Bear Valley Community Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Big Bear Lake, California.
- Location
- 41870 Garstin Rd, Big Bear Lake, California 92315
- CMS Provider Number
- 555468
- Inspections on file
- 23
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bear Valley Community Hospital during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was spoken to in a belittling manner by a CNA after requesting a shower at a preferred time, resulting in embarrassment in front of others. Staff interviews confirmed the CNA's unprofessional conduct and failure to respect the resident's right to self-determination and personal schedule, contrary to facility policy.
Surveyors found that staff failed to label and date refrigerated minced beef and tortilla flour, contrary to facility policy, and did not properly prepare a pureed cauliflower dish for a resident on a pureed diet, resulting in a meal that was watery and bland compared to the regular version. The Director of Nutrition Services confirmed that these actions did not meet professional standards for food safety or palatability.
Three residents with physician orders for assistive eating devices, such as plate guards and anti-spill cups, were not provided these items during meals. Two residents with conditions like hemiplegia, hemiparesis, COPD, and dementia did not receive their required devices at lunch, and another resident with dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease was not given a KCup as ordered. Staff confirmed the omissions, and facility policy requiring such support was not followed.
Two residents with significant cognitive and physical impairments were fed lunch by CNAs who stood over them rather than sitting and engaging at eye level, contrary to facility policy requiring dignified and respectful support during meals. Both CNAs acknowledged not following the expected practice, and the DON confirmed this did not meet the standard for resident dignity.
Three residents were not provided with updated informed consent forms when their psychotropic medication orders or dosages were changed. In each case, the consent documentation did not match the current physician orders, and staff confirmed that updated consents were not obtained. As a result, residents and their representatives were not informed of the risks, benefits, or their right to refuse the new or changed medications, in violation of facility policy.
A resident with multiple diagnoses, including dementia and depression, was not accurately assessed in the MDS, omitting key conditions despite being prescribed psychotropic medication. The MDS was not completed or submitted in accordance with federal and facility requirements, as confirmed by the LVN and DON, resulting in inadequate monitoring and reporting to CMS.
Two residents did not have their quarterly MDS assessments completed within the required 92-day timeframe, as confirmed by the DON during interviews and record review. One assessment was completed 52 days late, while another was not completed and was 92 days overdue, in violation of facility policy.
The facility did not transmit completed RAI/MDS assessments to CMS within required timeframes for three residents, including individuals with complex medical conditions such as schizencephaly, spastic quadriplegia, hypertension, diabetes, cerebrovascular accident, and severe disability post anoxic encephalopathy. The DON acknowledged responsibility for transmission and confirmed that facility policy requiring submission within 14 days was not followed, resulting in significant delays.
A resident with multiple diagnoses, including dementia and depression, was prescribed Abilify for behavioral and psychological symptoms. The care plan did not address the resident's dementia or the use of psychotropic medication, as confirmed by both an LVN and the DON. Facility policy requires such needs to be included in the care plan, but this was not done.
A resident with dementia, diabetes, and osteoarthritis was observed receiving oxygen therapy without the required labeling on the oxygen tubing to indicate when it was last changed. Facility policy mandates weekly changes and labeling by a licensed nurse, but this was not followed, as confirmed by both an LVN and the DON.
The facility did not ensure accurate recordkeeping for controlled medications on one medication cart, as two required signatures were missing from the shift count form for a night shift. Both a nurse and the DON confirmed that policy requires two licensed nurses to verify and sign off on narcotic counts at each shift change, but this was not done as required.
A medication refrigerator temperature log was found to be missing staff signatures for two shifts, indicating that required temperature checks were not documented as per facility policy. The DON confirmed that the policy, which requires twice-daily monitoring of medication storage temperatures, was not followed.
Two cups containing brown liquid were found on a folding table in the laundry room across from the nurse's station. EVS staff acknowledged the cups, with one stating he believed the coffee cup was allowed. The DOF confirmed that personal beverages are not permitted in the laundry room due to infection control concerns. The DON reviewed the facility's infection prevention policy and confirmed it was not followed, as drinks should only be in designated staff or break areas.
Failure to Honor Resident Dignity and Bathing Preferences
Penalty
Summary
Facility staff failed to treat a resident with respect and dignity when a Certified Nurse Assistant (CNA) spoke to the resident in a belittling and demeaning manner, using language and tone typically reserved for addressing a child. This incident occurred after the resident, who has a history of congestive heart failure, seizure disorder, stroke, hypothyroidism, and hypertension, requested a shower in the evening, having declined one earlier in the day. The CNA responded in a rude and unprofessional manner, scolding the resident in front of other staff and residents, which made the resident feel embarrassed and put down. Multiple interviews with facility staff, including a Registered Nurse (RN), another CNA, and the Director of Nursing (DON), confirmed that the CNA's behavior was inappropriate and did not respect the resident's right to self-determination or to choose their own bathing schedule. The facility's policy on resident rights, which emphasizes respect, dignity, and the right to choose personal schedules, was not followed in this instance. The Assistant Director of Nursing (ADON) and DON acknowledged that the resident's rights were not upheld during the incident.
Deficient Food Storage and Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure proper food storage and preparation practices, as observed during a survey. In the kitchen refrigerator, a bag of minced beef was found without a label or date, and an open, unlabeled bag of tortilla flour was also present. Both the Executive Chef and the Director of Nutrition Services confirmed that these items should have been labeled and dated according to the facility's policy and procedure for food storage, which requires all food to be covered, labeled, and dated to ensure safe consumption within use-by dates. Additionally, the facility did not follow proper procedures in preparing a pureed diet for a resident with chronic obstructive pulmonary disease and dementia, who was on a physician-ordered regular diet with pureed texture. During meal preparation, kitchen staff used only hot water to puree cauliflower, rather than following the recipe that called for adding gravy, sauce, or other liquids to achieve the correct taste and consistency. The pureed cauliflower was found to be watery and bland, lacking the buttery flavor of the regular diet version, and did not meet the facility's standards for palatability and comparability to regular meals. Interviews with staff and review of facility policies confirmed that the required procedures for both food storage and meal preparation were not followed. The Director of Nutrition Services acknowledged that these failures increased the risk of foodborne illness and did not provide residents with nourishing, palatable, and attractive meals as required by facility policy.
Failure to Provide Ordered Assistive Eating Devices During Meals
Penalty
Summary
The facility failed to provide required special assistive eating devices to three residents during mealtimes, as observed and confirmed by staff. Two residents with orders for a plate guard and anti-spill cup (KCup) were not given these devices during lunch, despite their meal tickets indicating the need for them. Both residents had medical conditions such as hemiplegia, hemiparesis, COPD, and dementia, which necessitated the use of these assistive devices. A Certified Nursing Assistant (CNA) confirmed that the devices were not provided during the entire meal, and the Director of Nutrition Services acknowledged that facility policy requiring such support was not followed. Another resident with diagnoses including dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease was also not provided with a KCup as ordered, despite this being indicated on the meal ticket. The resident was observed drinking with a straw instead, and the assisting CNA confirmed the absence of the KCup. The Director of Nursing reviewed the facility's policy and confirmed that the resident should have received the KCup with meals, and that the policy was not followed by the staff involved.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Staff failed to treat two residents with respect and dignity during mealtime. Observations showed that Certified Nursing Assistants (CNAs) stood over both residents while feeding them lunch in the activity/dining room, rather than sitting and engaging with them at eye level. One resident was seated in a high back wheelchair and required assistance due to diagnoses including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia. The other resident, also in a wheelchair, had diagnoses of dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease. Both CNAs confirmed in interviews that they did not sit while feeding the residents, despite acknowledging the importance of doing so to maintain a homely environment and provide dignified care. A review of the facility's policy and procedure for assistance with feeding indicated that staff are required to support residents in a manner that maintains their dignity, independence, safety, and nutritional well-being, and to engage with residents calmly and respectfully. The Director of Nursing confirmed that the observed actions were unacceptable and not in accordance with facility policy, as staff should have been seated and engaging respectfully with the residents during mealtime.
Failure to Update Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to ensure that residents or their representatives were properly informed and provided updated informed consent for changes in psychotropic medication orders. For three residents, documentation showed that either the consent forms did not reflect new medication orders or dosage changes, or the consent forms did not match the current physician orders. Specifically, one resident had new orders for Trazodone and Aripiprazole, but the consent on file was for different dosages and was not updated. Another resident had new orders for Escitalopram and Risperidone, but the consents on file reflected previous dosages and were not updated to match the current orders. Additionally, a third resident had a consent form for Abilify at a lower dosage than what was currently ordered by the physician, and the consent did not match the physician's order. In each case, staff interviews confirmed that updated consents reflecting the current medication regimens could not be found. The facility's own policy required that informed consent be updated with any change in psychotropic medications, but this was not followed. As a result, the residents and their representatives were not informed of the risks, benefits, adverse reactions, or their right to refuse the administration of the new or changed psychotropic medications. This failure violated the residents' rights to be fully informed about their care and treatment, as required by facility policy and regulatory standards.
Failure to Accurately Complete and Submit MDS Assessment
Penalty
Summary
The facility failed to complete and submit a comprehensive Minimum Data Set (MDS) assessment for a resident within the required federal timeframe. Upon review, it was found that the resident, who had diagnoses including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia, was admitted with these conditions documented in the admission record. However, the MDS assessment did not accurately reflect the resident's current diagnoses, specifically omitting depression and dementia, despite the resident being prescribed a psychotropic medication for behavioral and psychological symptoms of dementia. Interviews with the LVN responsible for MDS completion and the Director of Nursing confirmed that the assessment was not completed accurately or in accordance with facility policy and federal requirements. The facility's policy required timely and accurate completion and electronic submission of the MDS, but this process was not followed. As a result, the resident's progress or decline was not adequately monitored, and accurate, resident-specific information was not submitted to CMS for payment and quality measure monitoring.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the required federal submission timeframes for two residents. For one resident with a history of hypertension, type 2 diabetes mellitus, and cerebrovascular accident, the quarterly MDS assessment was completed 52 days late. For another resident diagnosed with dementia, the quarterly MDS assessment was not completed and was 92 days overdue. These lapses were identified through interviews and record reviews with the Director of Nursing (DON), who acknowledged responsibility for completing the MDS assessments and confirmed the assessments were not completed within the required 92-day interval as outlined in the facility's policy and procedure. The facility's policy, which requires quarterly reviews to be conducted within 92 days of the previous assessment, was not followed in these cases. The DON confirmed during interviews that the policy was not adhered to and recognized the importance of timely assessments for accurate reimbursement and care planning. The findings were based on direct review of medical records and interviews with the DON, who admitted the assessments were late or not completed as required.
Failure to Timely Transmit Resident MDS Assessments
Penalty
Summary
The facility failed to ensure timely transmission of the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, three residents' assessments were not submitted within the federally mandated timeframes. For one resident with schizencephaly and spastic quadriplegia, the quarterly MDS assessment completed in February was not transmitted as of May, resulting in a delay of 69 days. Another resident with hypertension, type 2 diabetes mellitus, and a history of cerebrovascular accident had a quarterly assessment transmitted 7 days late and another assessment 37 days late. A third resident, who had severe disability post anoxic encephalopathy, had a comprehensive assessment due in March that was not transmitted, resulting in an 81-day delay. Interviews with the Director of Nursing (DON) confirmed that it was her responsibility to transmit the completed MDS assessments and that the facility's policy required submission within 14 days of completion. Record reviews and interviews revealed that these policies were not followed, and the DON acknowledged the lapses. The facility's own policy, reviewed during the survey, reiterated the requirement for timely electronic transmission of completed MDS assessments to the CMS QIES-ASAP system, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed a psychotropic medication. The resident was admitted with multiple diagnoses, including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia. A physician's order was in place for Abilify to address behavioral and psychological symptoms of dementia. However, upon review of the resident's care plan, there was no documented evidence that addressed the resident's dementia or the use of psychotropic medication. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan did not include the resident's dementia diagnosis or the associated psychotropic medication. The facility's policy requires that all medical, nursing, and psychological needs identified in the comprehensive assessment, including the use of psychotropic medications, be addressed in the care plan. Staff acknowledged that the care plan was not developed or updated as required by facility policy.
Failure to Label and Change Oxygen Tubing per Facility Policy
Penalty
Summary
A deficiency occurred when a resident receiving oxygen therapy did not have their oxygen tubing labeled to indicate the date it was last changed, as required by facility policy. During an observation, the resident was found in bed with oxygen running at three liters per minute, and the tubing lacked any label or date. A Licensed Vocational Nurse confirmed that the tubing was supposed to be changed weekly and labeled accordingly, but this had not been done. Further review of the facility's policy and procedure for oxygen use confirmed that both the humidifier bottle and oxygen tubing should be changed every Sunday night by a licensed nurse, with a label attached noting the date, time, and nurse's initials. The Director of Nursing acknowledged that the staff did not follow this policy. The resident involved had a medical history including dementia, diabetes, and osteoarthritis, and was admitted with these diagnoses.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of two medication carts, specifically Medication Cart 1. Review of the Controlled Medication Shift Count (CMSC) form revealed two missing signatures for the night shift, indicating that the required verification and documentation by two licensed nurses at shift change did not occur on those occasions. This was confirmed by a nurse and the DON, who both acknowledged that the facility's policy requires two licensed nurses to conduct and sign off on narcotic counts at each shift change, and that this procedure was not followed as documented.
Medication Refrigerator Temperature Log Incomplete
Penalty
Summary
The facility failed to adhere to its policy and procedure for drug storage by not ensuring that the daily medication refrigerator temperature log was properly completed. During an observation in the medication storage room, it was found that the temperature log for the medication refrigerator was missing staff signatures for two shifts, specifically on two separate dates. The Director of Nursing confirmed that the required temperature checks were not documented as per the facility's policy, which mandates that all refrigerators used for medication storage be monitored twice daily. This lapse meant there was no proof that staff had monitored the refrigerator's temperature as required.
Improper Storage of Personal Beverages in Laundry Room Breaches Infection Control Policy
Penalty
Summary
Surveyors observed two cups containing brown liquid, one with a sippy lid and one clear, left on a folding table in the laundry room across from the nurse's station in Unit B. Both the Environment Service (EVS) staff and an EVS trainee acknowledged the presence of these cups during the observation. The EVS staff member stated he had been informed that the coffee cup was allowed in the area. However, the Director of Facilities (DOF) later confirmed that personal drinks or beverages are not permitted in the laundry room, citing infection control concerns. A review of the facility's infection prevention policy, confirmed by the Director of Nursing (DON), indicated that the policy was not followed in this instance. The policy requires the maintenance of a safe environment to prevent the spread of infection, and specifically prohibits drinks in care areas outside of designated staff personal or break areas. The DON acknowledged that the presence of drinks in the laundry care area was a violation of this policy.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
