive impairment was slapped by another, a second was punched in the thigh by a peer, and a third experienced emotional distress after being subjected to racial and verbal abuse by a roommate. Staff and documentation confirmed these incidents, and the affected residents had varying degrees of cognitive and physical impairment.
The facility did not follow the planned menu for therapeutic diets, affecting 128 residents. Twenty residents on CCHO diets received margarine, two residents on CCHO and renal diets did not receive the correct meal components, and nine residents on puree diets did not receive the puree wheat roll. Additionally, all residents missed the parsley garnish. The Director of Dietary Services acknowledged the issues, and the Registered Dietitian emphasized the need to adhere to the menu.
The facility failed to ensure food safety, with an unclean ice machine, improperly stored kitchenware, a missing air gap in a prep sink, incorrect dishwashing procedures, and staff without proper beard restraints. These issues posed a risk of food contamination for all residents.
The facility failed to securely close one of two garbage dumpsters outside, leaving gaps that could attract pests. The Dietary Assistant Manager confirmed the issue, and the Registered Dietitian emphasized the need for tightly closed lids to prevent pest problems. Facility policy and the FDA Food Code require secure, tight-fitting lids for waste receptacles.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). Additionally, medication accountability was lacking during shift changes, with missing signatures on controlled drug sign-in/sign-out sheets. The facility also did not have an efficient system to document and secure emergency medications (E-Kit), and medications were not secured safely, with retrievable crushed and partially crushed medications found in multiple medication carts.
The facility failed to ensure three residents were free from unnecessary psychotropic medication use. A resident received Seroquel without non-pharmacological interventions for bipolar disorder. Another resident was given Seroquel without adequate indication, and staff confirmed no symptoms of schizophrenia. A third resident's Lorazepam order did not match the behavior being monitored, with no documented non-drug interventions. Facility policies requiring non-pharmacological approaches were not followed.
A facility failed to maintain a medication error rate below 5%, with errors observed during medication passes for three residents. Errors included incorrect dosing of diclofenac gel, failure to prime an insulin pen, incorrect measurement of ClearLax, and administering glipizide without a meal. These actions were not in accordance with prescriber's orders or manufacturer's specifications.
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Medications were not stored according to manufacturer specifications, and discontinued medications were not disposed of properly. Medication carts were disorganized, with controlled medications not stored securely and some medications lacking resident-specific labels. Resident 81, with multiple diagnoses, was found with an albuterol inhaler at the bedside without authorization to self-administer, highlighting further issues with medication management.
The facility failed to have written agreements with dialysis clinics for three residents receiving dialysis treatment. Despite multiple attempts to secure contracts, the facility was unable to provide valid agreements, leading to potential accountability issues in the dialysis services provided.
The facility failed to maintain effective infection control practices, as evidenced by improper storage of nasal cannulas and nebulizer equipment for several residents, and environmental cleanliness issues in the laundry room. Staff confirmed these deficiencies, acknowledging the potential for contamination and infection risk.
The facility failed to maintain the laundry room in a safe and operable condition, with observations of wet floors and corroded, leaking pipes. The Director of Environmental Services confirmed the issue, noting that repairs were pending. The Infection Preventionist also observed moisture and lint on the ground, contrary to facility expectations.
A facility failed to obtain informed consents from the authorized representative for a resident with severe cognitive impairment. Consents for treatment, POLST, and psychotropic medication were signed by individuals not listed as the responsible party, such as the resident's daughter-in-law and son. Staff interviews confirmed the discrepancy, acknowledging that the responsible party's name was on the resident's chart, and the expectation was for them to sign the consents. Facility policies emphasized obtaining consents from the resident representative, which was not adhered to, leading to the deficiency.
The facility failed to secure confidential resident health data when a computer on Medication Cart 2A was left unattended with a resident profile open, facing the hallway. A nurse acknowledged the breach, and the DON confirmed the expectation for staff to protect resident records. The facility's policy requires only authorized access to electronic medical records.
A facility failed to provide written notice of bed hold to a resident's responsible party when the resident, who was severely cognitively impaired, was transferred to a hospital. Despite attempts to contact the RP, no written notice was documented, violating the facility's policy requiring notification within 24 hours of transfer.
A resident did not receive their prescribed Citalopram for eight days due to a failure in the facility's admission process to carry over the medication order. The resident, who was cognitively intact and had a history of depression, experienced withdrawal symptoms and reported these to the staff, but the medication was still not administered. The admitting nurse and DON confirmed the oversight, which was contrary to the facility's medication reconciliation policy.
A resident with diabetes and chronic kidney disease did not receive necessary podiatry care, resulting in long and thick toenails. Despite a physician's order for podiatry care every two months, the resident had not seen a podiatrist since admission. Internal communication failures led to the oversight, as the need for toenail clipping was noted but not addressed. Facility policy requires diabetic residents to be referred to podiatry services, but there was no evidence of rescheduled appointments.
A facility failed to ensure proper communication with a dialysis clinic regarding a resident's anemia management. The resident, with ESRD and anemia, was supposed to receive Epoetin Alfa at dialysis, but records showed it was not administered. Instead, the resident received Mircera, a different medication, without the facility's knowledge, impacting their ability to monitor treatment effectiveness.
A facility failed to ensure a consultant pharmacist conducted a Medication Regimen Review (MRR) for a resident with Major Depressive Disorder, schizophrenia, and diabetes. The resident had multiple orders for Seroquel, but the CP did not complete an MRR as required by the facility's policy. This oversight was confirmed by the Pharmacy Manager and the Director of Nursing, highlighting a lapse in monitoring the resident's medication regimen.
The facility failed to meet the dietary needs of two residents. A resident with dysphagia was served broccoli, which he dislikes, and another resident on a mechanical soft diet did not receive his preferred gelato. Staff confirmed these oversights, and the facility's policy requires honoring food preferences and substituting disliked items.
Two residents in the facility were found with inaccessible call lights, potentially leading to unmet needs and delayed staff response. One resident, with moderate cognitive impairment and requiring substantial assistance, had their call light on the floor, while another resident, cognitively intact but dependent on staff, had their call light pinned between the bed rail and bed frame. The DON confirmed the issue, which contradicts the facility's policy requiring accessible call lights.
A resident with multiple medical conditions left an LTC facility unsupervised without a physician's order for a Leave of Absence (LOA). The resident, who required assistance for mobility, used a rideshare service to visit his son. Facility staff, including a new CNA, failed to follow the LOA policy, leading to the resident's unsupervised departure. Miscommunication and misunderstanding of discharge procedures contributed to the incident.
A facility failed to maintain an effective IPCP for 134 residents, as staff did not wear required PPE during catheter care for a resident on ESP. PPE was not available outside the rooms of three residents on ESP, increasing cross-contamination risk. The LN was unfamiliar with PPE requirements, and the DON acknowledged the infection risk. Facility policies and CDC guidelines stress PPE availability and staff training for effective EBP implementation.
The facility failed to respond promptly to call lights, compromising the dignity and care of three residents. A resident's family reported long waits for assistance, leading to incontinence. Another resident expressed dissatisfaction with delayed responses, risking spills. Observations showed a resident left waiting over an hour for help, visibly distressed. Staff interviews revealed non-compliance with timely response policies, acknowledged by the DON.
The facility failed to report the results of a 5-day investigation within the required timeframe after an altercation between two residents, where one resident scratched the other. The facility did not provide evidence to the CDPH that a summary of the investigation and corrective actions were submitted on time. The DON confirmed the delay in submission.
The facility failed to ensure safe evacuation routes, as they were cluttered with carts, commodes, linen bins, and garbage bins. A resident demonstrated the issue by attempting to navigate an emergency exit in a wheelchair, finding it obstructed. The DON confirmed the clutter and non-functional alarms, acknowledging the routes should have been clear and bins covered for infection control.
Failure to Maintain Effective Pest Control Program Due to Missing Door Screens
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in residents' rooms. Observations and interviews revealed that two residents had flies in their rooms, with one resident confirming that flies were present all the time. Both rooms had sliding doors that were open and lacked screens, which was confirmed by a CNA. The Director of Maintenance acknowledged that 14 out of 16 sliding doors in the building did not have screening doors and confirmed an ongoing fly issue. The Director of Nursing also confirmed concerns regarding flies and expected staff to keep sliding doors closed until screens could be installed. A review of pest control service invoices for the preceding months showed ongoing pest control efforts, but these were not effective in preventing the fly issue. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents, but the lack of screens on most sliding doors and the presence of flies in resident rooms demonstrated a failure to meet this standard.
Failure to Maintain Resident Dignity Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, who was admitted in the summer of 2016 with a diagnosis of muscle atrophy and wasting, by leaving him in a soiled brief for an extended period. The resident, who was totally dependent on staff for toileting, was observed to have a strong odor coming from his room, indicating he was soiled. Despite the resident's call light being on and his verbal expression of discomfort and upset due to being soiled, staff members, including CNAs and an Infection Preventionist, did not promptly address his needs. The resident remained in a soiled brief for an extended period, which was confirmed by multiple staff members, including a CNA and the Director of Nursing, who acknowledged the importance of timely changing to prevent dignity issues and skin problems. Interviews with staff, including CNAs, a Licensed Nurse, and the Director of Nursing, revealed a lack of timely response to the resident's needs, with staff indicating that they would inform the primary CNA or wait for another staff member to address the issue. The facility's policy on dignity, which prohibits demeaning practices and emphasizes the importance of promptly responding to residents' requests for toileting assistance, was not adhered to in this instance. The Social Service Director confirmed that the resident was alert and oriented, capable of expressing his needs, yet his requests were not promptly met, compromising his dignity and comfort.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect three residents from abuse by their peers, resulting in incidents of physical and verbal abuse. In one case, a resident with major depressive disorder and schizophrenia, but who was cognitively intact, slapped another resident with severe cognitive impairment after an altercation involving personal belongings. Staff documentation and interviews confirmed that the physical contact occurred before staff could intervene, and the resident who was slapped was unable to recall the incident due to cognitive impairment. In another incident, a cognitively intact resident with a history of cellulitis and diabetes was observed by staff grabbing and punching the thigh of a severely cognitively impaired resident with end-stage renal disease and chronic respiratory failure. The staff member witnessed the physical aggression and noted that the aggressor had exhibited similar behaviors with a previous roommate during the same shift. The resident who was struck verbally threatened staff during an interview and did not wish to continue the conversation. A third incident involved a resident with difficulty walking and muscle weakness who experienced racial and verbal abuse from a roommate, leading to emotional distress and a panic attack. Staff and family members confirmed that the resident was subjected to racial slurs and mocking language, resulting in the resident being moved to another room and requiring medication for anxiety. The facility's policy prohibits all forms of abuse, including verbal and physical, but these incidents demonstrate that residents were not adequately protected from peer abuse.
Failure to Follow Therapeutic Diet Menus
Penalty
Summary
The facility failed to adhere to the planned menu for therapeutic diets during a lunch meal distribution, affecting 128 residents. Specifically, 20 residents on controlled carbohydrate (CCHO) diets received margarine, which was not part of their prescribed diet. Two residents on CCHO and renal diets did not receive the correct meal components, such as baked fish and wheat rolls, as indicated on the menu. Additionally, nine residents on puree diets did not receive the puree wheat roll as specified. Furthermore, all 128 residents did not receive the parsley garnish that was supposed to accompany their meals. These deficiencies were identified through observation, interviews, and record reviews. The Director of Dietary Services acknowledged the issues, attributing the lack of parsley garnish to a failure to order it. The Registered Dietitian confirmed awareness of the issues and emphasized the importance of following the menu/spreadsheet. The facility's policy mandates that menus meet the nutritional needs of residents and comply with the diet manual, which was not followed in this instance.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety in several areas, as observed during a survey. The ice machine was found to be unclean, with significant dark brown and yellow substances identified as calcium buildups on the evaporator unit. The maintenance department was responsible for monthly cleaning, while an outside vendor was tasked with deep cleaning every three months. However, despite a recent service, the machine was still dirty, indicating a lapse in the cleaning process. Additionally, various kitchenware items were improperly stored while still wet and with food particles, contrary to the facility's policy that requires them to be clean and air-dried before storage. The facility also failed to maintain proper sanitation standards in other areas. An air gap was missing from the fruit and vegetable prep sink, which is necessary to prevent backflow and contamination. Furthermore, a dietary aide incorrectly verbalized the manual dishwashing process, stating that dishes were immersed in sanitizer for only two seconds instead of the required 60 seconds. This discrepancy highlights a lack of proper training or adherence to established procedures, which could compromise the sanitation of kitchenware. Lastly, two kitchen staff members were observed without proper beard restraints, using medical masks instead. This was against the facility's dress code policy, which mandates beard restraints to prevent hair from contacting food and clean equipment. These deficiencies collectively posed a risk of food contamination, potentially affecting all 128 residents who rely on the facility's kitchen for their meals.
Improperly Secured Garbage Dumpster
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not securely closing one of two garbage dumpsters located outside the facility. During an observation and interview with the Dietary Assistant Manager, it was noted that the lids of one dumpster were not securely covering the bin, leaving gaps on both sides. The Dietary Assistant Manager confirmed that the lids lacked integrity and agreed that this was unacceptable. In a subsequent interview, the Registered Dietitian stated that the dumpster lids should be tightly closed without any openings or gaps to prevent pest and rodent issues. A review of the facility's policy indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and the trash collection area must be kept clean to avoid attracting vermin and rodents. The 2022 FDA Food Code also requires outside receptacles containing food residue to have tight-fitting lids, doors, or covers.
Controlled Medication Accountability and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications were signed out of the Controlled Drug Record (CDR) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. For instance, Resident 69 had tramadol signed out on two occasions, but the MAR did not reflect administration. Similarly, Resident 58 had discrepancies between the CDR and MAR for oxycodone, and Resident 65 had tramadol signed out without corresponding MAR documentation. The Director of Nursing (DON) confirmed that nursing staff were expected to document administered doses on both the MAR and CDR. The facility also failed to maintain medication accountability during shift changes, as evidenced by missing signatures on controlled drug sign-in/sign-out sheets for two medication carts. Nine signatures were missing for Medication Cart 2A, and five were missing for Medication Cart 1C. Licensed Nurses 7 and 8 acknowledged the missing signatures and confirmed the expectation for both outgoing and incoming nurses to sign the sheets during shift changes. The facility's policy required controlled substances to be reconciled at the end of each shift, with both nurses determining the count together. Additionally, the facility did not have an efficient system to document and secure emergency medications (E-Kit). An inspection revealed discrepancies in the E-kit log, with missing documentation for removed oxycodone tablets and Ativan vials. The DON stated that nursing staff were expected to ensure accurate E-kit logs and request replacements promptly. Furthermore, medications were not secured safely, as multiple medication carts contained retrievable crushed and partially crushed medications, including controlled substances. The DON confirmed that medications should be rendered irretrievable before disposal, as per the facility's policy.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use. Resident 7 was administered Seroquel for bipolar disorder without the implementation of non-pharmacological interventions to attempt a gradual dose reduction or discontinuation of the medication. The Director of Nursing confirmed that the care plans did not include non-drug interventions, despite the facility's policy requiring such measures to minimize medication use. Resident 128 was given Seroquel without adequate indication for its use. The resident's medical records showed a series of orders for Seroquel with varying dosages and indications, none of which were supported by documented evidence of hallucinations or delusions. Interviews with staff and the resident revealed that the resident did not exhibit symptoms of schizophrenia, and the resident expressed concern over a misdiagnosis. The facility's policy stated that antipsychotic medications should only be used when clinically indicated, which was not adhered to in this case. Resident 25's behavior order for Lorazepam did not match the behavior being monitored, and there was no documented evidence of non-pharmacological interventions being used when behaviors occurred. The resident's care plan and medication administration records showed inconsistencies in the behavior being monitored and the behavior for which the medication was prescribed. Interviews with staff indicated that non-drug interventions were not consistently documented, despite the facility's policy requiring such documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 12.5% during a medication pass. This was based on four medication errors out of 32 opportunities observed for three residents. The errors included incorrect dosing and administration of medications, which were not in accordance with the prescriber's orders or manufacturer's specifications. For Resident 110, a Licensed Nurse (LN 2) was observed preparing diclofenac gel but measured only 2 grams instead of the prescribed 4 grams. This discrepancy was confirmed during a review of the resident's medical record and an interview with LN 2. The facility's policy required medications to be administered as per the prescriber's orders, which was not followed in this instance. Resident 104 experienced two medication errors. LN 2 failed to prime an insulin aspart pen before administration and incorrectly measured ClearLax, not filling it to the indicated line for the correct dose. These errors were acknowledged by LN 2 during interviews. Additionally, Resident 12 was given glipizide without a meal, contrary to the manufacturer's instructions, which could lead to hypoglycemia. LN 3, who administered the medication, was unsure of the timing considerations for glipizide. The facility's policy emphasized the importance of administering medications in a safe and timely manner, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. During an inspection of medication carts and storage rooms, it was observed that medications were not stored according to manufacturer specifications. For instance, a bottle of acidophilus was not refrigerated as required, and an acetic acid irrigation solution was opened without an open or discard date. Additionally, discontinued medications were not disposed of properly, as evidenced by an opened box of aformoterol left on a shelf instead of being placed in the drug disposal bin. Medication carts were found to be disorganized and not securely locked when unattended. Controlled medications, such as phenobarbital, were not stored in the designated controlled drug drawer, and medications like clonidine patches were comingled with oral medications. Furthermore, several inhalers and nasal sprays lacked resident-specific labels, increasing the risk of incorrect administration. Expired medications, such as labetalol, were also found in the carts, and some medications were stored without proper labeling or dating, such as EvenCare G3 test strips and budesonide inhalation solution. Resident 81's case highlighted additional issues with medication management. The resident, who had multiple diagnoses including COPD and moderate cognitive impairment, was found with an albuterol inhaler at the bedside without an assessment or order to self-administer. Despite staff acknowledging the risk of overmedication and the need for the inhaler to be stored in the med cart, it remained at the bedside. The facility's policies indicated that medications should not be stored at the bedside unless authorized, which was not the case for Resident 81.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources, specifically dialysis services, had written agreements in place. This deficiency was identified for three residents who were receiving dialysis treatment without existing agreements with the dialysis clinics. The absence of these agreements could lead to a lack of responsibility and accountability in the dialysis services provided to the residents. Resident 36 was admitted with end-stage renal disease and required dialysis. The care plan and physician orders indicated the need for dialysis, but during interviews, the Administrator and Director of Transportation Services admitted that there was no current contract with the dialysis clinic. The agreement provided was outdated and lacked specific details, and the facility was unable to produce a valid contract during the survey. Similarly, Resident 15, who was severely cognitively impaired and dependent on dialysis, was also receiving dialysis services without a contract in place. Despite multiple attempts by the Director of Transportation Services to obtain a contract from the dialysis clinic, the facility was unable to secure one. Resident 51, also dependent on dialysis, was in a similar situation, with the facility still waiting for a contract from the dialysis center at the time of the survey.
Infection Control Deficiencies in Equipment Handling and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper handling and storage of medical equipment and environmental cleanliness issues. Resident 36's nasal cannula was repeatedly observed on the floor in their room, both when the resident was present and absent, despite the facility's policy requiring such equipment to be stored in a protective bag. Similarly, Resident 46's nasal cannula was also found on the floor, contrary to the facility's infection control expectations. Interviews with staff confirmed these observations and acknowledged the potential for contamination. Environmental issues were also noted in the facility's laundry room, where dust particles were observed on vents above the clean linen area, and moisture and dust were present at the back of the washers. The Director of Environmental Services confirmed these observations, acknowledging that the dust could contaminate clean linens and that the moisture and lint on the ground were not acceptable. The facility's policies require maintenance personnel to follow infection control precautions, which were not adhered to in this instance. Resident 71's nebulizer tubing and mask were improperly stored in a drawer without a protective bag and were not labeled with the date of change, as required by the facility's policy. The oxygen concentrator humidifier bottle was also not labeled with the date of change. The Infection Preventionist and Director of Nursing confirmed these deficiencies, noting that the improper storage and lack of labeling put the resident at risk for infection. Resident 3's oxygen tubing was similarly found on the floor, with the nasal cannula not properly stored, which was confirmed by a Certified Nursing Assistant and the Director of Nursing.
Deficiency in Laundry Room Maintenance
Penalty
Summary
The facility failed to maintain the building and equipment in a functional and operable manner, as evidenced by the condition of the laundry room. During an observation and interview, it was noted that the floor at the back of the washer was wet, and the pipes were dirty, corroded, and leaking. One pipe was observed to be corroded with a greenish color, and the leakage was confirmed to be coming from this pipe. The Director of Environmental Services acknowledged the issue and mentioned that a company had been contacted for repairs, but no confirmation on the repair timeline was available. The Infection Preventionist also confirmed the presence of moisture and lint on the ground, which was not in line with the facility's expectations. A review of the facility's maintenance policy indicated that maintenance service should ensure all areas of the building, grounds, and equipment are safe and operable at all times.
Failure to Obtain Informed Consent from Authorized Representative
Penalty
Summary
The facility failed to obtain informed consents from the authorized resident representative for a resident, identified as Resident 97, who was admitted with major depressive disorder and dementia. The resident's records indicated severe cognitive impairment, and the spouse was designated as the responsible party (RP). However, consents for treatment, Physician Orders for Life-Sustaining Treatment (POLST), and psychotropic medication were signed by individuals not listed as the RP, such as the resident's daughter-in-law and son. Interviews with facility staff, including a licensed nurse, the Assistant Director of Staff Development, and the Nurse Supervisor, revealed that verbal consents were obtained from individuals other than the RP, contrary to the facility's policy. The staff acknowledged that the RP's name was on the resident's chart, and the expectation was for the RP to sign the consents. The Director of Nursing and Nurse Consultant confirmed the discrepancy and stated that the RP should have been contacted for consent, as the RP has the decision-making capacity for the resident's care. The facility's policies and procedures emphasized the importance of obtaining consents from the resident representative, especially when the resident is deemed incompetent. The policies outlined that the RP should be informed of the care, risks, and benefits of treatments, and that informed consent for psychotropic medications should be verified and documented. The failure to adhere to these policies resulted in the deficiency, as the consents were not obtained from the designated RP, potentially compromising the resident's rights and care decisions.
Failure to Secure Resident Health Data
Penalty
Summary
The facility failed to protect and secure confidential resident health data and records for a census of 132 residents. During an observation, a computer on Medication Cart 2A was left unattended with a resident profile open, facing the resident hallway. This incident occurred in hallway 2A and was observed at 4:30 p.m. on January 7, 2025. Licensed Nurse 7 acknowledged the computer was left unlocked and unattended, making resident records accessible to unauthorized individuals, which he recognized as a violation of confidentiality. The Director of Nursing confirmed that nursing staff are expected to ensure resident records are not visible to unauthorized staff. The facility's policy, dated March 2014, states that only authorized persons with a password and user ID should access the electronic medical records system.
Failure to Notify Resident's Representative of Bed Hold
Penalty
Summary
The facility failed to provide written notice of bed hold to the responsible party (RP) of a resident when the resident was transferred to a hospital. The resident, who was severely cognitively impaired and unable to make their own decisions, was transferred to an acute care hospital for further evaluation due to hypotension and an infected catheter site. Despite attempts to contact the RP, the call went to voicemail, and no written notice of the bed hold was documented in the resident's clinical record for this transfer. The facility's policy requires that all residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours in the case of an emergency. However, the Director of Nursing acknowledged that the Transfer and Bed Hold Form was not completed, and the RP was not notified of the bed hold for the resident's transfer to the hospital. This oversight was identified during a review of the resident's clinical records and interviews with facility staff.
Failure to Administer Psychotropic Medication Upon Admission
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following their admission policy and procedure, resulting in a psychotropic medication order not being carried over for a resident upon admission. This oversight led to the resident not receiving their prescribed Citalopram, a medication for depression, for eight days. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of depression and was on Citalopram 20 mg daily as per their hospital discharge orders. However, the medication was not documented in the facility's records upon admission, and the resident experienced withdrawal symptoms as a result. The resident reported symptoms such as shaking, crying, nausea, dizziness, and muscle pain, which they attributed to the lack of their antidepressant medication. Despite informing the facility staff multiple times, the medication was not administered. The admitting nurse and the Director of Nursing confirmed that the medication order was missed during the admission process, which involved reviewing and reconciling hospital discharge orders with the admitting physician. The facility's policy on medication reconciliation, which aims to prevent medication errors and ensure accurate communication of medication orders, was not followed in this instance.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot care for a resident, identified as Resident 51, who had long and thick toenails. Resident 51, who was admitted with type 2 diabetes mellitus and diabetic chronic kidney disease, had not received podiatry care since admission, despite a physician's order for podiatry care every two months. The resident, who was cognitively intact, reported not having seen a podiatrist since admission, and observations confirmed the toenails were long and thick. Certified Nursing Assistant 2 noted the need for toenail clipping about a month prior, but the issue was not addressed. The facility's internal communication failed to ensure the resident received podiatry care. The Assistant Director of Staff Development stated that concerns noted in shower sheets should be directed to the responsible person, but the Social Services Director did not receive any notification regarding the resident's toenails. The Nurse Supervisor confirmed the need for podiatry care upon observing the resident's toenails. The facility's policy indicated that diabetic residents should not have their toenails trimmed by staff, and they should be referred to podiatry services if necessary. However, there was no documented evidence that the resident's podiatry appointments were rescheduled after being missed.
Failure in Communication of Anemia Management for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration between the facility and the dialysis clinic regarding the anemia management of a resident with end-stage renal disease (ESRD) and anemia. The resident was admitted with diagnoses including ESRD and anemia, and their care plan required the administration of Epoetin Alfa at the dialysis center. However, the facility's Medication Administration Records (MARs) indicated that the medication was signed off as given at dialysis, despite the dialysis communication sheets showing that the resident did not receive Epoetin Alfa during dialysis. Instead, the resident was receiving Mircera, a different anemia medication, every two weeks, which was not communicated to the facility. The dialysis nurse confirmed that Epoetin Alfa had been discontinued and replaced with Mircera. The Director of Nursing and Nurse Consultant acknowledged the lack of communication regarding the medication change, which resulted in the facility being unaware of the resident's current anemia management. This oversight decreased the facility's ability to monitor the medication's effectiveness and side effects, as outlined in their policies and procedures.
Failure to Conduct Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) conducted a Medication Regimen Review (MRR) for a resident, identified as Resident 128, who was admitted with diagnoses including Major Depressive Disorder, schizophrenia unspecified, and diabetes. The resident had several physician's orders for Seroquel, an antipsychotic medication, with varying dosages and indications for use. Despite these orders, the CP did not complete an MRR for Resident 128 in December 2024, as confirmed by both the Pharmacy Manager and the Director of Nursing during interviews and record reviews. The facility's policy and procedure, dated May 2019, clearly stated that the CP is responsible for performing an MRR for every resident receiving medication, particularly upon admission. However, the CP failed to adhere to this policy, resulting in inadequate monitoring of Resident 128's medication regimen. This oversight had the potential to impact the optimization of the resident's medications for the best possible health outcome, as the irregularities in the medication regimen were not identified or reported by the CP.
Failure to Accommodate Dietary Preferences and Requirements
Penalty
Summary
The facility failed to accommodate the special dietary requirements for two residents during a lunch observation. Resident 106, who has dysphagia, was served a puree meal that included broccoli, despite having a documented dislike for broccoli on his meal ticket. The Certified Nursing Assistant (CNA) confirmed the presence of broccoli and acknowledged that the resident did not want it. The Director of Nursing (DON) stated that staff are expected to review meal tickets and provide alternatives if a disliked food is served. Resident 108, who is on a mechanical soft diet, did not receive the gelato he preferred, as indicated on his meal ticket. The Assistant Director of Staff Development (ADSD) confirmed the absence of gelato on the meal tray and acknowledged that it should have been provided. The Director of Dietary Services (DDS) stated that resident preferences, as indicated on meal tickets, should be honored. The facility's policy on food preferences requires that dislikes be substituted with appropriate alternatives.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to potential unmet needs and delayed staff response. Resident 22, who was admitted with multiple diagnoses including generalized muscle weakness, had a moderate cognitive impairment and required substantial assistance for mobility. During an observation, Resident 22's call light was found on the floor, out of reach, despite the care plan indicating it should be within reach and monitored every two hours and as needed. Similarly, Resident 82, who was cognitively intact but dependent on staff for mobility, had their call light pinned between the bed rail and bed frame, making it inaccessible. Resident 82 expressed difficulty in calling for help due to the call light's position. The Director of Nursing confirmed the call lights were out of reach for both residents and stated that staff are expected to ensure call lights are accessible. The facility's policy requires each resident to have a means to call staff directly for assistance from their bed.
Resident Leaves Facility Unsupervised Due to LOA Policy Failure
Penalty
Summary
The facility failed to identify and prevent a resident from leaving the premises without staff awareness or a physician's order for a Leave of Absence (LOA). The resident, who was admitted with multiple diagnoses including acute osteomyelitis, pressure injury, and generalized muscle weakness, was cognitively intact but dependent on assistance for mobility. Despite these needs, the resident left the facility with an unidentified person and was not noticed missing until he returned on his own. The incident occurred when the resident, who was wheelchair-bound and required assistance for transfers, left the facility using a rideshare service to visit his son. The staff, including the assigned CNA and charge nurse, were unaware of the resident's departure due to a lack of communication and understanding of the LOA policy. The CNA, a new hire, mistakenly believed the person taking the resident was his son and did not verify the LOA process, leading to the resident's unsupervised exit. Interviews with facility staff and family members revealed confusion and miscommunication regarding the resident's whereabouts and the facility's discharge procedures. The Director of Nursing acknowledged the mistake, attributing it to the resident's room change and possible misunderstanding of being discharged. The facility's policy required a physician's order and proper documentation for LOA, which was not followed, resulting in the resident's unsupervised and potentially unsafe absence from the facility.
Inadequate PPE Use and Availability for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) for a census of 134 residents. Specifically, a staff member did not wear the required personal protective equipment (PPE) while providing catheter care for a resident on Enhanced Standard Precautions (ESP). Additionally, PPE was not readily available outside the rooms of three residents on ESP, increasing the risk of cross-contamination and potential infections among residents. The Licensed Nurse (LN) was unfamiliar with the necessary PPE requirements and did not use a gown or mask when changing the resident's indwelling urinary catheter. Observations and interviews revealed that PPE, including gowns, gloves, and masks, were not available outside the rooms of residents on ESP. The Director of Nursing (DON) acknowledged that not using required PPE could lead to infection. The facility's policy and procedure, as well as CDC guidelines, emphasize the importance of PPE availability and staff training for effective implementation of Enhanced Barrier Precautions. The deficiency was identified through a review of admission records, care plans, and physician's orders, highlighting the facility's failure to adhere to established infection control protocols.
Failure to Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to promote individual care and dignity by not responding to the call lights of three residents in a timely manner, leading to unmet needs and feelings of discomfort, embarrassment, and helplessness. Resident 1's family member reported that the resident, who was cognitively intact and had control over bladder and bowel functions, often had to wait over an hour for assistance, resulting in incontinence. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) and maintaining skin integrity, but these needs were not met due to delayed staff response. Resident 5, who was also cognitively intact, expressed dissatisfaction with the call light response, stating that he often had to wait 30 minutes or longer for help, which put him at risk of spilling his urine bottle. Observations confirmed that Resident 2, who had multiple diagnoses including difficulty walking and a recent shoulder dislocation, was left waiting for over an hour for assistance to use the commode. The resident was found standing in the doorway with wet incontinence briefs, visibly distressed and tearful, as staff walked by without offering help. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy on timely call light response. CNA 1 and LN 1 failed to assist Resident 2 promptly, and CNA 3, who was late for her shift, assumed other staff would attend to her residents. The DON acknowledged the issue and stated that call lights should be answered within 5-10 minutes, but observations showed that this standard was not met, resulting in compromised resident dignity and care.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of a 5-day investigation within the required timeframe for two residents involved in an altercation. Resident 1 scratched Resident 2 during an incident where Resident 2 approached Resident 1, exclaiming for her to leave, and swiped her hand towards Resident 1. In response, Resident 1 grabbed Resident 2's hand and swiped her own hand towards Resident 2's chest, resulting in three prominent scratch marks. The facility did not provide documented evidence to the California Department of Public Health (CDPH) that a summary of the investigation and appropriate corrective actions were submitted within 5 working days of the incident. The Director of Nursing (DON) confirmed during an interview that the 5-day follow-up investigation summary was not submitted within the required timeframe.
Cluttered Evacuation Routes and Non-Functional Alarms
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and the public by allowing evacuation routes to be cluttered with carts, bedside commodes, linen bins, and garbage bins. This deficiency was observed in a 139-bed facility and was highlighted by Resident 4, who expressed concerns about safety. Resident 4, admitted for aftercare of back surgery, demonstrated the issue by attempting to navigate an emergency exit route in his wheelchair. The route was obstructed by various items, making it impossible for him to pass through safely. Additionally, the emergency exit alarms did not sound when the doors were opened, further compromising safety. The Director of Nursing (DON) confirmed the presence of clutter and non-functional alarms during a concurrent observation and interview. The DON acknowledged that the evacuation routes should have been kept clear and that the garbage and linen bins should have been covered for infection control. A Certified Nurse Assistant (CNA) also confirmed that the bins were regularly placed outside the exit doors for staff use, despite knowing that these routes were designated for emergency use. The facility's policy stipulated that exits should be kept clear at all times to allow for rapid evacuation, which was not adhered to in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
