Bridgeview Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Yuba City, California.
- Location
- 521 Lorel Way, Yuba City, California 95991
- CMS Provider Number
- 056346
- Inspections on file
- 38
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Bridgeview Post Acute during CMS and state inspections, most recent first.
The facility failed to implement physician orders for psychiatric evaluation and treatment and to integrate these services into the care plans for two residents with diagnosed depression. One resident was admitted with major depressive disorder and a hospital discharge order for an antidepressant that was not continued, had an MDS showing depression, repeatedly refused therapy, showed low motivation and withdrawal after learning of a divorce, and had psychiatric referrals ordered but never completed. Another resident with major depressive disorder, cognitive decline, and cancer had documented depressive symptoms, including crying and poor intake, and had two separate psychiatric referral orders with no evidence of any psychiatric evaluation or treatment in the record. Staff interviews confirmed that psychiatric referrals were not followed through and that no counseling or psychological services were provided, resulting in both residents not receiving ordered mental health evaluations and services.
A resident with dementia, hemiplegia, and a high fall risk was left unsupervised on an outdoor patio by an RNA for about 30 minutes. The resident, dependent on staff for mobility and unable to call for help, was later found on the ground with a major head injury. The care plan did not specify supervision needs for outdoor activities, and staff were unaware of the resident's location. The resident suffered a subdural hematoma and died after emergency care.
A resident with vascular dementia, hemiplegia, and a history of falls was left unsupervised on a patio by an RNA for approximately 30 minutes, resulting in a major head injury and subsequent death. The resident was dependent on staff for all mobility and required close supervision, but staff failed to communicate the resident's location and did not provide adequate monitoring. The patio area could not be fully visualized from the nursing stations, and there was no call system available for the resident to request help.
A resident with significant cognitive and physical impairments was left unattended on a patio by a staff member, resulting in a fall that caused a subdural hematoma. The facility did not report the major injury to authorities, as required, because leadership did not consider it significant or unusual. This failure delayed investigation into the incident.
A resident with dementia and left-sided weakness, who enjoyed being outdoors, was not provided with outdoor activities as specified in their care plan. Activity staff were unaware of the care plan directive, and no documentation showed the resident was taken outside. The care plan also lacked clear instructions for supervision and frequency of outdoor activities, and staff did not facilitate the resident's participation due to not getting the resident up in a wheelchair.
A resident with multiple medical conditions and intact cognition reported being slapped by another resident, resulting in visible injuries. Although the incident was documented and known to facility leadership, it was not reported to the state agency as required by policy, due to staff misunderstanding about reporting requirements when the perpetrator has dementia.
Two residents with dementia and a history of falls experienced repeated incidents due to the facility's failure to determine the causes of falls, reevaluate care plan interventions, and develop new strategies to prevent further injuries. Direct care staff were not adequately informed about high fall risk residents or their care plans, and the electronic system used by CNAs did not provide sufficient information. The DON confirmed gaps in root cause analysis and communication regarding fall prevention interventions.
The facility failed to maintain a safe and homelike environment by storing construction materials in the rooms of three residents, creating potential hazards and cleanliness issues. Family members and residents raised concerns about tripping hazards and dustiness. The facility's policy required proper storage of supplies, which was not followed.
The facility failed to meet food safety and sanitation standards, with improper storage, labeling, and dating of food items in kitchen refrigerators. Expired and unlabeled food items were found, and kitchen equipment was unsanitary, with debris and grease on surfaces. Sanitizer levels were inconsistent, and dishwashing logs were incomplete. The kitchen environment was not clean, with food crumbs and spills on floors and walls. Resident food was not labeled or stored per policy, posing a risk of foodborne illness.
The facility failed to ensure resident dignity and privacy, as staff spoke in non-English languages in front of residents, night shift noise disturbed residents, and a CNA did not provide privacy during personal care. A resident was also inappropriately instructed to clean her own toilet, causing distress.
The facility failed to investigate and report alleged abuse involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported. A third resident reported being held down by a CNA, but the incident was not investigated, and the CNA continued to care for the resident.
Several residents in the facility reported issues with food being overcooked, undercooked, cold, or unappetizing. Despite complaints, the Dietary Manager failed to address these concerns effectively. Observations confirmed that food was not maintained at appropriate temperatures, with delays in meal service contributing to the problem. The facility's policies for food preparation and distribution were not followed, impacting the quality and safety of meals.
The facility failed to provide adequate social services and timely care for four residents, leading to unmet needs and potential delays in care. Care plans were not updated, financial assistance was not provided, and necessary referrals for outside services were delayed. Additionally, dental services were not promptly provided, resulting in significant delays for one resident.
The facility failed to properly store and label medications and supplies, with loose pills found in a medication cart, six medications opened but not dated, and expired Foley drainage bags and Pro-Stat liquid protein being used. The DON and ADON confirmed these actions were against facility policy.
A resident had teeth extracted and impressions taken for dentures, but due to an insurance change, the contracted dental service did not proceed with the dentures. The facility failed to follow up in a timely manner, leaving the resident unable to chew food properly.
A resident in a long-term care facility was prescribed both routine and PRN Ativan without an end date, contrary to CMS regulations. Despite recommendations from the consulting pharmacist to limit the PRN order to 14 days, the facility failed to address this in medication reviews. The resident, with a history of schizoaffective disorder and dementia, was at risk of adverse effects from excessive psychotropic medication use. Interviews revealed daily aggressive behaviors and unwitnessed falls, highlighting deficiencies in medication management.
A facility failed to document essential details for a resident's transfer to a hospital, including the date, time, destination, and mode of transportation. The resident, who had undergone hip replacement surgery and experienced a change in condition, was transferred without proper documentation, as confirmed by the DON.
A resident with severe cognitive impairment and a history of falls was observed without non-skid footwear, contrary to his care plan. Despite requiring maximal assistance, he was left to dress himself, and his call light was out of reach. A CNA assisted him but did not provide footwear, as the resident was not assigned to him that day. The DSD confirmed the need for non-skid footwear to prevent falls.
Two residents with g-tubes in an LTC facility received inappropriate care due to staff not following Physician's orders. One resident received incorrect fluid amounts, risking fluid overload, while another was given excessive fluids, leading to aspiration pneumonia. Documentation and communication lapses contributed to these deficiencies.
The facility failed to ensure complete, signed, and dated physician progress notes for two residents. One resident, with chronic conditions, had no physician notes for several months and reported never seeing a doctor. Another resident, awaiting eye surgery, had only one incomplete note and reported missed surgeries and no doctor visits. The DON confirmed the documentation issues, and the MRA noted the previous doctor's incomplete and inaccurate notes.
The facility failed to ensure nursing staff competencies, leading to deficiencies in resident care. LNs did not reassess or notify physicians about a resident's potentially infected eye, and suspicions of abuse were not reported for multiple residents. Additionally, LNs did not adequately monitor gastrostomy tube feedings or check meal trays, resulting in discrepancies and unmet resident preferences.
The facility failed to honor food preferences for several residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Residents with specific dislikes, such as eggs, rice, tomatoes, and certain vegetables, were repeatedly served these items despite documented preferences. Staff admitted to oversight due to being rushed, and corporate menu controls limited options. These issues were noted in resident council meetings and satisfaction surveys, indicating ongoing problems with food service.
Two residents experienced abuse in a facility, leading to emotional distress. A CNA grabbed a resident's arm during personal care, despite the resident's distress and request for the CNA not to enter his room. The incident was not reported or investigated, and the CNA continued to be assigned to the resident's room. In another case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing emotional distress. The housekeeper continued to be assigned to the resident's room until the issue was addressed. Both incidents highlight a failure in the facility's abuse prevention program.
The facility failed to report abuse allegations involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported by a CNA. Additionally, a resident reported being physically restrained by a CNA, but the incident was not investigated. These failures to report and investigate abuse allegations were confirmed by facility staff.
Failure to Implement Psychiatric Evaluation Orders for Depressed Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for psychiatric evaluation and treatment and to incorporate these services into the care plans for two residents with diagnosed depression. Facility policy on Behavioral Assessment, Intervention and Monitoring requires nursing staff to identify and report changes in mental status and for the IDT to evaluate behavioral symptoms and underlying causes. Despite this, Resident 1, admitted with major depressive disorder, cognitive communication deficit, and a history of alcohol abuse, had a hospital discharge order for Paroxetine that was not continued in the facility, and no other antidepressant was prescribed from admission through several months. Resident 1’s MDS identified depression and documented symptoms such as feeling tired, poor appetite, feeling life was a failure, and little interest or pleasure in activities, yet the psychiatric evaluation and treatment orders dated shortly after admission were not carried out. For Resident 1, multiple clinical notes documented ongoing depressive indicators and functional decline without corresponding psychiatric intervention or care plan updates. The NP ordered a psychiatric referral to assess for depression, and therapy notes showed repeated refusals of PT and OT, low motivation, and refusal to get out of bed. A care plan was initiated for feelings of loneliness and later for refusing showers, and social services documented that the resident “shut down” and became nonverbal after being informed of a pending divorce. CNA interview confirmed the resident was upset about the divorce and minimally participated in personal hygiene. The SSD acknowledged that no counseling or psychological evaluation was provided and that no new care plan or change-in-condition assessment was initiated after the emotional event. The DON confirmed that the psychiatric referral “got away from them” and that the resident received no psychiatric services while in the facility, and the NP acknowledged being unaware that the psychiatric evaluation had not occurred. Resident 2 was admitted with major depressive disorder, cognitive decline, and cancer, and the MDS documented mild cognitive impairment and depression, including feeling bad about self, being down and depressed, having little pleasure in activities, and difficulty staying asleep. Physician orders included psychiatric referral, evaluation, and treatment on two separate dates, but no psychiatric evaluations were found in the medical record. NP progress notes documented monitoring for signs and symptoms of depression, including episodes of crying and poor oral intake, yet there was no evidence that the psychiatric referrals were implemented. RN B confirmed the absence of psychiatric evaluation or treatment documentation and stated that the nurse receiving the psychiatric referral order is responsible for entering it into the EHR and coordinating care. Additional interviews with activities and social services staff described the resident as emotional, crying, and upset about dying, further indicating ongoing depressive symptoms without documented follow-through on ordered psychiatric services. This failure resulted in both residents not receiving mental health evaluation and had the potential for them not to reach their highest practicable level of mental and psychosocial well-being.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a restorative nursing assistant (RNA) left a resident, who was at moderate risk for falls and had significant cognitive and physical impairments, unsupervised on an outdoor patio for approximately 30 minutes. The resident had a history of vascular dementia, hemiplegia, muscle weakness, and was dependent on staff for all mobility and activities of daily living. The resident's care plan identified a need for a safe environment, assistance with all ADLs, and interventions to minimize fall risk, but did not specify supervision requirements for outdoor activities. On the day of the incident, the RNA took the resident outside in a wheelchair and left him alone on the patio, without informing other staff or ensuring supervision. The patio was not fully visible from the nursing stations, and there was no method for the resident to call for help. Staff interviews confirmed that the resident was not alert, was dependent on staff, and should not have been left unsupervised. The resident was later found on the ground, unresponsive, next to his wheelchair, having sustained a major head injury. Medical evaluation revealed a subdural hematoma with midline shift, and the resident was transported to the hospital for emergency care. The incident resulted in a significant decline in the resident's condition and ultimately led to death. Staff statements and record reviews confirmed that the lack of supervision and failure to communicate the resident's location contributed directly to the fall and subsequent injury.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a Restorative Nursing Assistant (RNA) left a resident with vascular dementia, hemiplegia, and a history of falls alone on a facility patio for approximately 30 minutes. The resident was known to be dependent on staff for all mobility, had impaired cognition, and was classified as a moderate fall risk. The resident's care plan required staff to provide a safe environment, prompt response to requests for assistance, and appropriate supervision, especially during activities that could increase the risk of falls. On the day of the incident, the RNA took the resident outside in a wheelchair and left them unsupervised on the patio. The RNA did not inform other staff members of the resident's location, and the nursing station was unstaffed at the time. The resident was later found unresponsive on the ground outside, having sustained a major head injury. The resident was transported to an acute care hospital, experienced a decline in condition, and subsequently died. Multiple staff interviews confirmed that the resident required total supervision due to their cognitive and physical impairments, and that the patio area could not be fully visualized or monitored from the nursing stations. Staff members, including CNAs and nurses, stated that it was common knowledge that residents with dementia or high fall risk should not be left unsupervised, particularly in areas where they could not be easily seen or heard. The RNA acknowledged the mistake of leaving the resident alone, and other staff confirmed that proper communication and supervision protocols were not followed. The facility's Director of Nursing also confirmed that there was no method for residents on the patio to call for help, such as a call light, further contributing to the lack of supervision and safety for the resident.
Failure to Report Major Injury After Resident Fall
Penalty
Summary
The facility failed to report a major injury involving a resident who was left unattended on a patio by a Restorative Nursing Assistant for 30 minutes. During this time, the resident, who had vascular dementia, hemiplegia, hemiparesis, and muscle weakness, fell and was found unresponsive with shallow breathing and unstable vital signs. The resident was transported to a hospital, where a CT scan revealed a small acute subdural hematoma with a midline shift. The resident was later returned to the facility on hospice care and subsequently died that evening. Despite the severity of the injury, which met the CMS definition of a major injury, the facility did not report the incident to the appropriate authorities. Both the Administrator and the Director of Nursing stated in interviews that they did not consider the injury significant or an unusual occurrence, and therefore did not report it. This failure delayed the investigation into the major injury and was not in accordance with facility policy or professional standards of practice.
Failure to Provide Outdoor Activity per Resident's Care Plan
Penalty
Summary
The facility failed to honor an activity preference that was documented in the activity care plan for a resident with dementia and left-sided weakness, who was unable to make his own health care decisions. The resident's care plan specified that staff should take him outside to sit in the sun when the weather was nice, and a quarterly activity review indicated he enjoyed being outdoors. However, a review of activity participation notes over several months showed no documentation of the resident being taken outside to the patio. Interviews with the Activity Assistant and Activity Director revealed that neither was aware of the care plan directive for outdoor activities for this resident. The Activity Assistant confirmed that she had not taken the resident outside and that there was no group activity for residents to go outdoors. The Activity Director also confirmed the lack of outdoor activities and stated that the care plan did not provide clear instructions regarding supervision or frequency for outdoor time. Additionally, the Activity Director noted that staff had not facilitated the resident's participation in outdoor activities due to not getting him up in his wheelchair, and that not all areas of the patio were visible from inside, raising concerns about supervision.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving one of five sampled residents. A resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including Parkinson's Disease, COPD, hypertension, and muscle weakness, informed staff that another resident had slapped them on the face and chest, resulting in discoloration and scratches. The incident was documented in the resident's progress notes and a report of suspected dependent adult/elder abuse was completed, confirming the physical altercation between the two residents. Despite the facility's policy requiring all reports and findings of resident abuse to be reported to local, state, and federal agencies, the incident was not reported to the state licensing/certification agency. Both the Administrator and the DON confirmed the incident occurred but stated their belief, based on an All Facilities Letter, that abuse involving a perpetrator with a dementia diagnosis did not require reporting. As a result, the abuse allegation was not reported as required by facility policy.
Failure to Prevent Repeated Falls Due to Inadequate Evaluation and Communication of Fall Interventions
Penalty
Summary
The facility failed to ensure that two of three sampled residents were free from accident hazards and received adequate supervision to prevent accidents. Post-fall evaluations did not determine the reasons for repeated falls, and the care plan interventions for these residents were not reevaluated for effectiveness. New interventions were not consistently developed to prevent further falls and injuries, and direct care staff were not adequately informed on how to identify high-risk fall residents or locate their fall plans of care. One resident, with diagnoses including dementia, difficulty walking, anxiety disorder, and a history of repeated falls, experienced multiple falls during their stay. Despite being identified as a high fall risk, the resident's care plan interventions, such as one-to-one supervision and toileting programs, were inconsistently applied and not evaluated for effectiveness. Several falls occurred during shifts not covered by the interventions, and repeated interventions were implemented without assessing their impact. Documentation showed that the interdisciplinary team did not address falls occurring during the day shift, and there was no clear rationale for changes in supervision levels. Another resident, also with dementia and a history of falls, was assessed as a moderate fall risk and had significant cognitive impairment. The care plan included interventions such as frequent checks and reminders to use the call light, despite the resident's inability to use the call light due to cognitive limitations. Staff interviews revealed a lack of awareness of the resident's fall risk status and care plan details, and the electronic care plan system used by CNAs did not provide comprehensive information. The Director of Nursing confirmed gaps in root cause analysis, care planning, and communication of fall risk interventions to direct care staff.
Improper Storage of Construction Materials in Resident Rooms
Penalty
Summary
The facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment by improperly storing construction materials in the room of three residents. The materials included piles of flooring and adhesive or paint, which were stored in a manner that created potential hazards and made the environment less homelike. Family members and residents expressed concerns about the tripping hazards and the difficulty in maintaining cleanliness due to the presence of these materials. The facility administrator acknowledged the situation, stating that the room had been vacant and was used for storage, but later needed for residents. Interviews with staff and residents confirmed the presence of the materials, with some residents noting the stuffiness and dustiness caused by the storage. The facility's maintenance director admitted that storing the materials in the residents' room was against the facility's policy and recognized it as a poor decision. The facility's policy on the receipt and storage of supplies and equipment clearly indicated that supplies should be stored in designated areas and that hazardous materials must be properly stored and labeled, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met, as evidenced by improper storage, labeling, and dating of food items in the kitchen refrigerator/freezers. Observations revealed expired food items, such as an open jar of applesauce and a foil-covered container of puree bread without a use-by date. Additionally, there were unlabeled and undated food items, including boiled eggs and sliced bread, which were not stored according to the facility's policy and procedure. The Registered Dietitian and Dietary Manager acknowledged these issues, noting that compromised packaging and improper labeling could allow bacteria or pests to enter, posing an infection control risk. The kitchen and food service equipment were found to be in unsanitary conditions, with thick, black debris under stovetop burners, greasy substances on the stove backsplash, and food crumbs on various surfaces. The sanitizer solution in the dishwashing sink was tested and found to be outside the acceptable range, indicating improper sanitization. The Dietary Manager acknowledged the cleanliness issues and the potential infection risks posed by the unclean equipment and utensils. Additionally, the dishwashing log entries were incomplete, and the sanitizer levels were not consistently monitored, further contributing to the unsanitary conditions. The kitchen environment was not maintained in a sanitary condition, with food crumbs, spills, and stains observed on the floors and walls. The dry storage room floor was visibly dirty, and the fan over the food preparation area was dusty. The facility's policy required the kitchen to be kept clean and sanitary, but observations revealed that these standards were not met. The Dietary Manager and Maintenance Supervisor acknowledged the cleanliness issues, and the Dietary Manager indicated that disciplinary actions would be taken due to the general lack of cleanliness in the kitchen. Additionally, resident food in the refrigerator was not labeled or stored according to policy, with expired and unlabeled items present, posing a risk of foodborne illness to residents.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination, as evidenced by several incidents involving six residents. Staff members were observed speaking in their native language in front of residents who did not understand, causing discomfort and feelings of disrespect. Residents 46, 90, and 100 reported feeling uncomfortable and disrespected when staff conversed in a language they did not understand, which was against the facility's policy that required staff to speak English in areas where residents could hear them. Additionally, the facility's night shift staff were reported to be loud, disturbing residents' sleep. Residents and their family members expressed concerns about the noise levels at night, which affected their well-being. Resident 106, who was not her own responsible party, expressed feelings of worthlessness and distress due to the noise, indicating a failure to maintain a peaceful environment conducive to rest and recovery. Furthermore, Resident 101 was not provided privacy during personal care, as observed when a CNA assisted the resident in dressing without drawing the privacy curtain or closing the door. This lack of privacy was acknowledged by the CNA, who admitted to forgetting to provide it. Resident 40 was instructed by a housekeeper to clean her own toilet, which was inappropriate and led to feelings of paranoia and distress. The housekeeper's actions were not reported immediately, contributing to the resident's emotional distress.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and protect residents from alleged abuse in three separate incidents involving Residents 22, 35, and 40. In the first incident, Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 exhibited fear during care, despite the resident's roommate corroborating rough handling by night shift CNAs. Resident 22, who had a moderately impaired memory, did not voice concerns directly, but CNA M noticed a change in behavior and failed to report it. In the second incident, Resident 40, who had no cognitive impairment, alleged that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite informing CNA J of the incident, CNA J did not report it to the administration. The housekeeper was later suspended pending investigation, but the initial failure to report left Resident 40 in a state of emotional distress. The third incident involved Resident 35, who had intact cognition but required full assistance with daily activities. Resident 35 reported that CNA E held him down during care, which was corroborated by another CNA. Despite this, the incident was not reported or investigated, and CNA E continued to be assigned to care for Resident 35. The facility's administration was unaware of the incident until it was brought to their attention during the survey, highlighting a significant lapse in reporting and investigation procedures.
Deficiencies in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Resident 77, who is the President of the Resident Council, reported that the food was consistently overcooked, such as burnt sausage, and cold, like the gravy served. Despite raising these issues with the Dietary Manager over several months, no effective solution was implemented. Resident 84 experienced undercooked pork, which led to digestive issues, and Resident 11 received melted ice cream, indicating improper food handling and timing during meal service. Resident 35 reported that his meals were often cold, his ice cream melted, and his biscuits burnt, which he found nauseating. The Dietary Manager acknowledged the complaints about cold food and mentioned that a new plate warmer had been acquired but not yet utilized. Observations during meal service confirmed that food carts were delayed, and the food was not maintained at appropriate temperatures, as evidenced by a pizza slice being served at 95 degrees, below the recommended 135 degrees for hot food. Resident 215 was served burnt pizza, which she found unpalatable, and this was confirmed by a CNA. The facility's policy and procedure for food preparation and meal distribution were not adhered to, as meals were not maintained at the required temperatures. The Dietary Manager admitted to being overwhelmed by complaints and recognized the need for better food temperature management. The report highlights systemic issues in the facility's food service operations, affecting the quality and safety of meals provided to residents.
Failure to Provide Adequate Social Services and Timely Care
Penalty
Summary
The facility failed to provide adequate medically-related social services for four residents, leading to unmet needs and potential delays in care. For two residents, the social service care plans were not updated quarterly or as needed, failing to reflect their discharge plans. One resident's care plan inaccurately indicated long-term care instead of short-term care, and another resident's discharge plan was uncertain, with no updates made to reflect their needs. Additionally, the facility did not assist one resident with financial documents when requested, hindering their ability to obtain necessary income for discharge. The Social Services Director (SSD) failed to assist with disability paperwork, despite the resident's request, and did not provide adequate support for discharge planning. This lack of assistance was confirmed by the facility's administrator, who stated that the SSD should have helped the resident with their financial needs. The facility also failed to make timely referrals for outside services for another resident, who required an ophthalmology consultation for a visual deficit. The SSD did not send the necessary referral, and the resident expressed concern about losing their vision due to the lack of timely intervention. Furthermore, dental services were not provided promptly for another resident, who had teeth extracted but did not receive dentures due to insurance issues. The SSD did not follow up on the dental services until prompted by the resident's family, resulting in a significant delay.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were stored and labeled according to professional standards. During an inspection of medication cart 2, two loose pills were found in a drawer, which was confirmed by the Assistant Director of Nursing (ADON) as inappropriate. Additionally, six medications being dispensed were opened but not dated, including two bottles of Tuberculin, one tube of Muscle Rub Cream, two bottles of Enulose, and a bottle of Geri tussin DM. The Director of Nursing (DON) and ADON confirmed that it was the facility's policy to date medications upon opening and discard them within 30 days. Furthermore, the facility stored expired medical supplies and medications. Four Foley drainage bags in the medication storage room were past their expiration date, and Pro-Stat concentrated liquid protein medical food was being dispensed despite being expired. The DON confirmed that expired items should be discarded and not available for use. The facility's policy indicated that no expired medication should be administered, and opened medications should be dated, which was not adhered to in these instances.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding dental services for a resident, leading to a deficiency. The policy required that residents needing dental services be promptly referred to a dentist. However, the facility did not ensure that a resident who had teeth extracted received the necessary follow-up care to obtain dentures. The resident, who was readmitted with multiple diagnoses including lung disease, depression, and left-sided paralysis, had his teeth extracted by a facility-contracted dental service. Impressions and x-rays for dentures were taken, but the process was halted due to an insurance change that the contracted dental service would not honor. The deficiency was further compounded by the facility's lack of timely follow-up. The Social Service Director admitted to not contacting the dental service to follow up on the resident's dentures until prompted by the resident's daughter during a care conference, five months after the extractions and impressions. This inaction resulted in the resident being unable to chew food properly, as he was left without dentures, impacting his ability to eat comfortably.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The deficiency involves the failure of a long-term care facility to adhere to regulations regarding the use of psychotropic medications for a resident, identified as Resident 61. The resident had both a routine and a PRN order for Ativan, an anti-anxiety medication, which was available for five months without an order end date. This was despite recommendations from the consulting pharmacist to discontinue the PRN order or limit it to 14 days, as per CMS regulations. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician examined the resident and documented the necessity for continuation. Resident 61, who had a history of multiple medical conditions including schizoaffective disorder, dementia, and anxiety disorder, was at risk of adverse effects from the excessive use of psychotropic medications. The resident's care plans indicated the use of Ativan for anxiety and aggressive behaviors, with interventions including monitoring for side effects and effectiveness. However, the facility failed to address the Ativan PRN order in the resident's medication regimen reviews, and the PRN order was not discontinued until four months after the initial recommendation by the consulting pharmacist. Interviews with facility staff revealed that the resident exhibited daily aggressive verbal behaviors and had experienced unwitnessed falls, which were not consistently documented. The consulting pharmacist noted the increased risk of serotonin syndrome toxicity due to the combination of medications the resident was receiving. Despite these risks, the facility did not conduct a Benefits v. Risks Review with physician documentation to justify the continuation of the PRN Ativan order, leading to the deficiency in medication management for Resident 61.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who was transferred to an acute care hospital. Specifically, the facility did not document the date and time of the transfer, the destination hospital, the mode of transportation, or the disposition of the resident's personal effects and medications. This lack of documentation was identified during a review of the resident's clinical record and was confirmed by the Director of Nurses (DON). The resident involved had been admitted to the facility with diagnoses including right hip joint replacement surgery, anxiety, and depression, and was their own healthcare decision maker. A Change in Condition Assessment/SBAR noted a change in the resident's condition, including pain and swelling in the right hip, which was assessed by a licensed nurse. However, the nursing progress note did not reflect the transfer details, and the DON acknowledged that the documentation should have included an assessment, intervention, and the doctor's order for the transfer.
Failure to Provide Non-Skid Footwear for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident 101, who was at risk for falls, was wearing non-skid footwear as per his care plan. Resident 101 was admitted with diagnoses including stroke, muscle weakness, difficulty in walking, and major depressive disorder. His cognitive status was severely impaired, requiring maximal assistance for daily activities such as dressing and transferring. The care plan specifically indicated that Resident 101 should have appropriate footwear when out of bed or mobilizing in his wheelchair to prevent falls. During observations, Resident 101 was seen in his room without shoes or socks, struggling to dress himself, and his call light was on the floor, out of reach. A CNA assisted him with his pants but did not ensure he had footwear on, as the CNA was not assigned to him that day. Resident 101 expressed difficulty in finding his call light and mentioned a previous fall when trying to get up by himself. The Director of Staff Development confirmed that Resident 101 should have been wearing non-skid socks or shoes to prevent falls.
Deficiencies in G-Tube Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with gastrostomy tubes (g-tubes), leading to significant deficiencies in their care. For Resident 87, Licensed Nurses (LNs) did not adhere to the Physician's orders regarding the prescribed amounts of liquid nutrition, hydration, and water flushes. The documentation of intake amounts was inaccurate, with instances of both excessive and insufficient fluid administration compared to the Physician's orders. Additionally, LNs provided g-tube care without a Physician's order and failed to document the care provided, including assessments of g-tube placement and residuals. Resident 214 experienced a similar lapse in care, receiving an excessive amount of fluids due to a failure to discontinue outdated orders. The Registered Dietitian (RD) had recommended a specific fluid intake, but the resident received significantly more than this amount, leading to fluid overload. This oversight was compounded by the fact that the RD was unaware of the excessive fluid administration, and the Nurse Practitioner (NP) confirmed the excessiveness of the fluid intake. The Assistant Director of Nursing (ADON) acknowledged that the order for 300 mL of water every four hours should have been discontinued but was not. These failures placed both residents at risk for serious health complications. Resident 87 was at risk for fluid overload and g-tube malfunction, while Resident 214 was sent to the emergency room due to formula leakage and was diagnosed with aspiration pneumonia. The deficiencies in care for both residents highlight significant lapses in following Physician's orders and ensuring accurate documentation and communication among the care team.
Incomplete Physician Documentation and Missed Visits
Penalty
Summary
The facility failed to ensure that physician progress notes were complete, signed, and dated at each required visit for two residents. Resident 34, who was admitted with chronic obstructive pulmonary disease, dementia, and bipolar disorder, had no physician notes for June and September 2024. Despite being in the facility for two years, Resident 34 reported never having seen a doctor. Resident 98, admitted with end-stage renal disease and a benign neoplasm on the right eyelid, had only one incomplete physician note without a date or assessment of the right eye. Resident 98 also reported that the doctor never visited, and his eye surgery was missed three times. During interviews, the Director of Nursing confirmed the absence and incompleteness of physician notes for both residents. The Medical Record Assistant revealed that the previous medical provider, who left the facility at the end of September 2024, often did not complete or date his notes, and his assessments were not always accurate. This lack of proper documentation and physician visits had the potential to negatively affect communication between disciplines and result in inappropriate care and service for the residents.
Deficiencies in Nursing Competencies and Reporting in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies in caring for residents, leading to several deficiencies. Licensed Nurses (LNs) did not reassess or notify the physician about a potentially infected right eye of a resident, who had been admitted with end-stage renal disease and a benign tumor on the right eyelid. Despite the resident's intact cognition and self-reported infection, there was no documentation or follow-up on the condition, and the Director of Nursing confirmed the lack of assessment and communication regarding the resident's eye condition. Additionally, the facility did not report suspicions or allegations of abuse for multiple residents. One resident reported rough handling by CNAs during personal care, which was witnessed by a roommate. A CNA suspected potential abuse due to the resident's change in behavior but failed to report it. Another resident reported emotional distress caused by a housekeeper's actions, which were not reported by a CNA who was informed of the incident. The facility's administrator confirmed that these incidents should have been reported immediately. Furthermore, LNs did not adequately monitor gastrostomy tube feedings, resulting in discrepancies between the physician's orders and the actual intake recorded. The LNs provided incorrect amounts of water flushes and did not document assessments of g-tube placement and residuals. Additionally, LNs failed to check meal trays properly, leading to a resident receiving a meal that included a disliked food item. The LN responsible admitted to not reviewing the meal trays for resident food preferences, resulting in the resident not eating the meal provided.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for five residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Resident 46, who has type 2 diabetes and anxiety, reported a dislike for eggs but continued to receive them for breakfast. Despite having a BIMS score indicating good memory, the resident's dietary profile did not reflect this preference. Similarly, Resident 90, also with type 2 diabetes and high blood pressure, expressed a dislike for rice, which was documented in their dietary profile, yet rice was frequently served. Resident 100, diagnosed with heart failure and depression, consistently received tomatoes despite a documented dislike. The resident expressed frustration, feeling that complaints about food led to worse service. An observation confirmed that tomatoes were served with their meal, and the facility's Infection Preventionist acknowledged the oversight. Resident 106, with dysphagia and poor memory, was served a tuna fish sandwich and an egg and cheese omelet, both of which were on their dislike list. The responsible Licensed Nurse admitted to not checking the meal trays for preferences due to being in a hurry. Resident 104, who often requested alternative meals like hamburgers and hot dogs, was served overcooked vegetables, including carrots, peas, and corn, which they disliked. The Dietary Manager confirmed that residents received items on their dislike lists due to corporate menu controls and the kitchen being rushed during a state survey. These failures to accommodate food preferences were documented in resident council meeting notes and satisfaction surveys, indicating ongoing issues with food service in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, leading to emotional distress and mental anguish. In the first case, a Certified Nursing Assistant (CNA) grabbed and held a resident's arm during personal care, despite the resident's clear distress and request for the CNA not to enter his room. The resident, who had intact cognition and could make his own decisions, reported the incident to a nurse, but the CNA continued to be assigned to his room. The incident was not reported or investigated by the facility, and the CNA admitted to grabbing the resident's wrist during an altercation over the resident's personal items. In the second case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing the resident to feel unwell and emotionally distressed. The resident, who had no cognitive impairment, reported that the housekeeper pointed to the toilet and handed her paper napkins to clean it. The resident informed a family member, who provided cleaning supplies, and reported the incident to a CNA, who did not escalate the complaint for investigation. The housekeeper continued to be assigned to the resident's room until the issue was brought to the attention of the housekeeping manager. Both incidents highlight a failure in the facility's abuse prevention program, as staff did not report or investigate the allegations of abuse. The facility's policies and procedures were not followed, resulting in continued exposure of the residents to the staff members involved in the incidents. The lack of immediate action and investigation contributed to the residents' emotional distress and the potential for ongoing abuse.
Failure to Report Abuse Allegations in LTC Facility
Penalty
Summary
The facility failed to report suspicions and allegations of abuse for three out of five sampled residents, which included incidents involving Residents 22, 35, and 40. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 showed fear during care, despite acknowledging a change in behavior that suggested potential abuse. Resident 22, who had a BIMS score indicating moderate memory impairment, expressed concerns about being handled roughly by night shift CNAs, which was corroborated by a roommate. However, CNA M did not escalate these suspicions to the appropriate authorities. In another incident, Resident 40, who had no cognitive impairment, reported that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite being informed of this by Resident 40, CNA J failed to report the incident to the facility management. The resident expressed fear of Housekeeper A, who was also accused of waking her up by hitting the bed with a mop. The facility's administrator confirmed that the incident should have been reported and investigated, but it was not. Additionally, Resident 35, who had intact cognition, reported being physically restrained by CNA E during care. The resident expressed distress over the incident, which was not reported or investigated by the facility. CNA E admitted to holding down the resident and informed the Infection Preventionist and a charge nurse, but no further action was taken. The Director of Staff Development confirmed that the incident occurred and that there should have been an investigation, but none was conducted.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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.
