Brighton Place San Diego
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 1350 N. Euclid Avenue, San Diego, California 92105
- CMS Provider Number
- 055795
- Inspections on file
- 46
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brighton Place San Diego during CMS and state inspections, most recent first.
A resident with anxiety disorder who required assistance with personal care alleged that a CNA attempted to slap her during a bed bath, causing a broken imitation fingernail when she raised her hand to protect herself. The resident reported the incident to an LN the same night and later discussed it with an SSA, who relayed the allegation to the ADM. Documentation reflected the resident’s agitation and verbal threats to report the CNA during care, and the ADM acknowledged being informed of the allegation by both the LN and SSA. Despite a facility policy requiring the ADM or designee to notify CDPH within two hours of any abuse allegation without serious bodily injury, the SOC 341 report was not submitted until two days after the incident, well beyond the required reporting timeframe.
The facility did not report a COVID-19 outbreak to CDPH L&C as required, despite multiple residents and a CNA testing positive. Additionally, a resident's family member was observed assisting with care in a contact precautions room without wearing PPE, contrary to facility policy. Staff confirmed the visitor had not previously reported any PPE allergies, and the facility's infection control policy required PPE use for all visitors in such situations.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
Two residents with complex medical needs were discharged without documented, person-centered discharge care plans. Interviews with nursing staff and the DON confirmed that such plans are required upon admission to ensure coordinated and goal-oriented discharges, but records showed no evidence of their development or implementation, contrary to facility policy.
Two residents were discharged without proper discharge care plans, as required by facility policy. One had a history of stroke and the other had dementia. Staff interviews confirmed that the discharge care plans were either not updated or not created, despite the responsibility lying with social services and the DON.
A resident's responsible party, seeking access to medical records for a resident with dementia, experienced a delay when the request was not communicated promptly to the Medical Records Director. Although the Admissions Coordinator and DON were aware of the request, the records were not provided within the facility's required two-business-day timeframe due to internal communication lapses.
The facility failed to maintain sanitary conditions in resident bathrooms, as reported by multiple residents and confirmed through observations. Bathrooms had feces on walls and around toilets, remaining uncleaned for extended periods, contrary to facility policies.
The facility did not ensure food temperatures were checked before serving on two days, as the Food Temperature Log was blank for breakfast and lunch. The Dietary Supervisor noted that two staff members were responsible for recording the temperatures but failed to do so, with one staff member unable to recall the reason. This failure increased the risk of food-borne illness.
The facility failed to ensure dietary staff were trained to properly test kitchen sanitizer, increasing the risk of food-borne illness. Cook 1 incorrectly tested the sanitizer, and Dietary Aide 2 was unaware of the procedure, lacking completed initial competencies. The Dietary Supervisor confirmed the need for all staff to know the procedure, and a review showed no evidence of training for Dietary Aide 2.
The facility failed to ensure proper food storage and handling, as expired food was not discarded, opened food items were unlabeled, and a dietary aide did not cover facial hair, increasing the risk of food-borne illness.
The facility failed to follow infection control policies, leading to potential cross-contamination and infection spread. A resident's oxygen supplies were improperly stored, and the facility lacked an infection surveillance tracker, hindering effective contact tracing during a COVID-19 outbreak. Additionally, staff and visitor screenings were inadequate, compromising infection control efforts.
A facility was found to have two rooms occupied by six residents each, exceeding the regulatory limit of four residents per room. The Administrator confirmed that the facility did not have any current waivers to allow for this increased capacity, with the last waiver being from 2012. This situation could potentially lead to overcrowding and affect the quality of care.
The facility failed to follow its smoking policy for two residents, leading to a deficiency in managing smoking and tobacco use. One resident with diabetes mellitus did not have quarterly smoking assessments completed, missing two assessments. Another resident with severe cognitive deficits also missed a quarterly assessment. The facility's policy required assessments upon admission, quarterly, annually, and upon any change in condition, which was not adhered to, potentially compromising resident safety.
A resident with Chronic Kidney Disease Stage 4 was not provided meals according to his dietary preferences and needs, as the facility failed to follow the meal tray card instructions. Despite having a dietary evaluation indicating specific dislikes and restrictions, the resident was served inappropriate foods, such as oranges and potatoes. The dietary staff and Licensed Nurse acknowledged the oversight, and the Director of Nursing emphasized the importance of honoring meal preferences to prevent complications like weight loss.
A resident with cognitive deficits and limited hand use received a meal not prepared in the required chopped form, despite the meal ticket indicating so. Staff interviews revealed a failure in the meal verification process, as acknowledged by the DON, which did not align with the facility's policy to provide meals consistent with residents' needs and physician's orders.
The facility failed to notify the LTC Ombudsman about the transfer of two residents to an acute care hospital, violating regulations. One resident was transferred due to an abnormal heart rate, and another for low hemoglobin levels. Staff were unaware of the requirement to notify the Ombudsman, leading to a deficiency in following the facility's policy on transfer and discharge notifications.
A resident with Alzheimer's disease eloped from the facility due to a failure to conduct a comprehensive elopement assessment. Despite known risks of wandering, the facility's elopement risk binder was outdated, and procedures were not effectively implemented, allowing the resident to leave the premises and be found at a nearby church.
The facility failed to accurately code the MDS for three residents, resulting in the transmission of incorrect health status information. A resident's fall was not documented, another resident's fall was omitted from the MDS, and a third resident's resolved pneumonia was inaccurately listed as active. The MDSN and DON acknowledged these oversights, highlighting the importance of accurate MDS coding for care planning.
A resident with psychosis and depression was admitted to a facility with an inaccurate PASRR screening that failed to reflect their mental health needs and medication. The MDSN and DON acknowledged the error, which was contrary to the facility's policy requiring accurate PASRR updates.
The facility failed to implement person-centered care plans for residents, leading to deficiencies in care. A resident with chronic kidney disease was served inappropriate meals, another resident on hospice lacked a hospice care plan, and a resident with Alzheimer's had inadequate elopement prevention measures. These issues highlight gaps in the facility's care planning process.
A resident with COPD was at risk of developing pressure injuries due to an improperly set low air loss mattress. The mattress was configured for a weight of 400 pounds, while the resident weighed 233.4 pounds. Staff interviews confirmed the incorrect setting could lead to pressure injuries, as the mattress would be too firm. The facility failed to adjust the mattress according to the resident's weight, as required by the mattress manual.
A facility failed to monitor and document urine output for a resident with a urinary catheter, contrary to its policy. The resident, admitted with a dysfunctional bladder, had no urine output measurements recorded, as confirmed by a CNA who stated they were not instructed to do so. Interviews with an LN and the DON revealed that the facility's policy required such monitoring, but it was not followed, leading to a lack of documentation in the resident's clinical record.
A resident who had a liver transplant did not receive their prescribed anti-rejection medication, tacrolimus, as ordered. The MAR showed missed doses due to the medication not being on hand or pending delivery, with some instances lacking documentation. Interviews confirmed the facility's failure to ensure the medication was available, despite the pharmacy supplying it, increasing the risk of organ rejection.
A resident with a colostomy did not receive proper care due to the facility's failure to develop a baseline care plan, obtain a physician order, and document treatments in the TAR. The Treatment Nurse changed the colostomy bag daily without recording these actions, and the Director of Nursing confirmed the lack of necessary documentation and planning.
A resident with the capacity to make medical decisions eloped from the facility after going out on pass with a family member. The facility failed to document the resident's departure and return, and the out on pass logbook was incomplete. An LPN did not clarify the duration of the out on pass order with the physician, and the resident's condition was not assessed upon return. The facility's policy required a physician's order and documentation of the resident's status before and after the pass, which were not followed.
The facility failed to conduct reference checks prior to hiring a CNA, which had the potential to increase the risk of abuse for residents. A resident reported an incident of physical abuse involving the CNA, who was subsequently suspended. A review of the CNA's personnel file revealed that no reference checks were conducted prior to hire, contrary to the facility's policy.
The facility failed to provide consistent dialysis access care and complete dialysis communication forms for three residents. This included not removing dialysis dressings within the required 4-6 hours and missing pre and post-dialysis assessments, leading to potential complications.
Failure to Timely Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident 1 to the California Department of Public Health (CDPH) within two hours of the initial allegation. Resident 1, who had an anxiety disorder and required assistance with personal care, reported that during an evening bed bath on 3/4/26, a CNA attempted to slap her when she objected to how her gluteal area was being cleaned. Resident 1 stated she raised her hand to protect her face and her imitation fingernail on the right pinky broke. She reported the incident that night to a licensed nurse at about 10 P.M., and the following day discussed the incident with the Social Services Assistant (SSA). The SSA overheard Resident 1 describing that the CNA was not following her instructions on how to clean her, and that when Resident 1 raised her hand, the CNA hit her and broke her nail. The Behavior Note by Licensed Nurse 1 on 3/4/26 documented Resident 1 making threatening verbal statements toward a CNA during care, speaking in a raised voice, appearing agitated, and stating, "You are not doing the right thing and I will report you," with the supervisor notified. The Administrator (ADM) acknowledged being informed of the incident by the licensed nurse on the night of 3/4/26 and again by the SSA on 3/5/26 at about 4 P.M., but did not report the alleged abuse to CDPH within the required two-hour timeframe. The SOC 341 report was not sent until 3/6/26 at 3:59 P.M., despite the facility’s abuse-reporting policy stating that the Administrator or designee will notify CDPH by telephone within two hours of an allegation of abuse with no serious bodily injury. The ADM stated that the expectation was to report any alleged abuse to CDPH within two hours of the allegation being made and recognized the importance of this requirement.
Failure to Report COVID-19 Outbreak and Ensure Visitor PPE Compliance
Penalty
Summary
The facility failed to implement required infection control practices in two key areas. First, the facility did not report a COVID-19 outbreak to the California Department of Public Health Licensing and Certification (CDPH L&C) as required by their own policy, despite having multiple residents and a staff member test positive for COVID-19 over a specified period. The Director of Nursing (DON) believed the Infection Preventionist had reported the outbreak, but did not verify this, and the Administrator later confirmed the outbreak was only reported to the local county, not to CDPH L&C. The facility's policy clearly stated that outbreaks meeting certain criteria must be reported to CDPH L&C. Second, the facility did not ensure that a resident's family member was educated on and compliant with infection control practices, specifically the use of personal protective equipment (PPE) while assisting a resident on contact precautions. During an observation, the family member was present in the resident's room and assisting with meals without wearing PPE, despite signage and facility policy requiring its use. The family member stated she was allergic to the gown and had not previously reported this issue. Staff confirmed that visitors were expected to wear PPE to prevent the spread of infection, and the facility's policy required donning gowns and gloves upon entry to rooms under contact precautions.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Person-Centered Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered discharge care plans for two residents during their stay, as identified through interviews and record reviews. One resident, admitted with Alzheimer's disease, was discharged to another facility for supervised care in a secured unit, but there was no documented evidence of a discharge care plan being created or followed. Similarly, another resident with encephalopathy was discharged to a board and care facility for a lower level of care, yet no discharge care plan was documented in the clinical record. Interviews with nursing staff and the Director of Nursing confirmed that discharge care plans are expected to be developed upon admission to ensure staff are aware of residents' discharge wishes and to facilitate coordinated, goal-oriented discharges. The absence of these care plans meant that staff were not informed of the residents' goals or wishes regarding discharge, and there was no organized or collaborative approach to preparing for their transitions. Facility policy requires comprehensive, person-centered, interdisciplinary care planning, but this was not followed in these cases.
Failure to Develop and Update Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that discharge care plans were developed and updated for two residents who were discharged from the facility. One resident, admitted with a history of stroke, was discharged without an updated discharge care plan. Another resident, admitted with dementia, was discharged without any evidence of a discharge care plan being developed. These deficiencies were identified through clinical record reviews and staff interviews. Interviews with the Social Service Director and Social Services Assistant confirmed that they were responsible for developing and updating discharge care plans but did not do so for these residents. The Director of Nursing also acknowledged that discharge care plans should have been developed to meet the residents' needs. The facility's policy requires social services staff to prepare discharge summaries and post-discharge plans of care in coordination with the interdisciplinary team, which was not followed in these cases.
Delay in Providing Resident Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records within two business days of the request, as required by its own policy. The responsible party for a resident with dementia requested copies of the resident's medical records by emailing the Admissions Coordinator, who then forwarded the request to the DON. The DON acknowledged receiving the request and speaking with the responsible party on the same day. However, the Medical Records Director was not informed of the request until eight business days later, at which point the records were provided. The delay in communication between staff members resulted in the responsible party not being able to review the resident's records in a timely manner. The facility's policy clearly states that copies of medical records should be provided within two working days after receiving a written request, but this was not followed due to the breakdown in internal notification procedures.
Unsanitary Bathroom Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain resident bathrooms in a sanitary condition, as observed in four of the 16 sampled bathrooms. Resident 144 reported that their bathroom had feces on the walls and at the base of the toilet, which had not been cleaned since their admission 48 days prior. Similarly, Resident 56 described their bathroom as dirty, with feces around the toilet for more than a week. Observations confirmed the presence of brown material at the base of the toilet and streaks of brown liquid on the walls and back of the toilet. Further observations revealed that another bathroom had brown material at the base of the toilet. Resident 60 expressed concerns about the cleanliness of their bathroom, and Resident 55 also noted that their bathroom was not clean enough. A subsequent observation with the Housekeeping Supervisor confirmed that the brown spots remained uncleaned three days after the initial observation. The facility's policies on maintaining a clean and homelike environment were not adhered to, as the bathrooms were not cleaned thoroughly with disinfectants as required.
Failure to Record Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were checked before serving to residents on two sampled days, the 10th and 11th of January 2025. This oversight was identified during a record review of the Food Temperature Log, which was found to be blank for breakfast and lunch on these days. During an interview, the Dietary Supervisor indicated that two staff members were responsible for recording the temperatures on these days but failed to do so. One of the staff members, when interviewed, could not recall why the log was not filled out, suggesting it may have been forgotten. The facility's policy requires that food temperatures be recorded at the beginning of the tray line process, but this procedure was not followed, placing residents at an increased risk of food-borne illness.
Inadequate Training of Dietary Staff on Sanitizer Testing
Penalty
Summary
The facility failed to ensure that dietary staff were adequately trained to test the strength of kitchen sanitizer, which increased the risk of food-borne illness. During an observation, Cook 1 demonstrated improper testing of the quaternary sanitizer by holding the test strip in the liquid for only four seconds, despite stating that it should be held for ten seconds. The container for the test strips clearly instructed to immerse the strip for ten seconds, indicating a lack of adherence to proper procedures. Additionally, Dietary Aide 2 admitted to not knowing how to test the sanitizer and had not completed his initial competencies, which should have been done within 90 days of his hiring. The Dietary Supervisor confirmed that all kitchen staff should know how to test the sanitizer and subsequently instructed Dietary Aide 2 on the correct procedure. A review of Dietary Aide 2's employee file revealed no evidence of orientation or training specific to his role, highlighting a gap in the facility's training and competency verification process.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, which increased the risk of food-borne illness for residents. During an inspection, it was observed that a container of dill pickle relish in the walk-in refrigerator was past its use-by date and had not been discarded. Both a staff member and the Dietary Supervisor acknowledged that the expired relish should have been thrown out. Additionally, the facility's policy on food storage and handling lacked specific guidance on handling pickled foods or general guidance on use-by dates. Further observations revealed that several food items in the walk-in refrigerator were opened but not labeled with use-by dates, including bags of shredded cheese and lettuce, and a container of what appeared to be applesauce. The staff member noted that these items should have been labeled and stored in reusable containers, but there were no containers available. The facility's policy required all opened food to be labeled with the date they were opened. Additionally, a dietary aide was observed preparing meals without covering his facial hair, contrary to the facility's infection control policy, which required all dietary staff to wear beard nets if they had facial hair.
Infection Control Deficiencies in Oxygen Storage and COVID-19 Management
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures, leading to potential cross-contamination and infection spread. Resident 72's oxygen supplies were improperly stored, with unlabeled tubing left on the floor and the concentrator placed on the roommate's side of the room. This improper storage was observed multiple times, and staff confirmed that such practices could lead to confusion and cross-contamination, as the supplies were not clearly identified or stored in a sanitary manner. Additionally, the facility lacked an infection surveillance tracker, which hindered effective contact tracing during a COVID-19 outbreak. The Infection Preventionist confirmed that no surveillance data was available for 2024 and January 2025, and contact tracing was not conducted after the first COVID-19 case was identified. This oversight was critical, as it prevented the facility from identifying and isolating potential cases promptly, thereby increasing the risk of further transmission among residents and staff. Furthermore, the facility did not properly screen staff and visitors during the COVID-19 outbreak. Screening for staff began late, and visitor logs were incomplete, with missing information on symptoms and dates. This lack of thorough screening compromised the facility's ability to control the spread of infection, as individuals who might have been symptomatic or exposed were not adequately monitored or restricted from entering the facility.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as observed during a tour on January 12, 2025. Two rooms were found to be occupied by six residents each, exceeding the maximum allowed capacity of four residents per room. During interviews and record reviews with the Administrator, it was revealed that the facility's Client Accommodations Analysis incorrectly indicated a capacity for six residents in these rooms. The Administrator acknowledged that the facility did not possess any current waivers to exceed the room capacity limit, with the last waiver dating back to 2012. This discrepancy could potentially lead to overcrowding and compromise the quality of care for the residents in these rooms.
Failure to Follow Smoking Policy for Residents
Penalty
Summary
The facility failed to adhere to its smoking policy for two residents, leading to a deficiency in the management of smoking and tobacco use. Resident 18, who was readmitted with a history of diabetes mellitus, had a smoking assessment that was not updated quarterly as required. The last assessment was completed on 4/29/24, and two subsequent quarterly assessments were missed. This oversight was acknowledged by the MDS nurse, who emphasized the importance of regular assessments to ensure the resident's safety and update the care plan accordingly. The Director of Nursing also confirmed the necessity of timely assessments to accommodate any changes in the resident's condition. Similarly, Resident 40, who also had a history of diabetes mellitus and severe cognitive deficits, did not have a smoking assessment completed for the October 2024 quarter. The last assessment for this resident was conducted on 7/22/24. The MDS nurse and the Director of Nursing both highlighted the importance of these assessments to monitor the resident's ability to smoke safely and to update the care plan as needed. The facility's policy required smoking assessments to be conducted upon admission, quarterly, annually, and upon any change in condition, which was not followed in these cases. The deficiency in following the smoking policy for both residents had the potential to lead to accidents and injuries. The facility's failure to conduct timely smoking assessments and update care plans as per their policy was identified through observations, interviews, and record reviews. This lapse in protocol could have compromised the safety and well-being of the residents involved, as regular assessments are crucial for evaluating the residents' current health status and ensuring appropriate safety measures are in place.
Failure to Honor Resident's Dietary Preferences and Needs
Penalty
Summary
The facility failed to ensure that the meal preferences and nutritional needs of Resident 84, who has Chronic Kidney Disease Stage 4, were met. The resident's meal tray card, which guides staff on what to serve, was not followed, leading to the resident being served foods that were not suitable for his condition. Despite having a dietary evaluation that indicated specific dislikes and dietary restrictions, the resident was served meals containing items such as oranges and potatoes, which are high in potassium and not recommended for kidney patients. Observations and interviews revealed that Resident 84 expressed dissatisfaction with the meals provided, stating that they were not appropriate for his kidney condition and included items on his dislikes list. The dietary staff, including the Dietary Supervisor, acknowledged that the resident's preferences were not honored and that the meal tray card should have been checked to ensure compliance with the resident's dietary needs. The Licensed Nurse also confirmed that the resident's meal preferences should have been respected and that the menu should have been adjusted to provide nutritionally adequate substitutes. The Director of Nursing stated that the expectation was for the dietary staff to honor the resident's meal preferences and that failure to do so could lead to complications such as weight loss. The facility's policy indicated that meals should be consistent with resident preferences and physician's orders, and suitable substitutes should be provided if a preferred item is not available. However, this policy was not followed, resulting in the deficiency.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to prepare food in a form that met the needs of Resident 27, who was admitted with diagnoses including cerebral infarction and end-stage renal disease. The resident had moderate cognitive deficits and limited use of hands, requiring adaptive devices for eating. Despite the meal ticket indicating chopped meat, the resident received a quarter-inch slice of meat, which he was unable to eat due to his inability to use a knife and fork in combination. This discrepancy was observed during a lunchtime meal delivery. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that there were procedures in place to check meal orders against meal tickets to ensure accuracy. However, the DON admitted to checking the meal tag, which incorrectly stated chopped meat, and acknowledged the error. The facility's policy required meals to be consistent with residents' preferences and physician's orders, but this was not adhered to in the case of Resident 27, potentially leading to unintended weight loss and medical complications.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman about the transfer of two residents to an acute care hospital, which is a requirement for ensuring residents' rights to appeal and receive advocacy. Resident 6, who had a history of cerebrovascular accident, was transferred due to an abnormal heart rate. The Social Services Director stated that nurses were responsible for notifying the Ombudsman for hospital transfers, but the Licensed Nurse involved was unaware of this requirement and only notified the medical doctor and family members. Similarly, Resident 72, with a history of cerebral infarction, was transferred to an acute hospital for low hemoglobin levels. The Licensed Nurse responsible for this transfer also did not notify the Ombudsman, as they were not aware of the requirement. The Medical Records Director mentioned that in her previous role, she was responsible for sending such notifications but had not been instructed to do so at the current facility. Interviews with the Director of Nursing revealed that it was expected that the Ombudsman be notified for hospital transfers, as they serve as patient advocates. However, the facility's policy and procedure on transfer and discharge notifications were not followed, leading to the deficiency. The policy required that the Ombudsman be notified as soon as practicable in cases of urgent medical needs requiring immediate transfer.
Failure to Conduct Comprehensive Elopement Assessment
Penalty
Summary
The facility failed to complete a comprehensive elopement assessment for a resident diagnosed with Alzheimer's disease, leading to the resident's elopement. The resident, who had a history of forgetfulness and wandering, was admitted on 12/27/24. Despite the known risks, the facility did not update the elopement and wander risk binder since June, and the resident was able to leave the facility on 1/2/25, setting off an alarm and climbing over a fence. The resident was found at a nearby church and returned to the facility. Interviews with staff revealed that the facility had procedures for assessing elopement risks and notifying relevant parties if a resident eloped, but these procedures were not effectively implemented. The Licensed Vocational Nurse mentioned that the binder for elopement and wander risk residents was outdated, and the Director of Nursing stated that assessments were conducted on admission, but there was no indication that a wander guard was implemented for this resident. The lack of timely and comprehensive assessment and updating of risk information contributed to the resident's ability to elope.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to the transmission of inaccurate health status information to the federal database. Resident 72 experienced an unwitnessed fall while attempting to self-toilet, which was not accurately captured in the MDS. The MDS Nurse (MDSN) acknowledged the oversight during a joint record review and interview, noting that the fall should have been documented in the MDS dated after the incident. The Director of Nursing (DON) emphasized the importance of accurate MDS coding for care coordination and planning. Resident 29, who was admitted with a degenerative disease of the nervous system, was found on the floor in their room, but this fall was not reflected in the subsequent MDS assessment. The MDSN admitted that the MDS assessment completed after the fall did not include this incident, which should have been documented to ensure accurate patient care guidance. The DON reiterated the necessity of updating the MDS to reflect such incidents for proper care planning. Resident 23's MDS inaccurately listed pneumonia as an active diagnosis despite the condition having resolved. The MDSN confirmed that pneumonia was diagnosed in December of the previous year and should not have been documented in subsequent MDS assessments. The facility's policy on the RAI process and diagnosis list emphasizes the need for accurate coding and documentation of resolved diagnoses, which was not adhered to in this case.
Inaccurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening Resident Review (PASRR) for a resident diagnosed with psychosis and depression. The resident was admitted with a history of mental illness and was prescribed aripiprazole, an antipsychotic medication, upon discharge from the hospital. However, the PASRR screening conducted prior to admission inaccurately indicated that the resident did not have a serious mental illness and was not on psychotropic medications. This discrepancy was identified during a review of the resident's medical records and interviews with facility staff. The Minimum Data Set Nurse (MDSN) acknowledged that the PASRR was not accurate and should have been corrected to reflect the resident's mental health needs. The Director of Nursing (DON) also confirmed that the PASRR should have included the resident's diagnosis of psychosis and the use of psychotropic medication. The facility's policy requires updates to the PASRR to be completed according to Minimum Data Set guidelines, but this was not adhered to in this case, potentially impacting the resident's mental health care.
Deficiencies in Person-Centered Care Planning
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for several residents, leading to deficiencies in their care. Resident 84, who has chronic kidney disease, was consistently served meals that did not align with his dietary preferences and restrictions. Despite having a documented dislike for certain foods and a need for a renal diet, the facility staff served him meals containing items like oranges and potatoes, which are not suitable for his condition. The dietary preferences were not included in his care plan, leading to repeated instances of inappropriate meal service. Resident 9, who was admitted to hospice care due to end-stage heart failure, did not have a hospice care plan included in their records. This omission meant that the care provided was not aligned with the resident's current health status and needs. The lack of a hospice care plan was acknowledged by the Director of Nursing, indicating a gap in the facility's care planning process. Resident 198, diagnosed with Alzheimer's disease, had a history of wandering and elopement risk, which was not adequately addressed in their care plan. Despite previous incidents and documentation indicating the resident's tendency to wander, the facility's care plan was not individualized to prevent future occurrences. The resident was not listed in the facility's elopement risk binder, and the care plan did not reflect the necessary interventions to manage the resident's behavior effectively.
Improper Mattress Setting for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to ensure proper interventions for skin breakdown prevention for a resident, identified as Resident 47, who was at risk of developing pressure injuries. Resident 47 was admitted with chronic obstructive pulmonary disease and was prescribed a bariatric low air loss mattress to prevent skin breakdown. However, during an observation, it was noted that the mattress was set to static mode and configured for a resident weighing 400 pounds, while Resident 47's actual weight was 233.4 pounds. This discrepancy in the mattress setting was confirmed through interviews with a Certified Nurse Assistant and a Licensed Nurse, both of whom acknowledged that the incorrect setting could lead to the development of pressure injuries due to the mattress being too firm. Further interviews with the Director of Nursing corroborated the importance of having the mattress set correctly to ensure the resident received the full benefit of the low air loss mattress, which is designed to prevent pressure injuries. A review of the mattress manual indicated that the pressure setting should be adjusted according to the patient's weight and height, which was not adhered to in this case. This oversight had the potential to compromise Resident 47's skin integrity and increase the risk of pressure injury development.
Failure to Monitor and Document Urine Output for Resident with Urinary Catheter
Penalty
Summary
The facility staff failed to monitor and document urine output for a resident with a urinary catheter, as per the facility's policy. This deficiency was identified during an unannounced visit following a complaint related to resident assessment. The resident in question was admitted with a urinary catheter due to a dysfunctional bladder. Despite the facility's policy requiring the monitoring and documentation of urine output for residents with urinary catheters, the staff did not measure or record the urine output for this resident. A Certified Nursing Assistant (CNA) confirmed that they only documented whether the resident was continent or incontinent, without measuring urine output, as they were not instructed to do so. Further interviews with a Licensed Nurse (LN) and the Director of Nursing (DON) revealed that the facility's policy was indeed to monitor and document urine output for residents with urinary catheters. However, there was no documentation of the resident's urine output in the clinical record, and the staff did not follow the policy. The DON confirmed that CNAs should have been checking and documenting the urine output when emptying the urinary catheter to ensure the resident was voiding properly. The facility's policy on indwelling catheters, revised in 2014, also indicated that output recording should occur in accordance with intake and output recording procedures.
Failure to Administer Anti-Rejection Medication as Prescribed
Penalty
Summary
The facility failed to ensure proper medication administration for a resident who had undergone a liver transplant. The resident was prescribed tacrolimus, an anti-rejection medication, to be administered twice daily via a gastrostomy tube. However, the medication administration record (MAR) revealed multiple instances where the medication was not administered as ordered. Specifically, there were entries indicating that the medication was not on hand or pending delivery, and on some occasions, there were no notes explaining the missed doses. Interviews with licensed nurses and the Director of Nursing (DON) confirmed that the facility did not have the medication on hand at times, despite the DON verifying that the pharmacy had supplied the medication. The lack of documentation and failure to administer the medication as prescribed increased the risk of organ rejection for the resident. The facility's policy required medications to be administered as ordered by the attending physician, highlighting a significant lapse in adherence to this policy.
Failure to Provide Proper Colostomy Care and Documentation
Penalty
Summary
The facility failed to provide necessary colostomy care and treatment for a resident who required such services. Upon admission, the resident did not have a baseline care plan developed, which is essential for ensuring proper care. Additionally, there was no physician order obtained for the colostomy care, and the treatments provided were not documented in the resident's Treatment Administration Record (TAR). This lack of documentation and planning led to inconsistencies in the care provided by licensed nurses, as evidenced by the absence of records for colostomy bag changes and skin condition monitoring. Interviews with the Treatment Nurse and the Director of Nursing revealed that the colostomy bag was changed daily, sometimes twice per shift, but these actions were not recorded in the TAR. The Treatment Nurse admitted to not signing the TAR for each treatment and acknowledged the absence of a baseline care plan. The Director of Nursing confirmed that the baseline care plan should have been created upon admission and that the TAR should accurately reflect the care provided. The facility's policies emphasize the importance of documenting treatments and monitoring the stoma and surrounding skin, which were not adhered to in this case.
Failure to Prevent Resident Elopement and Incomplete Documentation
Penalty
Summary
The facility failed to implement measures to prevent a resident from eloping and did not provide adequate monitoring for the resident. The incident involved a resident who had the mental capacity to make medical decisions and was admitted to the facility on an unspecified date. On 5/28/24, the resident went out on pass with a family member, but there was no documentation in the nursing notes indicating the resident's departure or return. The facility's out on pass logbook was incomplete, lacking details such as the licensed nurse who signed the resident out, the expected return time, and the condition of the resident upon return. Licensed Nurse (LN) 2 failed to clarify the duration of the out on pass order with the attending physician, which contributed to the lack of proper documentation and monitoring. LN 1, who was passing medications at the time, did not complete the necessary documentation in the resident's clinical record or assess the resident's condition upon return. The Director of Nursing (DON) confirmed that there should have been a physician's order and documentation indicating the resident was assessed before leaving and upon returning to ensure their safety. The facility's policy, revised in January 2016, required a physician's order specifying the length of time a resident may be on pass and mandated that a licensed nurse assess the resident's physical and mental status before and after the pass. The policy also required documentation of the time the resident left and returned, the name of the accompanying person, and the resident's condition upon return. These procedures were not followed, leading to the resident's elopement and the potential compromise of their health, safety, and well-being.
Failure to Conduct Reference Checks Prior to Hiring CNA
Penalty
Summary
The facility failed to conduct reference checks prior to hiring a certified nursing assistant (CNA), which had the potential to increase the risk of abuse for residents. Resident 1, who was admitted with diagnoses including schizoaffective disorder and anxiety disorder, reported an incident of physical abuse involving a CNA. The resident stated that the CNA pulled off her clothes and pushed her against the side rails, although no bruises were noted. The CNA was subsequently suspended. A review of the CNA's personnel file revealed that no reference checks were conducted prior to hire, which was confirmed by the facility administrator. The facility's policy required at least two reference checks from previous or current employers prior to hiring, but this procedure was not followed in this case.
Inconsistent Dialysis Care and Documentation
Penalty
Summary
The facility failed to consistently provide appropriate dialysis access care for Resident 1, who was readmitted with end-stage renal disease and dependence on dialysis. Despite the care plan interventions indicating the need to monitor and document any signs of infection at the access site, the facility did not remove the dialysis dressing within the required 4-6 hours after treatment. This was confirmed through interviews with the resident, a licensed nurse, the hemodialysis nurse, and the assistant director of nursing, all of whom acknowledged the importance of timely dressing removal to prevent clotting and infection. Additionally, the facility's policy on dialysis management was not followed, as it required daily assessment and documentation of the access site care, which was not done for Resident 1 on multiple occasions, including a missed post-dialysis assessment on 3/21/24. The facility also failed to complete the dialysis communication form consistently for three residents, including Resident 1, Resident 2, and Resident 3. For Resident 2, there was a missed dialysis assessment on 3/2/24, with no follow-up documentation from the facility's licensed nurses. Similarly, for Resident 3, there was a missed dialysis assessment on 3/23/24, again with no follow-up documentation. The assistant director of nursing confirmed that the expectation was for licensed nurses to follow up on the residents' treatment at the dialysis center and check for any new orders from the doctors. The facility's policy on dialysis management, which required pre and post-dialysis evaluations by licensed nurses and proper documentation of dialysis treatment and post-dialysis weight, was not adhered to. This lack of compliance with the facility's own policies and procedures resulted in missed assessments and inadequate care for residents dependent on dialysis, potentially leading to complications such as clotting and infection at the dialysis access sites.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
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