Bay View Rehabilitation Hospital, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Alameda, California.
- Location
- 516 Willow Street, Alameda, California 94501
- CMS Provider Number
- 056348
- Inspections on file
- 26
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bay View Rehabilitation Hospital, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was moved to a different room without receiving the required written notification, violating their rights. The facility staff only provided verbal notifications, contrary to the policy that mandates advance written notice, including the reason for the change.
The facility failed to maintain a safe and comfortable room temperature for three residents, with temperatures dropping below 71 degrees for over six hours. The Maintenance Director confirmed that resident rooms lacked hot air circulation outlets, and the Administrator acknowledged the issue, stating it would take hours to adjust temperatures. The Director of Staff Development and the Director of Nursing expressed concerns about health risks like hypothermia. A review of the temperature log showed multiple rooms with low temperatures, and no follow-up actions were taken despite awareness of the issue.
The facility failed to complete required Level I PASARR screenings for two residents who stayed beyond 30 days and did not ensure the accuracy of a screening for another resident with schizophrenia. The Administrator was unaware of the requirement, and the Director of Nursing was responsible for these oversights.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care due to a terminal illness. Despite the requirement to perform the SCSA within 14 days of hospice enrollment, the facility did not complete this assessment, resulting in a deficiency.
The facility failed to ensure accurate MDS assessments for six residents, leading to discrepancies in medical records. Errors included incorrect medication records, untriggered PASARR for mental illness, omitted PTSD diagnosis, incorrect discharge location, and inaccurate assessment of paraplegia. The facility's policy requires accuracy in MDS assessments, but these inaccuracies indicate a failure to adhere to this policy.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's intact cognition and medical history indicating the need for such a plan. The responsibility for developing the care plan was with the social services department, which acknowledged the oversight. The Administrator confirmed that a care plan should have been in place, as per the facility's policy.
A resident with quadriplegia developed a pressure injury on the upper back due to lying on a nephrostomy tube, which was not properly managed by the staff. The injury was noted as redness and attributed to trauma from the tube. Staff interviews indicated that preventive measures were not included in the care plan, and the injury could have been avoided by ensuring the resident was not lying on the tube.
A resident alleged that a CNA slapped them, but the LVN failed to report the incident within the required 2-hour timeframe. The resident, diagnosed with Major Depressive Disorder, showed redness on their face. The SOC 341 was completed and faxed several hours late, contrary to the facility's policy requiring immediate reporting to the Administrator, CDPH, ombudsman, and law enforcement.
A CNA in an LTC facility was reported for physically abusing a resident, including poking and forcefully seating them, causing distress. Despite the report, the facility returned the CNA to duty before completing a thorough investigation, which lacked a required post-incident assessment. This premature action placed residents at risk, leading to an Immediate Jeopardy situation.
A resident with dementia was physically abused by a CNA, who poked her cheek, smacked her hand, and forcefully sat her down in a wheelchair, causing distress. An LVN witnessed the incident and reported it, but was instructed by the ADM to alter her statement. The police investigation confirmed the abuse, highlighting a failure to uphold resident rights and abuse prevention policies.
The facility failed to ensure a safe environment by not having working locks on sliding and screen doors in multiple residents' rooms. Residents expressed concerns about safety, and the Maintenance Director confirmed the lack of locking mechanisms. Clinical records indicated various medical conditions among the residents involved.
Failure to Provide Written Notification of Room Change
Penalty
Summary
The facility failed to provide written notification to a resident and their responsible party (RP) regarding a room change, violating their rights. The resident, who was admitted with a diagnosis of dementia and had a severe cognitive impairment as indicated by a BIMS score of 6 out of 15, was moved to a different room without receiving the required written notice. The RP confirmed during a phone interview that they were not informed of the reason for the room change. The Social Services Assistant (SSA) and Registered Nurse Supervisor (RNS) both acknowledged that only verbal notifications were given, either in person or via phone call, contrary to the facility's policy which mandates advance written notice. The SSA was unaware of the requirement for written notification and could not locate the Notification of Room Change form for the resident in question. The facility's policy clearly states that all parties involved should receive advance notice, including the reason for the change, which was not adhered to in this case.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe room temperature for three residents, resulting in temperatures below 71 degrees for over six hours. This deficiency was identified through observations, interviews, and record reviews. The Maintenance Director (MD) confirmed that the resident rooms lacked hot air circulation outlets, which were only present in the hallways. The Administrator acknowledged the issue and stated that it would take several hours to adjust the room temperatures to the required range of 71 to 81 degrees. The Director of Staff Development and the Director of Nursing both expressed concerns about the potential health risks associated with the cold temperatures, such as hypothermia and blood circulation issues. The deficiency was further supported by a review of the facility's temperature log, which showed that eight out of 30 resident rooms had recorded temperatures below 71 degrees. Despite being aware of the low temperatures, the MD had not taken any follow-up actions. The facility's policy and procedure on maintaining internal temperature stated that the environment should be kept at a level that residents find comfortable, specifically between 71 and 81 degrees. However, this policy was not adhered to, leading to an unhomelike environment and potential health risks for the residents involved.
Failure to Complete and Ensure Accuracy of PASARR Screenings
Penalty
Summary
The facility failed to complete a Level I preadmission screening and resident review (PASARR) for two residents who remained in the facility beyond 30 days. Resident 116, admitted with a history of anxiety disorder, schizoaffective disorder, and PTSD, did not have a new Level I Screening submitted on the 31st day of admission, as required by the California Department of Health Care Services. Similarly, Resident 152, with a diagnosis of schizoaffective disorder, also lacked a new Level I Screening on the 31st day. The facility's Administrator was unaware of the requirement and the letter indicating the necessity for the PASARR, and the Director of Nursing was identified as responsible for ensuring the completion of these screenings. Additionally, the facility failed to ensure the accuracy of a Level I Screening for Resident 96, who had a diagnosis of schizophrenia. The resident's PASARR, dated 12/05/2023, inaccurately indicated the absence of a serious mental disorder, despite the resident's known condition. The Admission Director stated that nursing staff were responsible for reviewing PASARRs for accuracy, and the Administrator confirmed the inaccuracy, attributing responsibility to the Director of Nursing. The facility's policy required all admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but this was not adhered to in these cases.
Failure to Complete SCSA for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was admitted to hospice care. The resident, who was admitted to the facility with a medical history of cerebral infarction and Parkinson's disease, was enrolled in hospice care on 10/15/2024 due to a terminal illness related to a cerebrovascular accident. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required within 14 days of a resident's enrollment in hospice care. However, the facility did not complete this assessment within the specified timeframe, leading to a deficiency finding during the survey.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for six residents, leading to discrepancies in their medical records. Resident 116 was admitted with a cardiac pacemaker and was inaccurately recorded as taking anticoagulant medication, which was not prescribed. The MDS Resource confirmed the inaccuracy after reviewing the physician orders. Similarly, Resident 13 and Resident 17, both diagnosed with bipolar disorder, were not flagged by the state level II preadmission screening and resident review process (PASARR) for serious mental illness, despite having active diagnoses that should have triggered the PASARR. Resident 148, admitted with anxiety disorder, had an MDS indicating an active diagnosis of PTSD, which was later omitted in a subsequent assessment despite the condition being active. Resident 157 was recorded as discharged to a short-term general hospital, although the Nurses Notes indicated the resident was discharged home. The MDS Resource acknowledged the coding error. Lastly, Resident 60, diagnosed with paraplegia, was inaccurately assessed as having no functional limitations in range of motion, contradicting the diagnosis. The facility's policy on certifying the accuracy of resident assessments requires that any person completing a portion of the MDS must sign and certify its accuracy. The policy also specifies that the information captured should reflect the resident's status during the observation period. However, the inaccuracies in the MDS assessments for these residents indicate a failure to adhere to this policy, as confirmed by interviews with the MDS Resource and the Administrator.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with PTSD, as required by their policy. The resident, admitted on June 6, 2024, had a medical history that included anxiety disorder and PTSD, with an intact cognition as indicated by a BIMS score of 15. Despite these diagnoses, the resident's care plan lacked specific goals or interventions to address the PTSD, which is a critical component of their care needs. Interviews with facility staff revealed that the responsibility for creating the care plan for PTSD lay with the social services department. The Social Services staff acknowledged that a care plan should have been developed to ensure the resident's needs were met, particularly to help the staff understand how to make the resident feel safe. The Administrator confirmed that a care plan should have been in place, aligning with the facility's policy that mandates comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Prevent Pressure Injury from Nephrostomy Tube
Penalty
Summary
The facility failed to prevent a medical device-related pressure injury for a resident with quadriplegia and hydronephrosis, who was dependent on staff assistance for movement. The resident developed a pressure injury on the left upper back due to lying on a nephrostomy tube, which was not adequately managed or repositioned by the staff. The injury was first noted as redness on the resident's back, measuring 3.3 by 1.3 by 0 centimeters, and was attributed to trauma from the nephrostomy tube. Interviews with staff revealed that the injury could have been prevented by ensuring the resident was not lying on the nephrostomy tube. However, the care plan did not include preventive measures to address this issue. The staff, including a Licensed Vocational Nurse and Certified Nursing Assistants, were aware of the nephrostomy tube but failed to implement effective strategies to prevent the pressure injury, such as repositioning the resident or adequately securing the tube.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for the immediate reporting of alleged abuse. Specifically, the facility did not report an allegation made by a resident who claimed that a Certified Nursing Assistant (CNA) slapped them in the face. The incident was reported to a Licensed Vocational Nurse (LVN) at around 10:00 a.m., who observed redness on the resident's face. However, the LVN did not report the alleged abuse or complete and submit the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Administrator, California Department of Public Health (CDPH), the ombudsman, or law enforcement within the mandated 2-hour timeframe. Instead, the SOC 341 was completed and faxed at 6:10 p.m., several hours after the initial report. The resident involved in the incident was admitted to the facility in 2020 and had a diagnosis of Major Depressive Disorder, Single Episode. The Director of Nursing (DON) confirmed that the SOC 341 was submitted late and reiterated the facility's policy to report alleged abuse immediately or within 2 hours to ensure timely investigation and resident safety. The facility's policy, updated in 2019, mandates that all employees report suspected abuse immediately to the Administrator/Abuse Coordinator and other relevant authorities. The delay in reporting had the potential to hinder the investigation and affect the resident's physical and psychological well-being.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when a Certified Nursing Assistant (CNA1) deliberately poked a resident in the cheek, smacked the resident's hand, and forcefully sat the resident down in a wheelchair, causing the resident to cry out in pain. This incident was witnessed by a Licensed Vocational Nurse (LVN1), who reported the abuse to the Administrator (ADM). Despite the report, the facility returned CNA1 to direct care duties before completing a thorough investigation, which included interviewing all witnesses. The facility's investigation into the abuse allegation was deemed incomplete, as it failed to include a post-incident 72-hour assessment by the Interdisciplinary Team (IDT), as required by the facility's policy. The investigation was concluded prematurely, and CNA1 was allowed to resume duties, providing care to multiple residents, including the one involved in the incident. This decision was made despite the ongoing investigation and the lack of a comprehensive assessment of the situation. The failure to conduct a thorough investigation and the premature return of CNA1 to duty placed residents at risk of further abuse. The facility's actions resulted in an Immediate Jeopardy situation, as the safety and well-being of the residents were compromised. The facility's policy on abuse allegations required the suspension of the alleged perpetrator pending a complete investigation, which was not adhered to in this case.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with Alzheimer's Disease and Non-Alzheimer's Dementia, who primarily communicated in Tagalog. The abuse occurred when the CNA deliberately poked the resident in the cheek, smacked her hand, and forcefully sat her down in a wheelchair, causing the resident to cry out in pain, hyperventilate, and visibly shake. This incident was witnessed by a Licensed Vocational Nurse (LVN), who reported the abuse to the Director of Nursing (DON) and the Administrator (ADM). The LVN provided a detailed account of the incident, stating that the CNA handled the resident roughly and yelled at her in Tagalog. The LVN also reported that the CNA applied A&D ointment to the resident's face without a doctor's order. The LVN's initial written statement was altered at the request of the ADM, who instructed her to remove details that made the CNA look bad. The LVN complied out of fear of retaliation but later confirmed the original details to a police officer investigating the incident. The police officer's investigation corroborated the LVN's verbal account, noting discrepancies between the LVN's initial and rewritten statements. Another LVN, who was nearby during the incident, heard the resident's screams and confirmed the abusive actions described by the first LVN. The facility's policies on resident rights and abuse prevention were not upheld, as evidenced by the CNA's actions and the ADM's attempt to alter the LVN's statement.
Failure to Ensure Safe and Functional Environment
Penalty
Summary
The facility failed to ensure a safe and functional environment for residents and staff by not having working locks on sliding doors and screen doors in multiple residents' rooms. During observations and interviews, it was found that six out of 20 resident rooms in the Fernside Station had sliding doors that either did not have locks or had malfunctioning locks. These rooms had sliding doors that led to a public parking lot and a commercial shopping center, posing a potential safety risk. Residents expressed concerns about the lack of locks, especially at night, and the Maintenance Director confirmed that screen doors in all residents' rooms did not have locking mechanisms. The clinical records of the residents involved indicated various medical conditions, including difficulty walking, seizures, depression, morbid obesity, muscle weakness, anxiety disorder, dementia, and a history of falling. The Maintenance Director admitted that there was no record of regular inspections of resident rooms and doors for maintenance, and the facility's policy and procedure for general maintenance, which required monthly checks of resident rooms, was not being followed. The Licensed Vocational Nurse also noted that the sliding doors were sometimes hard to close and open because they would get stuck on the runners, further compromising the safety of the residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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