Balboa Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 3520 Fourth Avenue, San Diego, California 92103
- CMS Provider Number
- 056105
- Inspections on file
- 36
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Balboa Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility administered antibiotics for suspected UTIs without adequate clinical indication, assessment, or monitoring. One resident with a suprapubic catheter and immunodeficiency received multiple antibiotics for UTI treatment and prophylaxis despite an infection screening showing no symptoms, no documented diagnosis supporting prophylaxis, no stop date for a prophylactic agent, and no documented monitoring of UTI symptoms or side effects. Another resident with DM and moderate cognitive deficits was started on Ciprofloxacin for confusion and a positive urine culture, even though confusion alone did not meet McGeer criteria for UTI and the facility’s Infection Screening Evaluation was not completed, with no documentation of symptom or side-effect monitoring during therapy.
The facility failed to follow its antibiotic stewardship and infection screening processes for three residents treated for suspected or documented UTIs. One resident with quadriplegia, immunodeficiency, and a suprapubic catheter received multiple antibiotics, including Macrobid, Levofloxacin, and Methenamine Hippurate, without documented monitoring of UTI symptoms or side effects, and with prophylactic therapy ordered despite a negative infection screening and no defined stop date. A second resident with Parkinson’s disease and moderate cognitive deficits was started on Cefuroxime Axetil for dysuria and a urinalysis showing many bacteria, but no Infection Screening Evaluation was completed before therapy and only one late progress note documented UTI symptom monitoring. A third resident with diabetes and moderate cognitive deficits was prescribed Ciprofloxacin for confusion and a positive urine culture, even though confusion alone did not meet McGeer criteria for UTI, and no Infection Screening Evaluation or ongoing symptom monitoring was documented during treatment.
Surveyors found that the facility failed to protect PHI when EBP lists containing resident names, room numbers, and reasons for EBP were posted on shower room mirrors on multiple floors. CNAs, nurses, the QAN, the IP, and the DON all acknowledged that residents’ private information should not be displayed in public areas where anyone entering could view it. Facility policies on residents’ rights and PHI required that unauthorized release or disclosure of resident information be prohibited and that PHI use be limited to the minimum necessary, but these requirements were not followed in this instance.
The facility failed to maintain a safe, clean, and homelike environment when multiple resident rooms experienced significant water intrusion from leaking ceilings and walls during rain, resulting in flooded bathrooms and wet floors that required extensive towel use. Several residents with conditions such as fractures, CKD, COPD, CHF, neuropathy, RA, fibromyalgia, and depression reported that their bathrooms and walls leaked, that floors were very wet, and that the situation was not homelike and could be dangerous. Observations confirmed water damage, including wet ceiling spots and bubbling paint, while review of the maintenance binder showed no entries documenting these leaks or repairs. Although staff described a process of reporting leaks via phone or Teams and documenting them in a maintenance log, the DOM and a maintenance worker acknowledged that no such documentation existed for the affected rooms, despite a facility policy requiring a safe, clean, and orderly homelike environment.
A resident with Alzheimer's disease and a history of behavioral disturbances, including hitting and yelling at staff and other residents, was not properly assessed or care planned for these behaviors. Staff observed and reported the behaviors, but the MDS did not reflect them, and there was no care plan in place prior to documented altercations. Facility policy required behavioral assessment and care planning, which was not followed.
A resident with chronic pain did not receive prescribed pain medication in a timely manner after requesting it multiple times during the night. The delay occurred because the assigned medication nurse was on break without passing on the medication cart keys, and another nurse failed to communicate the resident's request when the medication nurse returned. This resulted in the resident experiencing unnecessary pain due to a breakdown in staff communication and medication administration procedures.
A resident with a history of independent ambulation left the facility without staff knowledge, failing to sign out or notify anyone. The resident was last seen using the elevator, and staff only realized the absence after a search. The facility has multiple entrances, with the front entrance open during the day and the back entrance locked. Staff interviews indicated that the resident was considered independent, and the receptionist relied on nurses to communicate supervision needs. There were multiple elopements in recent months, and this incident occurred during a weekend with reduced staffing.
A resident with a history of hemiplegia, hemiparesis, visual impairment, and prior falls was allowed to smoke outside the facility without staff supervision, despite assessments and a care plan requiring supervision due to poor safety awareness. Facility staff confirmed there was no designated smoking area, no scheduled smoking times, and no formal smoking supervision program in place, resulting in unsupervised smoking contrary to documented care needs.
The facility did not have a full-time DON to oversee and manage nursing services, as confirmed by staff interviews and record review. The QA nurse, who was the former DON, indicated that the facility was still in the process of hiring for the position, and a consultant was not present during the initial investigation. This resulted in a lack of designated leadership for clinical care and care planning for all residents.
A resident with a history of falls, substance abuse, and smoking left the facility unsupervised at night and was missing for about 14 hours before being found with injuries from a wheelchair fall. Staff did not promptly report the resident's absence or initiate a search, and care plan interventions for supervision were not followed. The facility lacked a policy to ensure supervision during smoking, contributing to the resident's elopement and injury.
Staff did not follow the prepared menu or serve correct portion sizes for residents on mechanical soft, ground meat, and pureed diets, using smaller scoops than required for BBQ chicken. This affected multiple residents and was confirmed by dietary staff, the RD, DON, and Administrator, all of whom stated the importance of adhering to menu guidelines and portion sizes.
A resident with ALS and total dependence for eating was repeatedly left with their meal tray out of reach and had to wait for extended periods before being fed, while observing their roommate being fed first. Staff interviews and observations confirmed inconsistent and delayed feeding practices, resulting in a lack of a dignified dining experience as required by facility policy.
The facility failed to ensure accurate completion of MDS assessments for two residents. One resident's discharge destination was incorrectly documented as a hospital instead of home, despite supporting documentation and staff awareness of the actual discharge. Another resident's MDS did not reflect a completed PASRR Level II, even though state records confirmed it. Staff interviews confirmed these inaccuracies and a lack of verification in the MDS process.
A resident with severe cognitive impairment, dysphagia, and a history of stroke was not supervised during meals as required by their care plan. Staff delivered meals and left the resident unsupervised, despite documentation and clinical recommendations for supervision to ensure safe swallowing. Staff interviews revealed a lack of awareness or adherence to the supervision requirement.
Staff did not provide required one-on-one supervision during meals for a resident with severe cognitive impairment and dysphagia, despite clear physician orders and care plan documentation. The resident was repeatedly observed eating alone, and interviews revealed staff were either unaware of or did not adhere to the supervision requirement.
A resident with moderate cognitive impairment and a history of muscle weakness and back pain experienced ongoing pain from an ingrown and mycotic toenail due to delayed podiatry care. Despite repeated complaints and a facility policy requiring prompt podiatry referrals, the resident remained on a waiting list and was not seen by the podiatrist in a timely manner, resulting in continued pain and an overgrown, thick toenail.
A resident with a history of suicidal ideation and Major Depressive Disorder was not adequately monitored, despite recommendations for close supervision. The resident was able to harm herself by ingesting medications and cutting her wrist with a butter knife due to a lack of communication and implementation of safety measures by the facility staff.
A resident with a history of major depressive disorder and suicidal ideation was not properly monitored due to a lack of communication and care planning at the facility. Despite being assessed as at moderate to high risk for suicide, staff were unaware of the resident's condition and access to medications, leading to a self-harm incident involving an overdose and wrist cutting.
A resident with bipolar disorder physically assaulted another resident, resulting in injury and fear. Despite having a care plan to monitor and intervene in such behaviors, the DON was unaware of the interventions, leading to a failure in protecting the assaulted resident. Previous incidents involving the aggressive resident were reported but not addressed, highlighting a deficiency in implementing the facility's abuse and neglect policy.
A facility failed to notify a resident's responsible party about skin issues and a change of condition. The resident, with severe cognitive impairment, had multiple skin issues identified during an assessment. A nurse did not notify the responsible party due to not knowing who they were. Another nurse documented a change of condition but did not follow up after an unsuccessful call attempt to the responsible party. The DON acknowledged the oversight, noting the absence of a notification policy.
A resident with severe cognitive impairment, bacteremia, and diabetes did not receive consistent skin care and IV antibiotics as ordered by the physician. The facility's records showed multiple missed applications of topical treatments for skin conditions and missed doses of critical antibiotics. The Director of Nursing confirmed that licensed nurses were expected to follow physician orders and document medication administration, but the facility's practices did not align with its medication administration policy.
A facility failed to ensure timely signing of a skin evaluation form by an LN, resulting in an incomplete medical record for a resident. The LN conducted a skin assessment upon the resident's admission, identifying several skin conditions, but did not sign the evaluation forms until months later. Interviews revealed the LN was unsure of the delay, and the DON confirmed the expectation for timely documentation, though no specific policy was in place.
A resident's medical record inaccurately indicated that an LVN administered IV antibiotics, when in fact, an RN did so using the LVN's password due to a malfunctioning password. This led to incorrect documentation in the MAR, as the RN failed to report the issue to the DON.
Unnecessary Antibiotic Use Without Proper UTI Assessment or Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs, specifically related to antibiotic use for suspected urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool and infection surveillance list as part of its infection prevention and antibiotic stewardship program. On one occasion, this resident had an Infection Screening Evaluation score of 50 with acute dysuria, and a urine culture showing Gram positive cocci with a colony count of 50,000–90,000, leading to a physician order for Macrobid for a UTI. However, there was no supporting documentation that staff monitored UTI symptoms or side effects during the antibiotic course, despite the expectation that such monitoring occur during antibiotic therapy. On a later occasion for the same resident, an Infection Screening Evaluation completed on a different date showed a score of zero, indicating no symptoms of infection. The prior urine culture still showed Gram positive cocci with a colony count of 50,000–90,000, yet the resident was prescribed Levofloxacin for a UTI and Methenamine Hippurate for infection prophylaxis. The Methenamine Hippurate order did not include a documented diagnosis that clearly supported infection prophylaxis and did not include a stop date. Again, there was no documentation of monitoring for UTI symptoms or side effects during the course of these antibiotics. The Infection Prevention (IP) nurse later acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order required clarification and a defined duration. Another resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and that confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting the antibiotic, and there was no documented monitoring of UTI symptoms or side effects during the antibiotic course. The DON and facility policy indicated that staff were expected to follow appropriate clinical criteria, including McGeer criteria, and to avoid premature diagnostic conclusions, but these expectations were not met in the cases reviewed, resulting in antibiotics being initiated and continued without adequate indication, evaluation, or monitoring. The facility’s written policy on urinary tract infection/bacteriuria stated that nurses should observe, document, and report signs and symptoms in detail and avoid premature diagnostic conclusions, and that physicians should carefully review persistent or recurrent UTIs before prescribing additional antibiotics, justifying any continuation or resumption of antibiotic treatment beyond an initial course. The DON stated that when a new antibiotic order is received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if criteria for antibiotic therapy are not met, and that new onset nonspecific symptoms alone, such as change in mental status or decline in appetite, are not enough to diagnose a UTI. Despite these policies and stated expectations, the survey findings showed that antibiotics were ordered and administered without documented adherence to these criteria, without completion of the Infection Screening Evaluation in at least one case, and without documented monitoring of symptoms and side effects, constituting unnecessary drug use.
Failure to Implement Effective UTI Antibiotic Stewardship and Symptom Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and antibiotic stewardship process for three residents with suspected or documented urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool as part of its surveillance program. On 1/12/26, this resident’s screening showed a score of 50 with acute dysuria, and a urine culture from 1/9/26 showed Gram Positive Cocci with a colony count of 50,000–90,000. The physician ordered Macrobid from 1/9/26 through 1/16/26 for UTI treatment, but there was no supporting documentation that nursing staff monitored UTI symptoms or potential side effects during the antibiotic course. For the same resident, an Infection Screening Evaluation completed on 2/11/26 showed a score of zero, indicating no symptoms of infection, yet the resident was prescribed Levofloxacin from 2/10/26 through 2/17/26 for UTI and Methenamine Hippurate for infection prophylaxis without a stop date. The Methenamine Hippurate order did not include a documented diagnosis supporting infection prophylaxis, and again there was no documentation of monitoring for UTI symptoms or side effects while the resident was on these antibiotics. The Infection Prevention (IP) nurse acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order lacked a defined duration and clear diagnostic basis. A second resident with Parkinson’s disease and moderate cognitive deficits complained of dysuria on 2/2/26 and had a urinalysis on 2/3/26 showing many bacteria. The resident, who was incontinent and did not have a urinary catheter, was prescribed Cefuroxime Axetil for seven days beginning 2/4/26 for a suspected UTI. However, the facility did not complete an Infection Screening Evaluation prior to starting the antibiotic to determine if McGeer criteria for UTI were met. During the antibiotic course, only one progress note dated 2/10/26 documented monitoring of UTI symptoms, stating the resident continued on antibiotics for UTI with no complaint of bladder discomfort, and no consistent monitoring of UTI symptoms was documented. A third resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin from 2/8/26 through 2/15/26 for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting antibiotics, and there was no documented monitoring of UTI symptoms while on treatment. Across all three residents, the facility’s documented practices did not align with its Antibiotic Stewardship policy, which required complete antibiotic orders including duration and the use of clinical criteria and evaluation tools before and during antibiotic therapy.
Failure to Protect PHI by Posting EBP Lists in Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ Protected Health Information (PHI) by posting detailed Enhanced Barrier Precautions (EBP) lists in multiple shower rooms. Surveyors observed that on the 2nd, 3rd, and 4th floors, documents titled "2nd Floor EBP," "3rd Floor EBP," and "4th Floor EBP" were posted on shower room mirrors at the entrances. These documents contained resident names, room numbers, and the reasons for EBP for a total of 59 residents out of 194. The lists were used to remind staff which residents required personal protective equipment (PPE) such as gowns, gloves, masks, and face shields during showers. During interviews conducted at the time of the observations, multiple CNAs confirmed that the posted lists were used as reminders for staff about which residents were on EBP and what PPE was needed when providing showers. CNA staff on each of the three floors acknowledged that the lists contained residents’ private information and that such information should not be posted in public areas where anyone entering the shower room could read it. One CNA indicated that they believed the Infection Preventionist (IP) had hung the lists. Additional interviews with licensed nurses, RNs, the Quality Assurance Nurse (QAN), the IP, and the Director of Nursing (DON) further established that facility staff understood that residents’ private information should not be posted in public areas and should be protected. The DON stated that PHI should not be posted in a public area like a shower room and emphasized that PHI should be kept in a secured area to prevent disclosure to the public. Review of facility policies on Residents’ Rights and Protected Health Information showed that unauthorized release, access, or disclosure of resident information is prohibited and that personnel are responsible for managing and protecting PHI, limiting its use or disclosure to the minimum necessary. Despite these policies, the facility allowed PHI to be posted openly in shower rooms, resulting in the cited deficiency.
Unaddressed Ceiling and Wall Leaks Created Non-Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment by not identifying and repairing leaking ceilings and walls in multiple resident rooms on the fourth floor. During a facility tour on 1/2/26, the Director of Maintenance (DOM) reported that the only leak he had been informed of was in the third-floor dining room and that it had been addressed by resealing a sliding glass door. However, observations and resident interviews revealed that rooms 417, 421, and 425 had experienced significant water intrusion during recent rain, with visible water damage to ceilings and walls and reports of flooded bathrooms and floors. The DOM stated he was not aware of the damage in these areas. Resident 3, who had a history including right femur fracture, fall, atrial fibrillation, and chronic kidney disease and a BIMS score of 11 (moderate cognitive impairment), reported that her bathroom floor had been very wet the previous night and that staff had to place many towels to absorb the water. Observation of her bathroom showed water damage on the ceiling with wet spots and towels on the floor, and she stated that the flooding and water damage were not homelike. Resident 4, with diagnoses including neuropathy, rheumatoid arthritis, and fibromyalgia and a BIMS score of 12 (moderate cognitive impairment), similarly reported that her bathroom had flooded the previous night and that staff had placed many towels to soak up the water. Her bathroom showed water damage and bubbling paint on the ceiling, and she stated that the water on the floor was dangerous and not homelike. Resident 5, with acute kidney failure, rheumatoid arthritis, and depression and a BIMS score of 15 (intact cognition), reported that her roommate’s wall had leaked a lot the previous night and that staff had put down many towels to absorb the water; she stated that the leaking wall was not homelike and could have been dangerous if someone slipped. Resident 16, with a history of fall, COPD, and CHF and a BIMS score of 11 (moderate cognitive impairment), reported that there had been a lot of water on the bathroom floor the previous week, that staff had placed big towels from the wall to the toilet to the door, and that no one could use the bathroom; she stated that the leaking ceilings and flood were not homelike. Staff interviews (RNs and CNAs) consistently described their immediate response to leaks as moving residents if needed, placing towels to control water, and contacting maintenance by phone or Teams and documenting in a maintenance binder, and they all acknowledged that leaking ceilings, flooded bathrooms, and water-damaged walls were not homelike and could present slipping hazards. Review of the fourth-floor maintenance binder on 1/2/26 and 1/9/26 showed no entries documenting the leaks or repairs for rooms 417, 421, or 425, despite staff and resident reports of flooding and water damage. The DOM and a maintenance worker stated that staff were expected to report leaks via phone or Teams and to document them in the maintenance binder, and that repairs should also be documented there so that completion could be tracked. Both the DOM and the Administrator acknowledged that leaking ceilings and water-damaged walls were not homelike and that the facility should be aware of and immediately repair such issues. The facility’s “Homelike Environment” policy stated that residents are to be provided with a safe, clean, homelike environment, including a clean, sanitary, and orderly environment, which was not maintained in the affected rooms due to the unaddressed leaks and resulting water damage.
Failure to Identify and Address Resident Behavioral Disturbances
Penalty
Summary
The facility failed to identify and address a resident's behavioral disturbances, specifically incidents of hitting and yelling at staff and other residents. Observations, interviews, and record reviews revealed that the resident, who had diagnoses including late-onset Alzheimer's disease and cerebral infarction, exhibited behaviors such as wandering, entering other residents' rooms, yelling, and attempting to hit others with her cane. Despite these behaviors being observed and reported by staff, there was no care plan in place addressing these issues prior to a documented altercation. The Minimum Data Set (MDS) assessment completed for the resident did not reflect any behavioral symptoms, and the social service assistant responsible for the MDS did not interview staff or have knowledge of the resident's behaviors. Further review showed that behavior monitoring was only ordered for a short period after an altercation occurred, and there was no ongoing monitoring or comprehensive assessment of the resident's behavioral symptoms prior to the incidents. The facility's policy required staff to evaluate behavioral symptoms as part of the comprehensive assessment and to develop a care plan accordingly, but this was not done in this case. Interviews with staff confirmed that the resident's behaviors should have been identified and care planned to ensure appropriate care and safety.
Failure to Timely Administer Pain Medication Due to Staff Communication Breakdown
Penalty
Summary
A resident with diagnoses including right trochanteric bursitis, type 2 diabetes, and chronic pain syndrome was admitted to the facility and had physician orders for pain management, including Hydrocodone-acetaminophen for moderate pain and Oxycodone for severe pain. On a specific night, the resident reported experiencing severe pain around 2 A.M. and requested pain medication multiple times but did not receive any at that time. The electronic Medication Administration Record confirmed that no pain medication was administered during the period in question. Interviews with nursing staff revealed that the nurse assigned to the resident was on break and did not hand over the medication cart keys, preventing another nurse from accessing and administering the medication. Additionally, the nurse who was aware of the resident's pain request forgot to inform the assigned medication nurse upon their return. As a result, the resident's pain was not addressed in a timely manner, and the opportunity to provide pain relief was missed during the overnight hours.
Resident Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A resident with a known history of independently ambulating throughout the facility and using the elevator was able to leave the building without staff awareness. The resident was last seen around lunchtime using the elevator, and staff later discovered the resident was missing after a facility-wide search. The resident did not inform staff, did not sign out, and left without a physician's order. The facility has three entrances/exits, with the front entrance/exit open from 8 A.M. to 8 P.M., and some residents are allowed in the lobby area near this entrance. The back entrance/exit was reported to be locked. Interviews with staff revealed that the resident was considered independent and frequently roamed the building. The receptionist stated that they would be informed by a licensed nurse if a resident required supervision. The facility experienced three elopements in the past six months, with two occurring in the same month as this incident. The elopement occurred on a weekend when staffing was lower, and no staff member witnessed the resident leaving the building.
Failure to Supervise Resident Smoking According to Assessment and Care Plan
Penalty
Summary
The facility failed to provide required supervision for a resident who smoked, as indicated by the resident's care plan and smoking assessment. The resident, who had a history of hemiplegia and hemiparesis affecting the left side of the body, as well as visual impairment and a history of falls, was assessed as needing supervision while smoking due to poor safety awareness. Despite these documented needs, the resident was allowed to smoke outside the facility premises without staff supervision, as confirmed by interviews with the resident, another resident, and the Activities Director. The facility did not have a designated smoking area or scheduled smoking times, and residents were left to find their own places to smoke outside the facility perimeter. Record review and staff interviews further revealed that the facility lacked a formal smoking program or process for supervising residents who smoke, and the current smoking policy did not address staff supervision for resident smoking safety. The Activities Director and QA nurse both acknowledged that supervision was not consistently provided, and that the facility was still in the process of developing a smoking program. The lack of supervision was contrary to the resident's care plan and assessment, which specifically required supervision to prevent smoking-related injuries.
Absence of Full-Time DON for Nursing Services Oversight
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services, as required by policy. During a complaint investigation, the Administrator confirmed that there was no DON in place and that the Quality Assurance (QA) nurse would provide assistance during the investigation. Multiple staff interviews, including with a licensed nurse and the Director of Staff Development (DSD), confirmed that the facility did not have a full-time DON at the time. The QA nurse, who was the former DON, stated that the facility was still in the process of hiring a new DON and that a consultant was available but not present during the initial investigation. A review of the facility's policy indicated that the DON is required to be employed full-time (40 hours per week) and is responsible for developing and updating nursing service objectives and overseeing standards of nursing practice. The absence of a full-time DON meant that there was no designated individual to oversee clinical care, care planning, and coordination for the safety and well-being of the facility's 188 residents. This lack of leadership and oversight was directly observed and confirmed through staff interviews and record review.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A resident with a history of unsteadiness, substance abuse, and smoking was able to leave the facility unsupervised late at night. The resident was not located by staff for approximately 14 hours and was later found with injuries, including abrasions to the face and a swollen, scraped knee, after falling from a wheelchair while away from the facility. The resident reported being lost and unable to find the way back, and required medical evaluation and wound care upon return. The facility's records indicated that the resident was at moderate to high risk for falls, but the fall risk assessments did not account for the antihypertensive medication the resident had been taking, which could have increased the risk. The care plans for substance abuse and smoking included interventions such as assessing the risk of leaving the facility without notification and providing supervision while smoking. However, these interventions were not effectively implemented, as the resident was not accompanied outside and was able to leave the premises without staff awareness. Staff interviews revealed that the licensed nurse on duty was aware the resident had left but did not report the incident until shift change, following advice from a senior nurse to wait until morning to notify the DON and police. There was no immediate search or notification to security or supervisors during the night, and the facility was unable to provide a policy ensuring supervision of residents while smoking. These actions and inactions resulted in the resident's elopement and subsequent injury.
Failure to Follow Menu and Serve Correct Portion Sizes for Modified Diets
Penalty
Summary
The facility failed to follow the prepared menu and serve the correct portion sizes for residents on mechanical soft, ground meat, and pureed diets. Specifically, for a planned lunch meal, staff served mechanical soft BBQ chicken and pureed BBQ chicken using a #12 scoop (2.67 oz) instead of the required #10 scoop (3.2 oz) for mechanical soft and #8 scoop (4 oz) for pureed, as indicated on the facility's Spring Cycle Menus. This deviation affected 30 residents on mechanical soft or ground meat diets and 21 residents on pureed diets. The facility's policy required that menus be followed, and any deviations be recorded and archived, but this was not done in these instances. Interviews with dietary staff, the Dietary Director, the Registered Dietitian, the DON, and the Administrator confirmed that the expectation was to follow the menu and serve the correct portion sizes to ensure residents received adequate nutrition and the nutrients ordered by physicians. The staff member responsible for serving the meals acknowledged using the incorrect scoop sizes and confirmed the discrepancy after reviewing the menu. The deficiency was identified through observation, interview, and review of facility documents and policies.
Failure to Provide Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis (ALS), dysphagia, contractures, and muscle wasting, who was dependent on staff for eating, was not provided a dignified dining experience. The resident's meal tray was repeatedly delivered to their room and placed out of reach, leaving the resident unable to access their food. On multiple occasions, the resident had to wait for extended periods before being fed, while observing their roommate being fed first. The resident expressed dissatisfaction with having to wait and watching their meal sit out of reach. Staff interviews confirmed that the resident was typically fed by a restorative nursing assistant (RNA) after meal trays were delivered, but there was inconsistency in the timing of feeding. The facility's policies required that residents receive assistance with meals in a manner that meets their individual needs and promotes dignity. However, observations and staff statements revealed that the resident was not fed promptly after meal delivery, and both the Director of Nursing and Administrator acknowledged that residents should be fed at the same time for a dignified experience, which was not occurring in this case.
Inaccurate MDS Assessments for Discharge Destination and PASRR Status
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For one resident with a history of multiple rib fractures, falls, and dementia, the discharge MDS incorrectly documented the discharge destination as a short-term general hospital, when in fact the resident was discharged home with family and home health services. The error was attributed to the Social Services Director (SSD) confusing the resident's discharge location, despite progress notes and care plans indicating the correct destination. The MDS Coordinator and SSD both confirmed the discrepancy during interviews, and the Administrator and Director of Nursing (DON) acknowledged the expectation for accuracy in MDS documentation. For another resident with a history of major depressive disorder, psychotic disorder, bipolar disorder, and generalized anxiety disorder, the annual MDS failed to accurately reflect the resident's Preadmission Screening and Resident Review (PASRR) Level II status, despite documentation from the state confirming its completion. The MDS Coordinator stated that the staff member responsible for the PASRR section did not ensure the information was accurate, and the SSD was unaware of the resident's PASRR Level II status. Both the SSD and DON confirmed the inaccuracy in the MDS coding during interviews.
Failure to Follow Care Plan for Meal Supervision of Resident with Dysphagia
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of hemiplegia, hemiparesis following a stroke, dysphagia, and functional quadriplegia. The resident had severe cognitive impairment and required supervision or touching assistance with eating, as documented in the Minimum Data Set and care plan. The care plan specifically indicated the need for supervision during meals due to moderate oropharyngeal dysphagia, which impeded safe swallowing. Facility policy also required that residents receive meal assistance according to their individual needs. Multiple observations revealed that the resident was left unsupervised during meal times, both at breakfast and lunch, despite the care plan's requirements. Staff interviews indicated a lack of awareness or adherence to the supervision requirement, with one CNA stating he was unaware of the need for supervision and another leaving the resident unsupervised to answer a call light. The Speech Language Pathologist confirmed the necessity for supervision throughout the entire meal to ensure safe eating practices. The administrator acknowledged that clinical recommendations must be followed, and failure to do so could have led to adverse outcomes.
Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
Staff failed to follow a physician's order requiring one-on-one supervision during meals for a resident with a history of hemiplegia, hemiparesis, dysphagia, and functional quadriplegia. The resident, who had severe cognitive impairment and required supervision or assistance with eating, was observed consuming meals alone in their room on multiple occasions. Despite clear documentation in the resident's care plan, Kardex, and tray tickets specifying the need for supervision, staff did not remain with the resident during meal times. Interviews with CNAs revealed a lack of awareness or adherence to the supervision requirement, with one CNA stating they were unaware of the need for supervision and another leaving the resident unsupervised to answer a call light. The Speech Language Pathologist confirmed the necessity for supervision throughout the entire meal to ensure safe eating practices. Facility leadership acknowledged that clinical recommendations and orders must be followed, and failure to do so could have led to adverse outcomes.
Failure to Provide Timely Podiatry Services for Resident with Foot Pain
Penalty
Summary
The facility failed to provide timely podiatry services for a resident who required foot care due to mycotic toenails and an ingrown toenail. The resident, who had a history of muscle weakness and back pain and demonstrated moderate cognitive impairment, was admitted with an order for podiatry evaluation and treatment every 90 days and as needed. Despite a referral to podiatry shortly after admission and repeated complaints of pain from the resident, the podiatrist did not see the resident in a timely manner. Observations revealed the resident's toenail was significantly overgrown and thick, and the resident reported ongoing pain that was not relieved by medication. Staff interviews confirmed that the resident had been requesting podiatry care and experiencing pain for at least one and a half weeks. The facility's policy required prompt assistance in arranging podiatry appointments, including urgent visits if needed. However, the resident remained on the waiting list for podiatry services, and the podiatrist had not responded to the urgent need prior to the scheduled visit. The delay in providing podiatry care resulted in the resident continuing to experience pain and discomfort related to their foot condition.
Failure to Monitor Resident with Suicidal Ideation
Penalty
Summary
The facility failed to protect a resident with suicidal ideation from harm due to inadequate supervision and communication among staff. The resident, who had a history of suicidal tendencies and was at risk of self-harm, was not properly monitored despite multiple recommendations from nurse practitioners. These recommendations included close monitoring and ensuring the resident did not have access to medications or potential weapons. However, the staff did not implement these measures, leading to the resident's ability to harm herself. The resident, who had been diagnosed with Major Depressive Disorder and had a history of overdosing on medications, was found attempting self-harm by cutting her wrist with a butter knife and ingesting a large quantity of metformin pills. Despite the nurse practitioners' assessments indicating the resident was at moderate to high risk for suicide, the facility staff were unaware of these assessments and did not communicate the need for close monitoring. This lack of communication and failure to follow through on the recommended safety measures allowed the resident to access medications and a butter knife, which she used in her suicide attempt. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's suicidal ideation and the necessary monitoring protocols. The Director of Nursing was not informed of the nurse practitioners' recommendations, and the staff did not conduct thorough checks of the resident's belongings, which allowed her to retain medications from home. The facility's policies on resident safety and comprehensive care planning were not effectively implemented, contributing to the resident's opportunity to harm herself.
Failure to Develop Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to communicate and develop a baseline care plan for a resident with suicidal ideation, leading to a serious incident. The resident, who was readmitted to the facility with hemiplegia and hemiparesis, had a history of major depressive disorder and was assessed multiple times by nurse practitioners for suicidal risk. Despite being identified as at moderate to high risk for suicide, with recommendations for close monitoring, the facility staff did not implement a care plan or communicate the resident's needs effectively. On several occasions, nurse practitioners documented the resident's suicidal ideation and the need for close monitoring, but this information was not communicated to the facility staff. Interviews with various staff members, including licensed nurses and certified nursing assistants, revealed a lack of awareness regarding the resident's suicidal ideation and the need for monitoring. The staff were unaware of the resident's access to medications and a butter knife, which the resident used in a self-harm attempt. The incident culminated in the resident attempting self-harm by ingesting a large number of metformin pills and cutting her wrist with a butter knife. The facility's failure to develop a care plan and ensure communication among staff members about the resident's suicidal ideation and risk factors contributed to this critical event. The Director of Nursing acknowledged that the message from the nurse practitioner regarding the resident's risk was not communicated, and a care plan was not developed to ensure the resident's safety.
Failure to Prevent Resident-to-Resident Assault
Penalty
Summary
The facility failed to prevent an incident of physical assault between two residents, resulting in a deficiency. Resident 1, who has a diagnosis of bipolar disorder, physically assaulted Resident 2 by striking him on the left cheek. This incident was observed by a staff member and reported to the State Agency. Despite having a care plan in place to monitor and intervene in episodes of bipolar disorder, the Director of Nursing was unaware of the interventions listed in Resident 1's care plan. This lack of awareness and intervention contributed to the failure to protect Resident 2 from harm. Resident 2, who has a diagnosis of displaced fractures of the 6th and 7th vertebrae, expressed feeling unsafe following the assault and reported previous incidents involving Resident 1 that were not addressed by the staff. The facility's policy on abuse and neglect, which includes identifying risk factors for abuse, was not effectively implemented, as evidenced by the repeated incidents and the lack of appropriate staff response to Resident 2's concerns. The failure to act on these risk factors and previous reports of problematic behavior led to the deficiency in protecting residents from abuse.
Failure to Notify Responsible Party of Resident's Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the resident's skin issues and change of condition. The resident, who was admitted with diagnoses including bacteremia and diabetes, had severe cognitive impairment as indicated by a Minimum Data Set score of six out of 15. During a skin assessment conducted by a licensed nurse, multiple skin issues were identified, including abrasions and rashes. However, the nurse did not notify the responsible party because she was unaware of who the responsible party was. Additionally, another licensed nurse documented a change of condition for the resident but failed to successfully contact the responsible party. The nurse noted an attempt to call the responsible party, but there was no documentation of a follow-up call to inform them of the resident's new diagnosis and medication orders. The Director of Nursing acknowledged that the responsible party should have been informed of the resident's health status, but the facility lacked a policy regarding responsible party notification.
Failure to Administer Prescribed Treatments and Medications
Penalty
Summary
The facility failed to consistently provide skin care and administer intravenous (IV) antibiotics as ordered by the physician for a resident with severe cognitive impairment, bacteremia, and diabetes. The resident's treatment administration record (TAR) showed multiple instances where prescribed topical treatments for various skin conditions were not applied. These included Bacitracin ointment for a cut on the right eyebrow, Vitamins A & D ointment for abrasions on the left elbow and forearm, Hydrocortisone cream for rashes on the abdomen, chest, and back, and Miconazole nitrate powder for moisture-associated skin damage in the groin and perianal areas. The omissions occurred on several dates in January 2022, indicating a pattern of non-compliance with physician orders. Additionally, the facility failed to administer IV antibiotics as prescribed for the resident's bacteremia. The medication administration record (MAR) revealed missed doses of Ampicillin Sodium and Ceftriaxone Sodium on multiple occasions in January and February 2022. These antibiotics were crucial for treating the resident's bloodstream infection, and the missed doses could have compromised the effectiveness of the treatment. The Director of Nursing (DON) confirmed that licensed nurses (LNs) were expected to follow physician orders and document medication administration in the electronic MAR. The facility's policy on administering medication, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed. The policy also requires that topical medications be recorded on the resident's treatment record and that the individual administering the medication initials the MAR after each administration. The repeated failures to adhere to these policies and physician orders highlight significant deficiencies in the facility's medication administration practices.
Failure to Timely Sign Skin Evaluation Forms
Penalty
Summary
The facility failed to ensure that a Licensed Nurse (LN) signed a resident's initial skin evaluation in a timely manner, which resulted in an incomplete medical record for the resident. The deficiency was identified during an unannounced onsite visit related to complaints about quality of care. The resident in question was admitted to the facility and later discharged in early 2022. During the admission, the LN conducted a skin assessment and identified several skin conditions, including abrasions and rashes. However, the LN did not sign the evaluation forms until several months later, in April 2022, which was not in accordance with the expected practice of signing forms upon completion of assessments. Interviews conducted with the LN and the Director of Nursing (DON) revealed that the LN was unsure why the forms were not signed at the time of the assessment, despite having documented the skin issues and taken photographs. The DON confirmed that the facility expected timely completion of medical records but did not have a specific policy in place regarding this. This lack of timely documentation led to the deficiency noted in the resident's medical record.
Inaccurate Medical Record Documentation Due to Password Sharing
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident who was admitted with osteomyelitis of the backbone. The deficiency occurred when the Medication Administration Record (MAR) for the resident indicated that an LVN had administered intravenous (IV) antibiotics, which was not in accordance with accepted professional standards. Upon review, it was found that the LVN did not administer the IV medication, and the signatures on the MAR were incorrect. The error was traced back to an RN who, due to a malfunctioning password, used the LVN's password to document the administration of the IV antibiotics. The RN admitted to administering the medication but failed to report the password issue to the Director of Nursing (DON) to obtain a new password. This action led to inaccurate documentation in the resident's medical record, as the MAR is a legal document that requires precise and truthful entries.
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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