Camino Ridge Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain View, California.
- Location
- 1949 Grant Road, Mountain View, California 94040
- CMS Provider Number
- 055315
- Inspections on file
- 34
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Camino Ridge Post-acute during CMS and state inspections, most recent first.
A resident with multiple medical and mental health conditions left the facility without an approved OOP order and without the required one-person assistance for ambulation, as outlined in the care plan. Staff did not notice the resident's absence until a scheduled medication was missed, and the receptionist, responsible for monitoring the entrance, was unable to prevent or confirm the resident's exit. The incident was not reported to CDPH as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions was discharged without updated fall risk assessments, an accurate MDS, a discharge care plan, or proper written notice. The facility also failed to verify the license and care capabilities of the discharge placement, resulting in the resident being sent to an unlicensed independent living facility where a fall occurred and acute care was required.
Surveyors identified that a bed remained unstable despite its wheels being braked, and several toilet seats and risers were wobbly or unstable. A resident reported having to reposition her portable toilet-seat riser for stability. Additionally, a toilet tank was found with an ill-fitting lid, creating an accident hazard. The maintenance director acknowledged these issues, which were not in line with facility policies requiring safe and stable equipment.
Staff failed to follow infection control protocols when a CNA carried soiled linens out of a resident's room with gloved hands, dropped linen in the hallway, and disposed of it improperly. A soiled pillowcase was left on the floor in a room prepared for new residents, and another CNA did not wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions, despite posted instructions.
A resident was found self-administering lidocaine liquid to the hip without a physician's order or a documented assessment for self-administration, despite facility policy requiring an interdisciplinary team assessment and documentation before allowing self-administration of medications.
The facility's Infection Preventionist (IP) did not complete the required CDC TRAIN course, having only finished three out of 15 modules. The IP cited being busy with orientation as the reason for not completing the training. The DON was unaware of this deficiency, which could lead to inadequate infection control measures.
The facility failed to protect the privacy and confidentiality of residents' personal and medical information. Care instructions for four residents were visibly posted in their rooms, accessible to visitors. Staff confirmed these postings should have been covered to maintain privacy, as per facility policy.
The facility failed to complete timely MDS assessments for two residents, leading to potential care planning issues. One resident with encephalopathy and dementia had late admission and discharge assessments, while another with hypo-osmolality and parkinsonism had a late admission assessment and no discharge assessment. The delays were attributed to the MDSC's absence.
The facility failed to develop and implement individualized care plans for several residents, leading to deficiencies in addressing their specific medical needs. A resident with PTSD did not have a care plan for her psychological needs, while another resident with bilateral femur fractures lacked a care plan for managing the new diagnosis. Additionally, fall care plan interventions were not implemented for two residents, and care plans for pressure injuries and bed rail use were either absent or not patient-centered.
The facility failed to provide adequate care and documentation for several residents, including a resident with a compromised cast, two residents with PICC lines lacking physician orders, and multiple residents using side rails without orders. Additionally, a resident's low phenytoin level was not reported to the physician, violating facility policy.
The facility failed to ensure the Sharps container on a medication cart was not overfilled, posing a risk of injury. During an observation, the container was found overfilled with used syringes, and the lid could not be closed. This was confirmed by an RN and the DON, who stated it is the medication nurse's responsibility to check the container's level. The facility's policy requires replacement when the container reaches the indicator line to prevent needle pricks.
The facility failed to provide proper oxygen care and safety signage for four residents. A resident's oxygen concentrator had a grayish substance build-up, and another's filters were dusty. Two residents lacked 'Oxygen in Use/No Smoking' signs on their doors. The DON confirmed the need for regular filter maintenance and proper signage for safety.
A resident receiving dialysis care was not provided with appropriate care as staff failed to adhere to the resident's fluid restriction order. A water pitcher was left accessible to the resident, and there was no documentation of fluid intake per shift, preventing accurate monitoring of compliance with the fluid restriction. Additionally, intake and output were not monitored, despite the resident being on dialysis, fluid restriction, and diuretics, increasing the risk of fluid overload or dehydration.
The facility failed to ensure licensed nursing staff had the necessary competencies for PICC line management, affecting two residents. The DON, responsible for training, had not conducted any in-services or competency evaluations since starting. Interviews revealed no documentation of training, and a nurse confirmed the absence of competency validation. The facility's policy required such training, but it was not followed, leading to the deficiency.
The facility failed to accurately document the administration of controlled drugs for three residents, leading to potential medication errors and drug diversion. A resident with bipolar disorder, another with malignant neoplasm of the thymus, and a third with malignant neoplasm and muscle weakness had discrepancies between the Controlled Drug Record and the Medication Administration Record. The Director of Nursing confirmed these discrepancies, which violated the facility's policy on controlled substance reconciliation.
The facility did not act on the Consultant Pharmacist's recommendations for two residents, failing to document and address medication regimen review findings. The CP's recommendations for monitoring and clarifying medication orders were not signed or dated by the physician or nursing staff, and the facility could not locate the MRR binder or reports for the year.
The facility was found to have violated food safety standards by storing wet insulated food covers and failing to label and date food items in the refrigerator. The dietary manager confirmed these practices, which contradict the 2022 FDA Food Code and the facility's own policies, potentially risking food contamination for residents.
The facility failed to implement proper infection control measures, including leaving nebulizer equipment uncovered, staff wearing gloves in hallways, and improper labeling and storage of personal items. Additionally, Enhanced Barrier Precautions were not followed for residents at risk of infection, such as those with Foley catheters or MRSA. These deficiencies were confirmed by staff and pose a risk to resident and staff safety.
A facility failed to maintain resident dignity during mealtime when a CNA stood while feeding a resident with dementia, who was lying in bed. The CNA confirmed the action, citing the absence of a chair. The resident was dependent on assistance for eating, and the facility's policy required staff to be seated and at eye level during feeding.
A resident with multiple health issues, including a recent fall resulting in bilateral femur fractures, did not receive a required significant change in status assessment (SCSA) within 14 days. Despite increased pain and changes in medication, the facility did not complete the necessary assessment, leading to a deficiency.
A resident with Parkinson's Disease and a history of falling was admitted to the facility, but the baseline care plan was not completed within the required 48 hours. The plan was initiated six days after admission, and the interdisciplinary team admission assessment was incomplete, missing signatures from the resident and their representative. The facility's policy mandates that a baseline care plan be developed within 48 hours, which was not adhered to in this case.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident experienced a fall resulting in fractures and increased pain management needs, yet their care plans were not revised. Another resident's care plan for antipsychotic use was not updated following a medication change, despite exhibiting aggressive behavior and requiring constant supervision. Staff confirmed the care plans were not revised as required by facility policy.
Two medication errors were identified in an LTC facility, resulting in a 6.67% error rate. A nurse failed to check a resident's pulse before administering carvedilol, and another nurse did not administer a Breo Ellipta inhaler due to a missing open date. Both actions violated the facility's medication administration policies.
The facility failed to ensure proper medication storage and labeling, as evidenced by an expired insulin vial and undated inhalers. An LVN found an opened insulin vial not discarded after the recommended period, and an RN discovered an undated fluticasone inhaler. The facility's policies required proper labeling and storage of medications, which was not adhered to, potentially compromising medication efficacy.
The facility failed to follow its Antibiotic Stewardship Program for two residents. A resident received antibiotics for pneumonia and UTI without proper assessment, despite negative diagnostic tests. Another resident was prescribed a topical antibiotic without a stop date. These actions were against the facility's policy, which requires specific protocols for antibiotic use.
A resident with multiple health conditions did not receive a pneumococcal vaccine despite having consent and a physician's order. The facility had a supply of the vaccine but failed to administer it, leading to the resident developing pneumonia. The issue arose due to a misunderstanding about insurance coverage, although the facility's policy allowed for independent administration of the vaccine.
The facility failed to offer the 2024-2025 COVID-19 vaccine to two residents, despite holding a vaccination clinic. One resident, with conditions including paraplegia and diabetes, did not receive the vaccine due to a lack of consent. Another resident, with a history of stroke and diabetes, was missed due to time constraints in collecting consents. This oversight placed both residents at risk for COVID-19 infection.
The facility was found to have a room accommodating six residents, exceeding the regulatory limit of four residents per room. Despite adequate space and no safety or privacy concerns, the room's occupancy was non-compliant. Interviews with residents and staff revealed no complaints or quality of care issues related to the room's occupancy.
Failure to Prevent Unauthorized Resident Exit and Report Incident
Penalty
Summary
A resident with a history of joint replacement surgery, stimulant dependence, schizoaffective disorder, generalized muscle weakness, and abnormal posture left the facility without an approved out-on-pass (OOP) order. The resident's care plan required one-person assistance for ambulation and locomotion, but this intervention was not implemented, allowing the resident to exit the facility unassisted. The resident was later found to have walked to a nearby store, rested outside, and returned to the facility on his own, stating he was unaware that a physician's approval was needed for an OOP. Facility records and staff interviews confirmed that there was no OOP order in place for the resident at the time of the incident. The facility's policy required a practitioner’s order for therapeutic leave, which was not obtained. Staff became aware of the resident's absence when he missed his scheduled medication, and a search was conducted, including contacting the police. The receptionist, responsible for monitoring the front entrance, observed an individual leaving but was unable to confirm the resident's identity or prevent the exit. Additionally, the facility failed to report the incident as an unusual occurrence to the California Department of Public Health (CDPH), as required by both facility policy and regulatory standards. The Director of Nursing confirmed that the incident was not reported, despite the policy mandating the reporting of events affecting the health, safety, or welfare of residents.
Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, poor memory, poor insight and judgment, and multiple medical diagnoses was discharged from the facility without adequate preparation or safeguards. The facility failed to update the resident's fall risk assessment for two consecutive quarters prior to discharge, despite policy requiring quarterly assessments. Interviews with the DON confirmed that these assessments were missing from the clinical record. The resident's discharge Minimum Data Set (MDS) was inaccurately coded, as it understated the level of assistance required for activities of daily living (ADLs) such as bathing, dressing, and personal hygiene. Multiple CNAs reported that the resident was dependent or required maximal assistance for these tasks, but the discharge MDS indicated only moderate assistance or supervision. The MDS director confirmed the inaccuracy after reviewing the documentation. Additionally, the facility did not provide a written discharge notice or develop a discharge care plan for the resident, nor were there discharge notes on the day of discharge. The social services director stated that discharge notices were only given to short-term residents, not long-term residents. The facility also failed to verify the license and care capabilities of the discharge placement, which was later found to be an unlicensed independent living facility. The resident was discharged to this setting, where she experienced a fall and was subsequently sent to acute care. The acute care facility determined that the discharge placement was inappropriate and refused to return the resident there.
Unstable Beds and Toileting Equipment Compromise Resident Safety
Penalty
Summary
Surveyors observed multiple environmental safety deficiencies during a facility inspection. One resident bed was found to be unstable, remaining movable even when its wheels were braked. Additionally, five out of eight toilet seats and five out of six toilet-seat risers were not stable, with one resident reporting the need to repeatedly reposition her portable toilet-seat riser to ensure stability before use. In one room, a toilet tank was covered with a lid that was the wrong size and shape, lying loosely on top of the open tank. Interviews with the maintenance director confirmed awareness of these hazards, including the accident risk posed by the improper toilet tank lid. Facility policies reviewed by surveyors required that beds be locked when not being moved and that all toileting equipment be maintained in safe working condition, including regular inspection for hazards such as loose fittings. The observed conditions were not in compliance with these policies and had the potential to compromise resident health and safety.
Failure to Implement Infection Control Practices During Resident Care and Linen Handling
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established infection control practices in several instances. One CNA carried soiled linens out of a resident's room with gloved hands, dropped a piece of linen on the hallway floor, picked it up, and continued to the linen hamper outside the room. The CNA acknowledged that gloves should have been removed in the resident's room and soiled linens should have been placed in a plastic bag before disposal. In another instance, a soiled pillowcase was observed on the floor behind the door in a resident room that had recently been prepared for new occupants. The registered nurse confirmed that the soiled pillowcase should not have been left on the floor. Additionally, a CNA provided incontinent care to a resident on Enhanced Barrier Precautions (EBP) without wearing a gown, despite signage indicating that both gloves and a gown were required for such care. The CNA admitted awareness of the EBP sign and the need for appropriate personal protective equipment. The infection preventionist confirmed that staff should remove gloves in the resident room, prevent soiled linens from touching the floor, and wear gowns and gloves when providing care to residents on EBP.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident, who was cognitively intact according to the Minimum Data Set, was observed self-administering Aspercreme Lidocaine Liquid Roll-On to his right hip without a physician's order for the medication or for self-administration. The resident confirmed during an interview that the applicator belonged to him and that he applied it himself. Review of the clinical record by nursing staff confirmed there was no physician order for the Lidocaine Liquid Roll-On or for self-administration, although there was an existing order for a different form of lidocaine (patch) to be applied to the same area. Further review of the resident's clinical record revealed that there was no assessment completed for self-administration of medication, as required by facility policy. The policy states that an interdisciplinary team must determine and document which medications may be safely self-administered by a resident, with the results recorded in the medical record. Despite the resident later receiving a physician order for self-administration of a lidocaine cream, there was still no documented assessment for self-administration in the record.
Incomplete Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed the required specialized training in infection prevention and control. The IP had only completed three out of the 15 necessary modules of the CDC TRAIN Nursing Home Infection Preventionist Training Course. This incomplete training was confirmed during an interview with the IP, who stated that she was unable to complete the course due to being busy with her orientation at the facility. The IP also confirmed that she had not received any other training related to her role as an IP. The Director of Nursing (DON) was unaware that the IP had not completed the training requirements before assuming her position. The facility's job description for the Infection Preventionist role indicated that training in infection prevention and control in accordance with federal requirements was necessary. The CDC TRAIN course description highlighted the importance of the training for effective implementation of infection prevention and control programs in nursing homes. The failure to complete the required training had the potential for inadequate infection control measures, which could result in mismanagement of infections among residents, staff, and the community.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information for four out of 18 sampled residents. Observations revealed that care instructions for Residents 35, 56, 91, and 2 were posted in their rooms in a manner visible to visitors, compromising their privacy. For instance, Resident 35's care instructions were posted above the head of the bed and on the wall beside the bed, detailing specific activities and schedules. Similarly, Resident 56 had care instructions posted above the head of the bed, visible from the room entrance, while Resident 91's instructions included a fluid restriction notice with the resident's full name and room number. Resident 2's room had care instructions for enteral tube feedings and wheelchair positioning posted on the wall. Interviews with facility staff, including a licensed vocational nurse, a registered nurse, a certified nursing assistant, and the director of nursing, confirmed the observations and acknowledged that the care instructions should have been covered to protect resident privacy. The facility's policy on dignity and privacy, dated October 2022, emphasized the importance of maintaining resident privacy, which was not adhered to in these instances.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for two residents, leading to potential issues in care planning and intervention. Resident 39 was admitted with conditions including encephalopathy, type 2 diabetes mellitus, and severe unspecified dementia with behavioral disturbances. The MDS admission assessment and discharge assessment for Resident 39 were completed late, with the admission assessment finalized on the thirteenth day post-admission and the discharge assessment completed six days after the required date. The Minimum Data Set Coordinator (MDSC) confirmed these delays and noted that a combined assessment should have been conducted due to the short duration of the resident's stay. Resident 81, admitted with hypo-osmolality, hyponatremia, and parkinsonism, also experienced delays in MDS assessments. The admission assessment was completed eight days late, and no discharge assessment was conducted. The MDSC acknowledged these oversights, attributing them to her absence on vacation during the critical period. According to the Center for Medicare and Medicaid Services' guidelines, the admission assessment should have been completed within 13 days of admission, and the discharge assessment within 14 days of discharge, which was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident 62, diagnosed with Post Traumatic Stress Disorder (PTSD), did not have a care plan developed to address her psychological needs, despite the diagnosis being listed in her records. The Minimum Data Set Coordinator confirmed the absence of a care plan for PTSD, acknowledging that one should have been created to implement appropriate interventions. Resident 11, who sustained bilateral femur fractures after a fall, did not have a care plan developed for this new diagnosis upon returning from the hospital. The Director of Nursing confirmed the lack of a care plan for managing the fractures, which was necessary for guiding staff in providing appropriate care. Additionally, Resident 11's fall care plan intervention, which required the bed to be in the lowest position, was not implemented, as observed during multiple visits. Other residents also experienced similar deficiencies. Resident 68's use of bed rails for repositioning was not supported by a care plan, despite being indicated in the Bed Rail Safety Assessment. Resident 91, identified as a fall risk, did not have the fall care plan intervention of a low bed implemented. Resident 40's stage 4 pressure injuries on both heels lacked developed care plans, and Resident 59's care plan for a stage 2 pressure injury was not patient-centered, with only one intervention listed. Lastly, Resident 98's Moisture-Associated Skin Damage (MASD) did not have a care plan developed, despite physician orders for treatment being in place.
Deficiencies in Care and Documentation for Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for several residents. Resident 89, who was admitted with a fracture of the lower end of the radius and dementia, had a compromised cast on her right forearm. There was no physician order or care plan for the cast, and the integrity of the cast was compromised with shredded gauze visible. Both the registered nurse and the director of nursing confirmed the lack of documentation and monitoring for the cast, which should have included checks for circulation, sensation, and signs of infection. Residents 54 and 156 had PICC lines but lacked physician orders for their management. Resident 54 had a PICC line with no orders for dressing changes, monitoring for infection, or flushing the line, despite receiving intravenous antibiotics. Similarly, Resident 156 had a PICC line for antibiotic administration but had no documented flushes for 31 occasions in March, and there were no orders for dressing changes. The director of nursing confirmed these deficiencies and acknowledged the absence of necessary physician orders and care plans for PICC line management. Multiple residents, including Residents 62, 73, 89, 153, 156, 68, 91, 40, 38, 50, 98, and 64, were observed using side rails without physician orders. The director of nursing confirmed the lack of orders and stated that residents should have physician orders before the installation and use of side rails. Additionally, Resident 68's physician was not notified of a critically low phenytoin level, and there was no documentation of physician notification, which was against the facility's policy for handling diagnostic test results.
Overfilled Sharps Container on Medication Cart
Penalty
Summary
The facility failed to ensure that the Sharps container on medication cart 4 was not overfilled, which could lead to potential injury to staff and residents. During an observation, the Sharps container was found overfilled with used syringes, and the lid could not be closed properly. This was confirmed by Registered Nurse G, who attempted to close the lid but was unsuccessful as the syringes were not falling inside the container. The Director of Nursing (DON) also confirmed the overfilled condition of the Sharps container and stated that it is the responsibility of the medication nurse to check the container's level. According to the facility's policy, the Sharps container should be replaced when it reaches the indicator line to prevent needle pricks, especially for residents with dementia who might come into contact with it. The facility's policy on handling biohazardous waste specifies that containers should be secured to deny access to unauthorized persons and should not be more than three-quarters full.
Deficient Oxygen Care and Safety Signage
Penalty
Summary
The facility failed to provide proper care and treatment services for oxygen use for four residents. Resident 42's oxygen concentrator had a grayish substance build-up on the filter, and there was no 'Oxygen in Use/No Smoking' sign posted at the entrance of the room. The certified nursing assistant confirmed the observation, and the registered nurse stated that the filter should be changed every 72 hours or as needed. The director of nursing confirmed that the filter should be changed weekly and that a sign should be posted for safety. Resident 155's oxygen concentrator filters were dusty with an accumulation of whitish gray substances. The registered nurse confirmed the filters were dirty and should be changed. The director of nursing stated that the concentrator filter should be cleaned weekly and replaced as needed, following the manufacturer's recommendations. The facility's policy indicated that the filters should be cleaned at least once a week. Residents 303 and 40 did not have 'Oxygen in Use/No Smoking' signs posted on their doors, despite having oxygen concentrators in use. The director of nursing confirmed the absence of signage and stated that signs should be posted for safety, even if the oxygen order is as needed. The facility's policy on oxygen safety indicated that 'No Smoking' signs should be used to identify when oxygen is in use and remain in place until oxygen administration is discontinued.
Failure to Adhere to Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 91, who required dialysis treatment. The staff did not adhere to the resident's fluid restriction order, which was crucial due to the resident's medical conditions, including end-stage renal disease, congestive heart failure, and dependence on dialysis. During an observation, a pitcher of water was found on the resident's overbed table, which was accessible to the resident, despite the fluid restriction order. A certified nursing assistant acknowledged the presence of the water pitcher and attributed it to the night shift staff, indicating a lapse in communication and adherence to care instructions. Additionally, there was a lack of documentation regarding the resident's fluid intake per shift, which is essential for monitoring compliance with the fluid restriction order. The Medication Administration Record showed that nurses only initialed their names without recording the exact amount of fluids consumed by the resident. This lack of documentation prevented the staff from accurately assessing whether the resident adhered to the fluid restriction, increasing the risk of fluid overload or dehydration. Furthermore, the facility did not monitor or document the resident's intake and output, despite the resident being on a fluid restriction, dialysis, and diuretics. The registered dietitian confirmed the absence of intake and output monitoring and stated it was not their responsibility to recommend such monitoring. The director of nursing acknowledged the oversight and confirmed that the resident was at risk of dehydration, emphasizing the need for accurate documentation and monitoring to ensure the resident's safety and compliance with medical orders.
Lack of Competency in PICC Line Management
Penalty
Summary
The facility failed to ensure that the licensed nursing staff had the appropriate competencies and skill sets related to intravenous (IV) therapy, specifically for the management of peripherally inserted central catheter (PICC) lines. This deficiency was identified during a survey when it was found that there were no records of in-services or competency evaluations conducted for IV and PICC line care. The Director of Nursing (DON), who had been in the position for five weeks, acknowledged the lack of competency evaluations and ongoing education programs for the nursing staff regarding PICC line management. The facility had two residents with PICC lines at the time of the survey, and the absence of proper training could compromise their safety and quality of care. Interviews with the DON and the Regional Director of Clinical Operations (RDCO) revealed that the responsibility for conducting competency evaluations and in-services fell on the DON after the Director of Staff Development (DSD) retired. However, no documentation was provided to show that such training or evaluations had been conducted. A registered nurse (RN O) confirmed that she had not received competency validation or attended any in-services for PICC management since being hired, despite having prior experience. The facility's assessment policy indicated that staff training and competencies, including PICC line management, should be conducted upon hire and annually, but this was not adhered to, leading to the deficiency.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled drugs and proper documentation of medication administration for three residents, leading to potential medication errors and drug diversion. Resident 38, diagnosed with bipolar disorder, had a physician's order for morphine sulfate to be administered as needed for severe pain. However, on two occasions, the nursing staff signed out the medication on the Controlled Drug Record (CDR) but did not document its administration on the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed these discrepancies during a review. Similarly, Resident 56, with a diagnosis of malignant neoplasm of the thymus, had a physician's order for Percocet for severe pain. The nursing staff signed out the medication on the CDR but failed to document its administration on the MAR on two separate occasions. Resident 59, diagnosed with malignant neoplasm and muscle weakness, had a physician's order for oxycodone. The nursing staff signed out the medication on the CDR but did not document its administration on the MAR on three occasions. The facility's policy and procedure require routine reconciliation of controlled substances, which was not adhered to in these cases.
Failure to Act on Consultant Pharmacist's Recommendations
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's (CP) recommendations during the Medication Regimen Review (MRR) for two residents, Resident 2 and Resident 32, between December 1, 2024, and January 31, 2025. For Resident 2, the CP noted the absence of a fasting lipid panel in the medical records within the previous twelve months, despite the resident being on medications associated with dyslipidemia. The CP recommended monitoring of uric acid and a fasting lipid panel, but these recommendations were not signed and dated by the facility's physician or nursing staff. Additionally, there was no clarification on concerns about the medication administration record and prescriber order sheets. For Resident 32, the CP recommended discontinuing duplicate orders of glycolax and Miralax, clarifying items on the medication administration record, and monitoring side effects and target behaviors for duloxetine. However, the facility's physician and nursing staff did not respond to these recommendations, leaving the designated portions of the report blank. The Director of Nursing (DON) acknowledged that the physician and nursing staff did not complete the documents in response to the CP's recommendations. The facility's policy requires that the CP's recommendations be acted upon by the physician or prescriber, with documentation of any actions taken or reasons for rejecting recommendations. However, the facility failed to maintain readily available copies of the MRRs as part of the residents' permanent health records. The DON and the Regional Director of Clinical Operation were unable to locate the MRR binder or paper copies of the CP's reports for the year 2024/2025, indicating a lack of proper documentation and follow-up on the CP's recommendations.
Food Safety Violations in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a kitchen inspection. Insulated food covers were found stacked and stored while still wet, which is against the 2022 FDA Food Code that requires equipment and utensils to be air-dried after cleaning and sanitizing. The dietary manager confirmed that the covers were wet and acknowledged that they should have been air-dried before being stored. This oversight in the drying process could potentially lead to food contamination. Additionally, the facility did not properly label and date food items in the reach-in refrigerator. Three brown bags containing tuna sandwiches were found unlabeled and undated, with only the word 'Tuna' marked on the outside. The dietary manager confirmed that these lunches were prepared for dialysis residents who were not present during the lunch meal service and admitted that the bags and sandwiches should have been labeled and dated. This practice is contrary to the facility's policy on food safety in receiving and storage, which mandates that repackaged food be labeled with the contents and the date of transfer.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by multiple observations of staff not adhering to established protocols. Resident 73's nebulizer equipment was found uncovered and undated, contrary to the facility's policy requiring such equipment to be cleaned, air-dried, and stored in a plastic bag. Additionally, several certified nursing assistants (CNAs) were observed wearing gloves in the hallway after providing resident care, which is against the facility's infection control policy. These actions were confirmed by the staff involved, who acknowledged the oversight in not removing gloves and performing hand hygiene before exiting resident rooms. Further deficiencies were noted in the handling and storage of resident personal items. Used basins in shared bathrooms were found unlabeled and improperly stored on top of toilet tanks, which was confirmed by the infection preventionist and CNAs. The facility's policy mandates that personal items be labeled and stored appropriately to prevent cross-contamination. Additionally, Resident 15's urine bag was observed on the floor, which poses a risk of contamination and infection, as it should be hung on the bed frame according to the care plan and facility policy. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of infection. Resident 11, who had a Foley catheter, did not have EBP signage or an isolation cart outside the room, as required by the facility's policy. Similarly, staff did not adhere to contact precautions for residents with MRSA infections, as observed with the RNA entering a shared room without donning appropriate personal protective equipment. These lapses in infection control measures have the potential to compromise the health and safety of residents and staff.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to promote and maintain resident dignity during mealtime for a resident when a Certified Nursing Assistant (CNA) was observed standing while providing feeding assistance. The incident involved a resident who was lying in bed with the head of the bed elevated, and the meal tray placed on a bedside table across the bed. The CNA was standing and feeding the resident, who was not at eye level with the CNA. This action was confirmed by the CNA, who stated that there was no chair available in the resident's room. The resident involved had been admitted to the facility with a diagnosis of dementia, which affects thinking and social abilities. The resident's clinical record indicated that they were dependent on assistance for eating on multiple occasions. The Director of Nursing (DON) confirmed that staff should be seated and at eye level when feeding residents to maintain dignity. The facility's policy and procedure on promoting and maintaining resident dignity during mealtimes also stated that staff should be seated while feeding residents.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within 14 days after a significant change in condition was identified for a resident. The resident, who was admitted with multiple diagnoses including a nondisplaced supracondylar fracture, type 2 diabetes, dementia, chronic pain, and urinary retention, experienced an unwitnessed fall. Following the fall, the resident was found on the floor and later transferred to the emergency department where bilateral femur fractures were diagnosed. Observations and interviews revealed that the resident, who previously attended group activities, was now confined to bed for comfort and experienced increased pain, leading to changes in medication. Despite these changes, the Minimum Data Set Coordinator confirmed that no SCSA had been completed since the fall, which was a requirement given the resident's new fractures, increased pain, and inability to participate in activities. The Director of Nursing and other staff confirmed the resident's condition and changes in medication, but the interdisciplinary team did not complete the necessary assessment. The failure to conduct the SCSA was a deficiency as it did not comply with the guidelines that require an assessment when there is a significant change in a resident's condition that impacts multiple areas of health status and requires a review and revision of the care plan.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident diagnosed with Parkinson's Disease and a history of falling. The resident was admitted on an unspecified date, but the baseline care plan was not initiated until six days later. This delay in developing the care plan meant that the resident and/or their responsible party were potentially unaware of the plan of care. The Director of Nursing confirmed during an interview and record review that the baseline care plan was initiated late and that the interdisciplinary team admission assessment was incomplete, lacking necessary signatures from the resident and their representative. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, and a supervising nurse must verify its completion within this timeframe. However, these procedures were not followed in this instance.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and updated by the interdisciplinary team (IDT) for two residents, leading to potential compromises in their health, safety, and psychosocial well-being. Resident 11, who was admitted with multiple diagnoses including a fracture and dementia, experienced an un-witnessed fall resulting in bilateral femur fractures. Despite a significant change in condition, including increased pain management needs, Resident 11's fall, activity, and pain care plans were not updated. Observations revealed that Resident 11 was mostly bedridden and unable to participate in group activities, yet the care plans remained unchanged. Resident 68, who was readmitted with severe dementia and other behavioral disturbances, had a care plan for antipsychotic use that was not updated following a change in medication order. The resident exhibited aggressive behavior and required constant supervision to prevent wandering and elopement. Despite these changes, the care plan did not reflect the updated target behaviors associated with the antipsychotic medication. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the care plans for both residents were not revised as required. The facility's policy mandates that care plans be reviewed and revised by the IDT following a significant change in condition, but this was not adhered to in these cases, leading to the identified deficiencies.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility was found to have a medication error rate of 6.67% during a survey, exceeding the acceptable threshold of 5%. This was due to two medication errors observed during the administration process. In the first instance, a registered nurse (RN H) failed to check the pulse rate of a resident before administering carvedilol, a medication that requires monitoring of both blood pressure and pulse rate as per the physician's order and the facility's policy. The nurse acknowledged the oversight during an interview, confirming that the pulse rate was not checked prior to administering the medication. In the second instance, another registered nurse (RN G) did not administer a Breo Ellipta inhaler to a resident because the inhaler lacked an open date, which is required to ensure the medication's validity. The nurse indicated that the pharmacy needed to be contacted to confirm the medication's usability. However, the Director of Nursing later confirmed that the inhaler had been delivered and should have been administered to the resident. Both incidents reflect a failure to adhere to the facility's medication administration policies and procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as evidenced by the presence of an expired insulin vial and undated multi-dose vials and inhalers. During an inspection of medication cart 1, a Licensed Vocational Nurse (LVN C) identified an opened multi-dose vial of insulin that was not discarded after the recommended 28 days. The manufacturer's label for the insulin indicated that it should be discarded after 42 days at room temperature. The Director of Nursing (DON) confirmed that the insulin should not be used due to its reduced effectiveness. The facility's policy and procedure on medication storage and expiration dating required that expired medications be stored separately until destroyed or returned. Additionally, during a medication administration observation in medication cart 4, a Registered Nurse (RN G) found a fluticasone furoate inhaler without an open date. The RN acknowledged that the inhaler should have an open date and planned to contact the pharmacy to confirm its usability. The manufacturer's label indicated that the inhaler should be discarded six weeks after opening. The facility's policy required staff to record the open date on medication containers with shortened expiration dates once opened. These lapses in medication management had the potential to compromise the efficacy of medications administered to residents.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program for two residents, leading to inappropriate antibiotic use. Resident 68 was administered two different antibiotics, Levofloxacin and Nitrofurantoin, for pneumonia and a urinary tract infection (UTI) without a full assessment by the provider. Diagnostic tests indicated that Resident 68 was negative for both infections. The resident's medication administration record showed the antibiotics were given despite the absence of fever or other confirming symptoms, and the infection preventionist confirmed that the resident did not meet the McGeer or Loeb Minimum Criteria for initiating antibiotics. Resident 301 was prescribed a topical antibiotic, Neosporin Original Ointment, for a skin graft infection without a specified stop date, leading to indefinite use. The infection preventionist confirmed the absence of a stop date and acknowledged that nurses should have requested this information from the prescribing doctor. The facility's policy requires that prescriptions for antibiotics specify the dose, duration, and indication for use, which was not followed in this case. These deficiencies in the facility's antibiotic stewardship practices were identified through observation, interviews, and record reviews. The lack of adherence to established protocols and failure to communicate effectively with prescribing providers contributed to the inappropriate use of antibiotics, potentially increasing the risk of multi-drug resistant organisms.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal vaccination, despite having consent and a physician's order. The resident, who was admitted with multiple diagnoses including end-stage renal disease, type 2 diabetes with neuropathy, congestive heart failure, and dependence on dialysis, had consented to receive the PCV20 pneumococcal vaccine in January 2025. However, the Medication Administration Record for January, February, and March 2025 showed that the vaccine was not administered. This oversight occurred even though the facility had a house supply of the vaccine and did not need to rely on the vaccination clinic's schedule. The resident developed a dry cough with crackles in March 2025, leading to a positive chest x-ray for pneumonia in the right lower lobe. The resident was treated with antibiotics from March 17 to March 24, 2025. Interviews with the infection preventionist and the director of nursing revealed that the resident did not receive the vaccine due to an issue with the vaccination clinic not providing it because of the resident's insurance. However, the director of nursing confirmed that insurance should not have been a barrier, as the facility had the necessary supply and could administer the vaccine independently. The facility's policy required offering pneumococcal immunization in accordance with CDC guidelines, but this was not followed in this case.
Failure to Administer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to ensure that the updated COVID-19 vaccination for 2024-2025 was offered to two residents, Resident 15 and Resident 35, as part of their immunization protocol. Resident 15, who was readmitted to the facility with conditions including paraplegia, type 2 diabetes mellitus, essential hypertension, and schizophrenia, had not received the 2024-2025 COVID-19 vaccine. The infection preventionist (IP) confirmed that a consent form was not obtained from Resident 15, which resulted in the resident not receiving the vaccine during the vaccination clinic held on March 19, 2025. Similarly, Resident 35, who was admitted with diagnoses such as hemiplegia following a cerebral infarction, type 2 diabetes mellitus, paroxysmal atrial fibrillation, and hyperlipidemia, also did not receive the 2024-2025 COVID-19 vaccine. The IP acknowledged that due to time constraints, consents were not collected for all residents, and Resident 35 was among those missed during the vaccination clinic. This oversight placed both residents at risk for COVID-19 infection and had the potential to contribute to the spread of the virus within the facility.
Excessive Room Occupancy
Penalty
Summary
The facility failed to comply with the regulatory requirement that limits the number of residents per room to a maximum of four. During observations on two separate days, room [ROOM NUMBER] was found to accommodate six residents, each having 133 square feet of space within an 800 square foot room. Despite the room providing adequate space for movement and care, and no safety hazards or privacy concerns being noted, the room's occupancy exceeded the allowed limit. Interviews with residents and staff revealed no complaints or concerns regarding the room's occupancy, and no quality of care or quality of life issues were identified related to the number of residents in the room.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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