Bayshire San Dimas Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Dimas, California.
- Location
- 1740 S San Dimas Ave, San Dimas, California 91773
- CMS Provider Number
- 555737
- Inspections on file
- 33
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bayshire San Dimas Post-acute during CMS and state inspections, most recent first.
A resident who required a two-person assist for transfers was placed on a bedpan by an LVN and staff, despite being able to use the toilet with assistance and expressing a desire not to use the bedpan. The LVN cited low staffing as the reason, though facility leadership confirmed staffing was adequate. This action was not consistent with the resident's care plan or facility policy, resulting in the resident feeling disrespected.
A resident with a recent hip fracture and moderate cognitive impairment was not informed when their pain medication was changed from tramadol to norco. The resident only became aware of the change after requesting pain medication, and there was no documentation that staff had notified the resident, despite facility policy requiring such notification.
A resident with a history of hip dislocation reported acute pain and suspected another dislocation after attempting to retrieve an abductor pillow. An LVN texted the attending physician but did not receive a response and failed to escalate the issue or make further contact attempts, resulting in a delayed physician notification and assessment.
A resident with multiple medical conditions, including neuropathy and a recent hip injury, did not receive scheduled doses of bupropion SR and gabapentin upon admission because the pharmacy processed the medications the next day. Staff did not consult with or document communication with the attending physician regarding the delay, as required by facility policy.
A resident's banana allergy was not properly documented in assessment notes or on the dietary tray card, as required by facility policy. Instead, bananas were only listed as a dislike, and the allergy section was left blank, despite the resident reporting an allergic reaction to bananas. The Dietary Supervisor confirmed the inability to enter the allergy in the system and did not update the tray card accordingly.
A resident with a history of hip dislocation experienced acute pain and a possible dislocation after attempting to retrieve an abductor pillow. An LVN failed to document the condition change on the day it occurred, inaccurately recorded the event date and physician notification, and did not report the incident to the RN supervisor, resulting in incomplete and inaccurate medical records.
The facility failed to offer and provide information about advance directives (ADs) to three residents, including one with dementia and psychosis who lacked decision-making capacity. Despite facility policy requiring inquiry about ADs upon admission, there was no documented evidence that these residents or their responsible parties were informed about their right to formulate an AD, potentially leading to unwanted care or treatment.
The facility failed to maintain kitchen sanitation and proper food storage. A staff member was observed preparing food without a hair net over their beard, violating hygiene policies. Additionally, a banana cream pie in the freezer and a tray of green beans in the refrigerator were found undated and uncovered, contrary to the facility's food storage policy. These lapses could lead to foodborne illnesses.
A resident with cognitive impairment and dysphagia was referred to as a 'feeder' by a CNA during a dining observation, which was confirmed by the Director of Staff Development as disrespectful and against facility policy. The facility's policies emphasize treating residents with dignity and avoiding labels.
A resident experienced delayed treatment for vaginal itching due to the facility's failure to notify the physician about pharmacy delays in receiving Vagisil. Despite the resident's discomfort and the facility's policy requiring prompt notification of changes in condition, the nursing staff did not inform the physician, resulting in a delay in care.
A resident's bathroom toilet leaked, causing water to puddle on the floor, which was observed by staff and confirmed as a safety risk. The resident, who required substantial assistance for daily activities, reported the issue after plumbing work was done. The facility's policy on maintaining a homelike environment was not upheld.
A CNA at the facility did not maintain current BLS/CPR certification, as revealed during a review of personnel records. The Director of Staff Development could not provide documentation of renewal, and the tracking log for CPR certification was incomplete. The Director of Nursing stressed the importance of CPR, but the facility lacked a specific policy, relying instead on the State Operations Manual. This deficiency could affect the facility's ability to provide immediate emergency care.
The facility failed to provide sufficient nursing services on specific dates, affecting two residents who experienced significant delays in receiving assistance. One resident, with hemiplegia, reported waiting up to 30 minutes for help, while another, requiring maximal assistance, waited up to 40 minutes. The facility's CNA schedule showed inadequate staffing on these nights, contrary to their policy, as confirmed by the DSD.
A CNA at the facility demonstrated a lack of competency in performing CPR, incorrectly stating the compression-to-breath ratio as 10:10 instead of the correct 30:2. Despite having a current CPR/BLS card, the CNA's misunderstanding posed a potential risk to residents in need of emergency care. The facility's policies clearly outlined the correct procedure, indicating a gap in ensuring staff maintained necessary skills.
The facility did not post accurate nurse staffing information, failing to display the actual hours worked by nursing staff responsible for resident care per shift. The Director of Staff Development (DSD) acknowledged that actual hours were calculated after the fact, contrary to the facility's policy requiring daily posting within two hours of each shift's start.
A facility failed to follow a Consultant Pharmacist's recommendations during a Medication Regimen Review for a resident with multiple diagnoses, including cerebral infarction and type 2 diabetes. Despite the physician's acceptance of the recommendations for TSH and A1C blood tests, the facility did not conduct these tests, contrary to their policy and procedure.
A resident with endometrial cancer and diabetes experienced a documentation error when Vagisil was inaccurately recorded as administered, despite the medication not being available. The error was identified during a review, and the DON emphasized the importance of accurate MAR documentation for effective communication and care.
A resident's wound vacuum drainage tubing was observed touching the floor, violating infection control practices. The resident, with endometrial cancer and diabetes, required significant assistance with daily activities. Staff confirmed the tubing should not contact the floor to prevent cross-contamination, as per the facility's infection control policy.
A resident's wheelchair had a faulty right-side brake, which was not addressed despite being reported. The resident, with a history of falling and other health issues, expressed safety concerns. Inspections confirmed the brake issue, but the maintenance log showed no record of it being reported. The facility's policy requires equipment to be maintained safely at all times.
A resident with dementia and identified as an elopement risk left an LTC facility unsupervised through an unlocked door, resulting in a fall and serious injuries. The facility's staff failed to monitor the resident effectively, and a laundry attendant mistook the resident for a visitor, failing to report their presence outside the designated area. The exit door alarm was deactivated during the day, contributing to the incident.
The facility failed to provide timely care for residents, leading to delays in assistance for basic and emergent needs. Residents reported inconsistent response times to call lights, with some waiting up to 20 minutes or more without receiving assistance. Staffing shortages, particularly during the 3 p.m. to 11 p.m. shift, contributed to these delays, as confirmed by resident council notes and family member observations.
A resident with multiple diagnoses was discharged from an LTC facility without proper discharge planning. The facility failed to consider the caregiver's capacity, assess the need for assistive devices, and arrange home health services as ordered. The discharge was rushed due to the resident's insurance coverage ending, leading to an unsafe discharge without necessary support and equipment at home.
A resident with multiple diagnoses was discharged from a facility without an accurate discharge summary or proper post-discharge plan, leading to a lack of continuity of care. The resident's representative was unprepared for the discharge, and necessary home health services and equipment were not arranged. The facility's policy for discharge planning was not followed due to short notice from the insurance company.
A resident with multiple health issues and moderate cognitive impairment did not receive adequate social services for discharge planning. The Social Services Director failed to document timely referrals to Medicaid-certified LTC facilities and did not update the resident's discharge care plan. Despite claims of sending referrals, there was no evidence of these actions, and the resident's responsible party was referred to a third-party individual for assistance. The Director of Nursing highlighted the importance of proper documentation, which was not maintained, potentially impacting the resident's well-being.
A facility failed to accurately document a resident's legal decisionmaker, leading to confusion during the resident's discharge. The resident, with multiple diagnoses including cerebral infarction and aphasia, was discharged without the legal decisionmaker's knowledge, and no home health services were arranged. The Director of Nursing recognized the need to update records to prevent such issues.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with respiratory issues and another with multiple fractures were unable to access their call lights. Staff interviews revealed that call lights were sometimes not long enough, and the facility's policy required accessibility, which was not followed.
A resident was discharged without the necessary home health services and equipment ordered by the physician, including physical and occupational therapy and a wheelchair. The facility's Social Services Director did not confirm the arrangement of these services, and the resident reported not receiving them post-discharge. This failure to adhere to the facility's discharge policy resulted in a deficiency.
Resident Denied Dignified Toileting Assistance
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) instructed staff to place a resident on a bedpan instead of assisting the resident to the bathroom, despite the resident's ability to communicate needs and a care plan indicating that transfers could be safely performed with two staff members. The resident, who had diagnoses including abnormalities of gait, muscle wasting, and required assistance with personal care, expressed distress and did not want to use the bedpan. The resident's caregiver had specifically requested that the resident be assisted to the toilet, noting that the resident had previously been able to use the bathroom with assistance. The LVN cited low staffing as the reason for not assisting the resident to the toilet, although facility leadership later confirmed that staffing was adequate at the time. Review of the resident's care plan and Kardex confirmed that a two-person assist was required for transfers, and the Director of Staff Development stated that the resident should have been allowed to use the toilet, as this was their right and promoted dignity. Facility policy emphasized the importance of caring for residents in a manner that enhances well-being and prohibits practices that compromise dignity, including failing to promptly respond to toileting requests. The actions taken by the LVN and staff did not align with the resident's care plan or facility policy, resulting in the resident feeling disrespected and distressed.
Resident Not Informed of Pain Medication Change
Penalty
Summary
A resident was admitted to the facility with a history of a right femur fracture, right hip dislocation, and required assistance with personal care. Upon admission, the resident was prescribed tramadol for pain management, as indicated in the discharge documentation from the previous hospital. The resident was assessed as moderately impaired in cognitive skills but was determined to have the capacity to understand and make decisions regarding care and treatment. On the day following admission, the resident's pain medication was changed from tramadol to norco by physician order. The resident was not informed of this change and only discovered the switch when requesting pain medication. During interviews, the resident stated that nursing staff did not notify them of the change, and review of the medical record confirmed there was no documentation of resident notification. Facility policy requires residents to be informed of and participate in care planning and treatment, but this was not followed in this instance.
Failure to Promptly Notify Physician of Resident's Suspected Hip Dislocation
Penalty
Summary
The facility failed to promptly notify a resident's physician after the resident complained of pain and suspected a right hip dislocation. The resident, who had a history of right femur fracture and hip dislocation and was dependent on staff for personal care, reported waking up in pain after hearing a pop in the right hip while attempting to retrieve an abductor pillow. The resident expressed that the hip felt dislocated and requested to be sent to the emergency room. Documentation showed that a nurse texted the attending physician about the resident's condition, but the physician did not respond during the nurse's shift, and no further attempts were made to contact the physician or escalate the issue to the medical director as required by facility policy. The physician was not made aware of the resident's complaint until later that afternoon, at which point an X-ray was ordered. The facility's policy required nursing staff to contact the physician based on the urgency of the situation and to escalate to the medical director if there was no timely response. The delay in physician notification and lack of escalation resulted in the resident not receiving timely assessment and intervention for the reported hip dislocation and pain.
Failure to Provide Scheduled Medications and Document Physician Consultation
Penalty
Summary
The facility failed to provide scheduled medications to a resident who was admitted with multiple diagnoses, including a femur fracture, hip dislocation, and neuropathy. Upon admission, the resident had physician orders for bupropion SR and gabapentin, both of which were due to be administered at 9:00 PM on the day of admission. However, the medications were not given as scheduled because the pharmacy did not process the order until the following day. There was no documentation in the resident's medical record indicating that the attending physician was consulted about delaying the initiation of these medications. The resident was moderately impaired in cognitive skills and dependent on staff for personal care, as documented in the Minimum Data Set. The facility's policy required staff to consult with the prescriber and document any changes if a medication could not be started as ordered, but this was not done. The failure to provide the scheduled medications and to document physician consultation constituted a deficiency in meeting the pharmaceutical needs of the resident.
Failure to Document and Communicate Food Allergy on Dietary Records
Penalty
Summary
The facility failed to ensure that a resident's documented food allergy to bananas was properly recorded and communicated according to its own policies and procedures. The resident, who was moderately impaired in cognitive skills and dependent on staff for daily care, reported an allergy to bananas that caused mouth swelling. Despite this, the allergy was not documented in the resident's assessment notes, Nutrition Risk Review Form, or admission evaluation. The resident's tray card, which is used by kitchen staff to prepare and deliver meals, did not indicate the banana allergy in the allergy section; instead, bananas were only listed as a dislike, and the allergy section was left blank. During interviews, the Dietary Supervisor confirmed responsibility for updating dietary records and tray tickets with resident allergies but stated that the system would not allow banana to be entered as an allergy, so it was only marked as a dislike. Facility policies require that all reported food allergies be documented in assessment notes and included on tray cards. The failure to document and communicate the banana allergy as required by policy had the potential for the resident to experience an allergic reaction.
Failure to Accurately Document and Communicate Resident's Acute Condition Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a history of right femur fracture and hip dislocation and required assistance with personal care. On the morning of the incident, the resident experienced acute pain and a possible hip dislocation after attempting to retrieve an abductor pillow. The Licensed Vocational Nurse (LVN) on duty did not document the resident's acute condition change on the day it occurred. Instead, the LVN created the Change in Condition Evaluation (CIC) document the following day, and the documentation inaccurately recorded the event as having started on the later date. Additionally, the documentation incorrectly indicated that the attending physician was notified at a time when there was no response from the physician during the LVN's shift. The LVN also failed to report the resident's complaint of pain and possible hip dislocation to the Registered Nurse (RN) supervisor during shift change, and the CIC was not completed before the LVN left the facility. As a result, the RN supervisor was unaware of the resident's acute condition change. The facility's policies required timely, objective, complete, and accurate documentation of acute condition changes, including reporting to the appropriate staff and physician, which was not followed in this instance.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that three residents, identified as Residents 7, 27, and 83, were offered and provided information regarding their right to formulate an advance directive (AD). This deficiency was identified through interviews and record reviews. Resident 7, who was cognitively intact and required maximal assistance with daily activities, did not have an AD, and the Social Services Director (SSD) acknowledged that the resident should have been offered one. Similarly, Resident 27, also cognitively intact and requiring maximal assistance, had no documented evidence of being offered an AD, and the Registered Nurse was unsure if the resident had been provided with information about ADs. Resident 83, who was diagnosed with dementia and psychosis and lacked the capacity to make decisions, also did not have an AD. The SSD confirmed that there was no documented evidence that an AD was offered to Resident 83's responsible party. The facility's policy and procedure, revised in September 2022, indicated that residents have the right to formulate an AD and that the social services director or designees should inquire about the existence of any written ADs prior to or upon admission. The failure to adhere to this policy resulted in the potential for residents to receive unwanted care or treatment.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during a survey. A kitchen staff member was found preparing food without a hair net over their beard, which is against the facility's personal hygiene policy. This policy requires all hair, including beards, to be completely covered when staff are working with food. The staff member acknowledged the requirement for a hair net over their beard, indicating a lapse in adherence to the facility's hygiene standards. Additionally, during the kitchen tour, a banana cream pie was found in the walk-in freezer without a date, and a tray of green beans was observed in the walk-in refrigerator uncovered and undated. The Culinary Director confirmed that all opened food items should be labeled and dated with an expiration date, and that food is only good for three days after opening. The facility's policy on food storage mandates that all food should be covered, labeled, and dated, with use-by dates for items in refrigerators. These oversights in food storage and handling could potentially lead to foodborne illnesses.
Resident Referred to as 'Feeder' by CNA
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a Certified Nursing Assistant (CNA) referred to the resident as a 'feeder.' This incident involved a resident who was admitted to the facility with a history of a compression fracture of the T11-T12 vertebra, a history of falling, and dysphagia. The resident was moderately impaired in cognitive skills and required assistance with daily activities such as toileting hygiene, showering, and personal hygiene. During a dining observation, the CNA referred to the resident as a 'feeder' in the presence of another staff member while assisting the resident with their meal. The Director of Staff Development confirmed that referring to residents as 'feeders' is considered disrespectful and is against the facility's policy. The facility's policy on Assistance with Meals emphasizes feeding residents with attention to safety, comfort, and dignity, explicitly advising against using labels like 'feeders.' Additionally, the facility's Resident Rights policy mandates that all employees treat residents with kindness, respect, and dignity. This incident highlights a failure to adhere to these policies, potentially leading to the resident feeling disrespected.
Failure to Notify Physician of Pharmacy Delays
Penalty
Summary
The facility failed to notify the physician regarding pharmacy delays and the inability to carry out the physician's order for Vagisil for a resident. The resident, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, had an active order for Vagisil to be applied daily for vaginal itching. Despite the order being placed, the medication was not received from the pharmacy, resulting in a delay in treatment. The resident expressed frustration and discomfort due to the lack of treatment for her symptoms, which included vaginal itching and burning. Interviews with the nursing staff and the Director of Nursing revealed that the nursing staff should have informed the physician about the delay in receiving the medication. The facility's policy requires prompt notification of the physician and resident representative regarding changes in the resident's condition or status, which was not adhered to in this case.
Leaking Toilet Creates Unsafe Environment for Resident
Penalty
Summary
The facility failed to provide a safe and homelike environment for Resident 27, as evidenced by a leaking toilet that caused water to puddle on the bathroom floor. This issue was observed during a visit to Resident 27's bathroom, where a puddle of water was found on the floor between the toilet and the wall. Resident 27 reported that the toilet began leaking after three unidentified men worked on the plumbing, and the resident had informed some nurses about the issue. The leaking toilet persisted for three days, creating a potential safety risk for Resident 27. Resident 27 was admitted to the facility with diagnoses including type 2 diabetes mellitus, aftercare following joint replacement surgery, and anxiety disorder. The Minimum Data Set indicated that Resident 27 had no cognitive impairments and required substantial assistance for daily activities such as oral care, toileting, personal hygiene, and dressing. The Plant Operations Director confirmed the presence of the water puddle and acknowledged the safety risk it posed. The facility's policy on maintaining a homelike environment emphasized the importance of providing a clean, sanitary, and orderly setting, which was not upheld in this instance.
CNA Lacks Current CPR Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 5) maintained current Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) certification. During an interview and record review, it was revealed that CNA 5's BLS/CPR certification had expired, and the facility could not provide documentation of renewal or completion of necessary courses. This deficiency was identified during a review of CNA 5's personnel record by the Director of Staff Development (DSD), who acknowledged the absence of a current BLS/CPR card and the incomplete tracking log for CPR certification dates. The Director of Nursing (DON) emphasized the importance of CPR in emergencies, stating that all staff should be prepared to perform CPR to save lives. However, the facility lacked a specific policy for CPR, and the Administrator indicated reliance on the State Operations Manual for policy development. The facility's policy required recertifications to be presented before expiration, but this was not adhered to in CNA 5's case. The State Operations Manual mandates that staff maintain current CPR certification, which was not met, potentially impacting the facility's ability to provide immediate emergency care.
Insufficient Nursing Staff Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing services on specific dates, as required by their policy and procedure titled 'Staffing, Sufficient and Competent Nursing.' This deficiency was observed through the experiences of two residents. Resident 19, who was admitted with conditions including hemiplegia and hemiparesis, reported having to wait up to 30 minutes for assistance at night. The resident's care plan indicated a need for assistance from 1-2 persons for most activities of daily living, highlighting the importance of timely staff response. Similarly, Resident 27, who required maximal assistance for various activities due to conditions such as an artificial hip joint and dysphagia, reported waiting up to 40 minutes for help after pressing the call light. The facility's CNA schedule showed that only two CNAs were scheduled for the night shift on the dates in question, despite the facility's policy to staff three CNAs. The Director of Staff Development confirmed the importance of adequate staffing for resident safety and timely assistance.
CNA Lacks Competency in CPR Procedure
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistant 6 (CNA 6) possessed the necessary competencies and skills required during a medical emergency, specifically in performing Cardiopulmonary Resuscitation (CPR). During an interview, CNA 6 demonstrated a lack of understanding of the correct compression-to-breath ratio for CPR, stating it was 10 compressions followed by 10 breaths per cycle, which is incorrect. The Director of Staff Development (DSD) confirmed that the correct ratio should be 30 compressions to 2 breaths. This deficiency was identified during a review of CNA 6's personnel record, which showed a current CPR/BLS card, indicating that CNA 6 had been trained but was not competent in the procedure. The facility's policy and procedure for CPR and Basic Life Support (BLS) clearly outlined the correct method for performing CPR, including the 30:2 compression-to-breath ratio. Despite this, CNA 6's misunderstanding of the procedure posed a potential risk to residents requiring emergency care. The facility's job description for Certified Nursing Assistants required First Aid Training, but the deficiency highlighted a gap in ensuring that staff maintained the necessary skills and knowledge to perform lifesaving procedures effectively.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift, on a daily basis. This information was not displayed in a prominent location accessible to residents and visitors. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the actual hours worked by nursing staff for specific dates were not recorded or posted. The DSD explained that actual hours were calculated by the next business day, and on weekends, they were calculated by the following Monday. The facility's policy and procedure, revised in August 2022, required daily posting of nurse staffing data, including the number of nursing personnel providing direct care, within two hours of the beginning of each shift. However, this procedure was not followed, resulting in the absence of posted nurse staffing hours.
Failure to Follow Pharmacist's Recommendations for Blood Tests
Penalty
Summary
The facility failed to follow through with the Consultant Pharmacist's recommendations during the Medication Regimen Review (MRR) for a resident. The resident, who was admitted with diagnoses including cerebral infarction, urinary tract infection, and type 2 diabetes mellitus, was moderately impaired in cognitive skills and dependent on staff for daily activities. During the MRR, the Consultant Pharmacist recommended a thyroid-stimulating hormone (TSH) blood test and an A1C test, both of which were accepted by the resident's physician. However, the facility did not conduct these tests as recommended. The facility's policy and procedure for Medication Regimen Review indicated that the Consultant Pharmacist would conduct MRRs and that the facility should encourage the physician or prescriber to act upon the recommendations. Despite this, the facility did not follow through with the pharmacist's recommendations, even though the physician had accepted them. This oversight had the potential to impact the resident's health and wellbeing, as the necessary blood tests were not performed.
Inaccurate Medication Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate medication administration documentation for a resident, identified as Resident 11, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling. The resident required substantial assistance with activities of daily living and moderate assistance with mobility. The deficiency occurred when the facility inaccurately documented the administration of Vagisil, a medication prescribed for vaginal itching, on February 4, 2025. The Medication Administration Record (MAR) indicated that the medication was administered on that date, despite the facility not having received the medication from the pharmacy. The error was identified during an interview and record review with a registered nurse, who confirmed that the medication had not been available and had not been administered. The nurse noted that the licensed vocational nurse responsible for the documentation acted in good faith and did not intend to falsify the record. The Director of Nursing emphasized the importance of accurate MAR documentation for clear communication between healthcare providers and to ensure a complete and accurate record of a resident's medication regimen. The facility's policy on charting and documentation requires that records be objective, complete, and accurate.
Infection Control Breach with Wound Vacuum Tubing
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident by allowing the wound vacuum drainage tubing to come into direct contact with the floor. This was observed during a visit when the tubing, attached to the resident's abdomen, was seen touching the floor while the wound vacuum pump rested on the bed. The resident had been admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, and required substantial assistance with activities of daily living and mobility due to moderate cognitive impairment. Interviews with facility staff, including a Certified Nursing Assistant and the Infection Preventionist, confirmed that the tubing should not have been in contact with the floor as it could lead to cross-contamination and increase the risk of infection. The facility's policy on infection prevention and control, revised in 2018, emphasized maintaining a safe and sanitary environment to prevent the transmission of infections, which was not adhered to in this instance.
Failure to Maintain Wheelchair Brakes in Safe Condition
Penalty
Summary
The facility failed to maintain equipment in a safe and operable condition, specifically the wheelchair brakes for a resident. The resident, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, reported that the right-side brake of the facility-provided wheelchair was not functioning. This issue had persisted for more than a week despite being reported to the staff. The resident expressed concern about the potential safety risk, as the faulty brake could cause the wheelchair to roll unexpectedly during transfers. Upon inspection, both the Social Services Director and the Director of Maintenance confirmed the brake was faulty. The maintenance log showed no record of the issue being reported or addressed. The Director of Maintenance stated that wheelchair inspections were a collaborative effort among various departments and emphasized the importance of immediate reporting and daily inspections to ensure safety. The Director of Nursing also highlighted the significance of routine inspections to maintain equipment in optimal working condition. The facility's policy indicated that the maintenance department was responsible for ensuring all equipment was safe and operable at all times.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised. The resident, who had a history of dementia and was identified as an elopement risk, managed to exit the facility through an unlocked door adjacent to their room. This door led to a transition space and ultimately to the outside of the building. The facility's policy required monitoring of residents at risk for elopement, but the resident was able to leave without being noticed by staff. On the day of the incident, the resident was seen by a laundry attendant standing by a storage room on the assisted living side of the facility. The attendant did not recognize the resident and did not report the sighting to nursing staff, mistaking the resident for a visitor. The resident subsequently left the facility, fell outside, and sustained significant injuries, including multiple mandibular fractures and facial trauma, requiring hospitalization. Interviews with staff revealed that there was a lack of clear communication and understanding of the resident's care plan and elopement risk. Although staff were aware of the resident's tendency to wander, there was no effective system in place to ensure the resident's safety. The exit door used by the resident was frequently accessed by staff and had its alarm deactivated during the day, further compromising the facility's ability to prevent the resident's elopement.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely care for eight of 11 sampled residents, leading to delays in assistance for basic and emergent needs. Resident 4, who was admitted with chronic obstructive pulmonary disease, tachycardia, and major depressive disorder, required substantial assistance for daily activities. However, Resident 4 reported inconsistent response times to call lights, sometimes waiting up to 20 minutes without receiving assistance. Resident 2, admitted with acute kidney failure and respiratory failure, was dependent on staff for daily activities. This resident experienced a significant delay in care, waiting in a soaked diaper for three and a half hours despite multiple requests for assistance. The resident attempted to gain staff attention by going to the doorway, highlighting the facility's staffing issues. The report also noted observations of staff behavior, such as a CNA using a phone while on duty, which the Director of Nursing acknowledged as neglectful. Resident 10, with a history of UTIs and diabetes, reported long wait times for call light responses, particularly during the 3 p.m. to 11 p.m. shift due to staffing shortages. Family members and resident council notes corroborated these issues, indicating a pattern of inadequate staffing and delayed responses to resident needs.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure timely discharge planning for a resident, leading to several deficiencies in the discharge process. The resident, who had multiple diagnoses including cerebral infarction with hemiplegia and aphasia, was discharged without proper consideration of the caregiver's capacity and capability to provide necessary care. The resident's representative was not provided with caregiver training prior to discharge, and the facility did not assess the need for assistive devices at home to safely perform activities of daily living and mobility. Additionally, the facility did not arrange and confirm home health services as ordered by the resident's physician before discharge. The discharge summary indicated that home health services were arranged, but this was not confirmed, and no outpatient therapy services were arranged. The resident's representative was surprised by the discharge and expressed concerns about the lack of support and equipment at home, as well as the absence of arranged home health services. Interviews with facility staff revealed that the discharge planning process was rushed due to the resident's health insurance company's decision to stop coverage, leading to a discharge without proper arrangements. The Director of Nursing acknowledged that discharge planning should begin on the first day of admission and that the facility failed to ensure a safe discharge by not confirming home health services and assessing the caregiver's ability to provide care. The facility's policies and procedures for discharge planning and social services were not followed, resulting in an unsafe discharge for the resident.
Failure to Ensure Accurate Discharge Summary and Post-Discharge Plan
Penalty
Summary
The facility failed to ensure an accurate discharge summary and post-discharge plan for a resident, leading to a lack of continuity of care and a delay in services. The resident, who had multiple diagnoses including cerebral infarction with hemiplegia and aphasia, was discharged without proper arrangements for home health services or necessary medical equipment. The discharge summary inaccurately stated that home health services were arranged, but no such services were confirmed or provided. The resident's representative was surprised by the discharge and disagreed with the insurance's decision to stop coverage. The representative was not prepared to care for the resident at home, lacking the necessary skills and equipment to assist with mobility and personal care. The facility's Director of Nursing admitted that home health services were not arranged prior to discharge, and the Social Services Director failed to document any referrals made to home health agencies. The facility's policy required a discharge summary and post-discharge plan to be developed and reviewed with the resident and family at least 24 hours before discharge. However, due to short notice from the insurance company, the facility did not adhere to this policy, resulting in the resident being discharged without the necessary support and services in place.
Inadequate Social Services and Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident, identified as Resident 1, which resulted in deficiencies in discharge planning. Resident 1 was admitted with multiple diagnoses, including a wedge compression fracture, history of falling, and moderate cognitive impairment. The resident was dependent on staff for various activities of daily living. Despite these needs, the Social Services Director (SSD) did not document timely referrals to Medicaid-certified long-term care (LTC) facilities, which was necessary for the resident's continued care after the expiration of Medicare benefits. Interviews and record reviews revealed that the SSD did not update or individualize Resident 1's discharge care plan to reflect the need for placement in a Medicaid-certified LTC facility. The SSD claimed to have sent referrals to multiple LTC facilities, but there was no documented evidence of these referrals or the responses from the facilities. The SSD also referred the resident's responsible party to a third-party individual for assistance, but this was not documented as part of the facility's efforts to secure appropriate placement. The Director of Nursing (DON) acknowledged the lack of documentation and emphasized the importance of complete and accurate records to demonstrate the facility's efforts in assisting Resident 1. The facility's policy and procedure required social services to document referrals and maintain contact with the resident's family, but these were not followed. The failure to provide sufficient and appropriate social services had the potential to impact Resident 1's physical and psychosocial well-being due to inadequate discharge planning.
Failure to Document Legal Decisionmaker
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident, specifically regarding the documentation of the resident's legal decisionmaker. The resident was admitted with multiple diagnoses, including cerebral infarction with hemiplegia and aphasia, and required assistance with personal care. The admission record inaccurately indicated that the resident was self-responsible, despite the history and physical examination noting the resident's inability to make medical decisions. The deficiency was further highlighted when the resident was discharged home without the knowledge of the legal decisionmaker, who was surprised by the discharge and found that no home health services were arranged. The legal decisionmaker faced difficulties communicating with the resident's health insurance company due to the lack of proper documentation of their authority. The Director of Nursing acknowledged the need to update the admission record to reflect the correct responsible party, as per the facility's policy on maintaining accurate medical records.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care. Resident 2, who was admitted with viral pneumonia and chronic obstructive pulmonary disease, was observed sitting in a recliner chair with the call light attached to the bed and out of reach. The resident stated that the staff who assisted her did not ask if she had access to a call button. Similarly, Resident 3, admitted with acute kidney failure and multiple fractures, was found sitting in a wheelchair with the call light by the bed, making it inaccessible. Resident 3 confirmed she was unable to call for assistance due to the call light's location. Interviews with facility staff, including a CNA and the Director of Staff Development, revealed that call lights were sometimes not long enough for residents to reach, and residents were supposed to have a bell if the call light was not reachable. The facility's policy, revised in September 2022, stated that call lights should be accessible to residents in various locations, including from the bed, toilet, and shower. Despite this policy, the observations and interviews indicated a failure to adhere to these guidelines, resulting in the deficiency.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, resulting in the resident being discharged without the necessary services ordered by the physician. The resident, who had been admitted with fractures and an open wound, was dependent on assistance for various activities of daily living. The physician had ordered home health services, including physical and occupational therapy, and a safety evaluation by a registered nurse, as well as the provision of a wheelchair. However, upon discharge, these services and equipment were not arranged or confirmed. Interviews revealed that the Social Services Director did not follow up to confirm the arrangement of home health services or the delivery of the wheelchair. The resident reported not receiving the wheelchair or any home health services after discharge. The facility's policy and procedure for preparing a resident for discharge required that nursing services obtain orders for discharge and ensure recommended services and equipment were in place, which was not adhered to in this case.
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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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