Canyon Springs Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 180 North Jackson Avenue, San Jose, California 95116
- CMS Provider Number
- 056082
- Inspections on file
- 36
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Canyon Springs Post-acute during CMS and state inspections, most recent first.
A resident was administered Ivermectin based on a physician's order that lacked an indication for use. An LVN, uncertain about the medication's purpose, added 'for parasite infection' to the MAR without confirming a diagnosis or clarifying the order with the prescriber. The facility's policy requires all medication orders to include a clinical indication, and assigning a diagnosis is not within the LVN's scope of practice.
Licensed nurses did not consistently document the application of BiPAP therapy at bedtime for a resident with chronic respiratory and cardiac conditions, as required by physician order and facility policy. The DON confirmed that missing documentation meant the procedure was not considered completed, resulting in a failure to provide respiratory care according to professional standards.
Staff failed to follow infection prevention protocols, including not performing hand hygiene between glove changes during wound care, allowing a urine drainage bag to touch the floor without a protective cover, and storing unlabeled used basins and bed pans improperly. Additional lapses included using contaminated gloves for medication administration, placing IV supplies on soiled surfaces, improper disinfection of equipment, feeding multiple residents without hand hygiene, and not adhering to contact precaution signage and PPE requirements.
Three residents received psychotropic medications, including anti-anxiety, antidepressant, and antipsychotic drugs, without documentation of attempted non-pharmacological interventions or appropriate behavior monitoring. The DON confirmed the absence of required documentation and monitoring, despite facility policy mandating these practices.
A resident with a history of stroke, aphasia, and dysphagia was admitted with a gastrostomy tube and received enteral nutrition as ordered. Despite this, five MDS assessments failed to document the presence of the feeding tube and the proportion of nutrition and fluids provided by tube feeding. The MDS nurse and RD confirmed the omission, and observations verified the ongoing use of a feeding pump at the bedside.
Two residents were affected when an LVN administered the wrong nutritional supplement, giving Boost Plus instead of the ordered Ensure Plus, and an RN failed to use the push-pause method while flushing a PICC line with normal saline. Both actions did not follow physician orders or professional standards, as confirmed by staff interviews and record reviews.
Nursing staff failed to consistently document the administration and removal of controlled medications, such as hydrocodone-acetaminophen and tramadol, on both the Controlled Substance Accountability Sheet (CSAS) and Medication Administration Record (MAR). In several cases, medications were signed out but not recorded as given, or recorded as given but not signed out, leading to discrepancies in medication counts. The DON and nursing staff confirmed these documentation lapses during interviews and record reviews.
Surveyors observed a medication error rate of 9.68% when three errors occurred during medication administration: a resident received two puffs of an inhaler without the required interval, another self-administered an extra puff of a prescribed inhaler without staff instruction, and a third received multiple medications via G-tube without water flushes between doses. Nursing staff were unaware or unsure of proper procedures, and facility policies requiring correct intervals, instructions, and water flushes were not followed.
Surveyors found that medications, including inhalers, eyedrops, and controlled substances, were not properly labeled or stored, with expired and discontinued drugs remaining in medication rooms and carts. Staff confirmed that medications lacking resident names, open dates, or correct expiration dates were present, and that expired or discontinued medications were not consistently removed as required by facility policy.
Two residents had delays in the documentation of discharge orders and interdisciplinary team (IDT) meeting notes. In both cases, required entries such as physician notifications, ombudsman notifications, and IDT meeting notes were recorded days or months after the actual events, contrary to facility policy requiring timely charting of care and services.
Two residents were not provided with a dignified dining experience when staff stood while feeding them, contrary to facility policy. One resident with severe cognitive impairment and another with a cognitive communication deficit were both assisted with meals by staff who remained standing, despite the residents' needs and facility expectations that staff should be seated during meal assistance.
A resident with a diagnosis of schizophrenia and an active order for Aripiprazole did not have a comprehensive care plan developed to address their mental health needs. The DON confirmed that no care plan was in place for this active diagnosis, despite facility policy requiring person-centered care plans for all resident needs.
A resident with severe cognitive impairment and multiple medical conditions did not receive the prescribed amount of enteral feeding, and required oral care was not performed. Staff failed to document and monitor the amount of tube feeding administered, and oral care supplies were not available or used as ordered. These actions were inconsistent with physician orders and facility policy.
A resident with COPD, asthma, and CHF was given oxygen therapy at a higher flow rate than ordered by the physician, as confirmed by an LVN and the DON. The facility's policy requires adherence to physician orders for oxygen administration, but the resident received 1.5 lpm instead of the prescribed 1 lpm via nasal cannula.
A resident with Alzheimer's disease was found using bilateral quarter upper bed rails without a physician's order, timely care plan, or informed consent prior to installation. Staff confirmed that required assessments and documentation were completed only after the bed rails were already in use, contrary to facility policy.
A resident with intact cognition did not receive the planned menu meal or the correct food alternative on multiple occasions. The resident was served repeated meals not matching the posted menu and, when requesting an alternative, was given an unlisted item instead. The dietary manager confirmed these errors and that the facility's policy requiring adherence to planned menus was not followed.
Two residents who were fully dependent on staff for activities of daily living were found without accessible call lights; in one case, the call light was on a feeding tube pole, and in another, it was clipped to privacy curtains. Both a CNA and an RN confirmed the call lights were not within reach, contrary to facility policy.
A resident with a history of pneumonia and UTI experienced symptoms such as vomiting and decreased intake, prompting a physician's order for repeat CBC and CMP tests. Although the lab results, which included multiple abnormal findings, were received by the facility, there was no documentation that these results were communicated to the physician as required by facility policy.
The facility failed to maintain proper infection control in four out of six shower rooms, with issues such as feces on the floor, used personal items left behind, and unclean conditions confirmed by the Maintenance Director and Director of Nursing. Facility policies require daily cleaning and disinfection to prevent infection.
A facility failed to notify a responsible party about a resident's elbow injury, despite obtaining a physician's order for treatment. The clinical record lacked documentation of notification, and the DON confirmed this oversight. The facility's policy required notification of significant changes in a resident's status, which was not followed.
A resident with diabetes and malnutrition experienced delayed wound care and inadequate documentation at an LTC facility. Physician's orders for MRSA-infected leg wounds were obtained and implemented late, and no order was obtained for a toe wound. A STAT lab revealed severe dehydration, but the change in condition was not documented. Additionally, documentation for an elbow wound was insufficient, lacking weekly skin status updates and change of condition notes, contrary to facility policies.
A resident prescribed Lasix, a diuretic with a black box warning, was not monitored for potential side effects, such as dehydration, as required. The consultant pharmacist failed to report drug irregularities, and the resident's clinical records lacked documentation for monitoring these side effects. The resident was later hospitalized with severe dehydration and hypernatremia, highlighting the oversight in monitoring.
A resident at risk for dehydration experienced a delay in receiving STAT lab results, which revealed a critical high sodium level. The results were obtained a day after the order, leading to a delay in hospital transfer. Interviews indicated that the lab specimen took 9 hours to reach the lab, exceeding the facility's policy of 4 to 6 hours for STAT results.
A resident with diabetes had an elevated A1c level, but the facility failed to promptly notify the physician, delaying medication adjustment. The facility's policy required notification, but there was no documentation of compliance, confirmed by the DON.
Medication Order Lacked Indication and Was Inappropriately Modified by LVN
Penalty
Summary
A deficiency occurred when a resident was prescribed Ivermectin without an indication for use identified in the physician's order. The order, dated 6/24/25, specified the dosage and duration but did not state the clinical reason for prescribing the medication. Upon review, the Medication Administration Record (MAR) reflected the medication was to be given for a 'parasite infection,' but this indication was not present in the original order. During interviews, the Licensed Vocational Nurse (LVN) who processed the order admitted to not knowing the intended use of Ivermectin and stated she added 'for parasite infection' to the MAR after searching for information online, without confirming a diagnosis or indication with the prescriber. Further review and interviews with the Assistant Director of Nursing (ADON) confirmed that the facility's process requires clarification of any medication order lacking an indication, and that assigning a diagnosis is outside the LVN's scope of practice. The facility's policy mandates that medication orders must include the clinical condition or symptoms for which the medication is prescribed. The failure to clarify the order and the unauthorized addition of an indication by the LVN resulted in care and treatment not being provided in accordance with professional standards of practice.
Failure to Document BiPAP Application for Resident on Oxygen Therapy
Penalty
Summary
Licensed nurses failed to consistently document the application of BiPAP therapy at bedtime for a resident with multiple respiratory and cardiac diagnoses, including chronic respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic pulmonary edema, and dependence on supplemental oxygen. The physician's order specified that BiPAP should be applied at bedtime, and the facility's policy required documentation of the time BiPAP was started and notification of the physician if the resident refused the procedure. Record review revealed multiple dates over several months where there was no documentation of BiPAP application in the resident's Respiratory Administration Record. During an interview, the DON confirmed that if the application was not documented, it was considered not done, and acknowledged that licensed nurses were expected to initial the record to confirm BiPAP application as ordered. The lack of documentation indicated a failure to provide respiratory care consistent with professional standards of practice.
Infection Control Lapses in Multiple Care and Environmental Practices
Penalty
Summary
Staff failed to implement proper infection prevention and control practices in several instances throughout the facility. During a wound dressing change for a resident with a non-pressure chronic ulcer and local skin infection, two nurses changed gloves multiple times without performing hand hygiene between glove changes, contrary to facility policy and infection prevention standards. In another case, a resident with a suprapubic catheter had their urine drainage bag touching the floor and not covered with a protective bag, despite staff acknowledging that this practice increases infection risk. Multiple observations revealed that used basins, bed pans, and urinals belonging to residents were unlabeled and improperly stored on top of toilet tanks or under sinks in shared bathrooms. Staff confirmed these items were not labeled with resident identifiers and cited lack of storage space as the reason for improper storage. Additionally, a nurse used contaminated gloves to administer eye drops to a resident after touching various surfaces, and another nurse placed IV supplies on a visibly soiled overbed table without cleaning it or using a protective barrier. Further deficiencies included improper disinfection practices, such as using the same germicidal wipe to clean both contaminated and uncontaminated surfaces, and staff donning and doffing gloves without performing hand hygiene. A staff member was observed feeding two residents simultaneously without hand hygiene between residents. There were also lapses in transmission-based precautions: signage indicating contact precautions was missing from a resident's door, and a staff member entered the room of a resident on contact isolation without wearing required PPE, despite facility policy and physician orders.
Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and that psychotropic medications were used appropriately. For one resident with diagnoses including chronic subdural hemorrhage, dementia, and anxiety disorder, lorazepam and trazodone were administered for anxiety and depression without any clinical documentation that non-pharmacological interventions were attempted or provided. Nursing progress notes and medication administration records over several months did not indicate any such interventions, and the DON confirmed the absence of this documentation. Another resident with type 2 diabetes, dementia, and depression continued to receive mirtazapine and sertraline for depression, again without documentation of non-pharmacological interventions being attempted or provided. Review of nursing progress notes and medication administration records for multiple months confirmed this lack of documentation, which was also acknowledged by the DON. The facility's own policy required the use of behavioral interventions unless contraindicated and proper documentation of the clinical need for psychotropic medications. A third resident, diagnosed with Alzheimer's disease, was prescribed quetiapine for psychosis manifested by paranoia. However, there was no monitoring of the target behavior for which the medication was prescribed. The DON confirmed that behavior monitoring should have been in place for this medication, and the facility's policy required ongoing evaluation of the effectiveness of psychotropic medications and assessment for adverse consequences, including periodic reevaluation of behavioral symptoms.
Failure to Accurately Code MDS for Tube Feeding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for one resident who had a feeding tube in place. Despite clear documentation in the clinical record and physician orders indicating the resident was receiving enteral nutrition via a gastrostomy tube, five separate MDS assessments did not reflect the presence of the feeding tube or the percentage of nutritional and fluid intake provided by this artificial route. Observations confirmed the presence of a feeding pump at the resident's bedside, and interviews with the MDS nurse and registered dietitian (RD) revealed that the relevant MDS sections were either left blank or not coded, which was acknowledged as an error by the RD responsible for completing those sections. The resident in question had diagnoses including aphasia and dysphagia following a cerebral infarction, and had been on tube feeding since admission. The facility's documentation and staff interviews confirmed that the resident was receiving a prescribed formula via enteral pump for a specified number of hours each day. However, the MDS assessments failed to capture this information in Section K0520B (nutritional approaches), K0710A (proportion of total calories received through tube feeding), and K0710B (average fluid intake per day by tube feeding), resulting in inaccurate assessments that did not reflect the resident's actual nutritional status.
Failure to Follow Physician Orders and Proper Technique in Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) administered the wrong nutritional supplement to a resident by providing Boost Plus instead of the physician-ordered Ensure Plus. The LVN prepared and gave the entire carton of Boost Plus to the resident, despite the clinical record and registered dietitian's note specifying Ensure Plus as the required supplement to address the resident's weight loss and variable oral intake. The LVN later confirmed the error upon review of the resident's order summary report. In a separate incident, a registered nurse (RN) failed to use the push-pause method when flushing another resident's peripherally inserted central catheter (PICC) line with normal saline. The RN flushed the line quickly without the recommended technique, which was confirmed during a follow-up interview. The director of nursing (DON) stated that the push-pause method should be used to maintain the patency of the PICC line, and this was supported by a referenced clinical article.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and complete records for controlled substances for four of six randomly selected residents. In one instance, nursing staff signed out a controlled medication from the Controlled Substance Accountability Sheet (CSAS) for a resident but did not document its administration on the Medication Administration Record (MAR). This discrepancy was confirmed by the Director of Nursing (DON) during a review of the records, where a dose of hydrocodone-acetaminophen was signed out but not recorded as administered on the MAR. In other cases, nursing staff documented the administration of controlled medications on the MAR for three residents but did not sign out the medications on the CSAS. For example, doses of hydrocodone-acetaminophen and tramadol were recorded as given on the MAR but were not reflected on the CSAS, indicating a lack of reconciliation between the two records. The DON confirmed that there were no additional CSAS records to account for these discrepancies and acknowledged that the medications were dispensed from the Automated Dispensing Unit (ADU), but the required documentation was not completed. Additionally, during a controlled substance count, a nurse confirmed that the physical count of a resident's medication did not match the CSAS, as one tablet was removed and administered but not signed out. The facility's policy requires that all controlled substances be properly documented on both the CSAS and MAR, and that inventory counts be reconciled at the end of each shift. These failures in documentation and reconciliation were observed and confirmed through interviews and record reviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Failures
Penalty
Summary
A medication error rate of 9.68% was identified during medication administration observations, with three errors noted out of 31 opportunities involving three residents. In the first instance, a resident prescribed albuterol sulfate inhalation received the second puff only 10 seconds after the first, rather than waiting the recommended one minute between puffs. The nurse administering the medication was unaware of the required interval, and the facility's policy and national guidelines both specify a one-minute wait between inhalations. In the second case, a resident self-administered three puffs of budesonide-formoterol fumarate dihydrate inhaler instead of the two puffs ordered by the physician. The nurse did not provide instructions or verify the correct dosage with the resident before allowing self-administration. The facility's policy requires staff to explain the procedure and verify the correct medication, dosage, and administration method prior to administration. The third error involved a resident receiving five different medications via gastrostomy tube without water flushes between each medication. The nurse administered each medication sequentially without flushing the tube, contrary to facility policy, which requires a water flush between medications to ensure safe administration. The nurse stated that she was taught to mix medications with extra water but was not instructed to flush between medications, and the DON was unsure of the correct procedure.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility’s medication management practices, specifically regarding the labeling and storage of drugs and biologicals. During inspections of medication rooms and carts, numerous instances were observed where medications, including inhalers, nasal sprays, eyedrops, and topical solutions, lacked appropriate labeling with resident names or usage instructions. Additionally, several multi-dose vials and insulin vials were found without open dates or with incorrect expiration dates, and some were being used past their discard dates. Expired over-the-counter medications and expired home medications were also found stored alongside current medications in resident bins and medication rooms. Controlled substances and antibiotics that had been discontinued were still present in narcotic boxes within medication carts, rather than being removed and secured as required. In one instance, a medication refrigerator contained discontinued eye drops for a resident, despite facility policy stating that such medications should be removed and discarded. Staff interviews confirmed that these medications should not have remained in storage and that regular checks were expected to prevent such occurrences. The facility’s own policies require that all medications be properly labeled with at least the medication name, dose, strength, expiration date, and resident’s name, and that discontinued or expired medications be removed and either returned or destroyed according to pharmacy instructions. Despite these policies, surveyors found that expired, discontinued, and unlabeled medications were not consistently identified or removed from storage, and that staff were aware of but did not always follow the required procedures.
Late Documentation of Discharge and IDT Notes
Penalty
Summary
The facility failed to ensure timely and accurate documentation in the clinical records for two residents. For one resident, the discharge order and related progress notes, including physician notification, ombudsman notification, and interdisciplinary team (IDT) meeting notes, were documented several days after the actual discharge and associated events. The case manager confirmed that the discharge order was given and the ombudsman was notified on earlier dates, but the documentation was not completed until later due to being behind on paperwork. For another resident, the IDT meeting notes were also documented late, with the meeting having occurred months prior to the actual documentation. The social services director acknowledged that IDT meeting documentation was typically completed after the meeting. The facility's policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record, but this was not followed in these cases.
Staff Failed to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to maintain respect and dignity for two residents during meal assistance. In the first instance, a certified nursing assistant (CNA) was observed standing while feeding a resident with severe cognitive impairment, dementia, dysphagia, and adult failure to thrive. The resident was sitting up in bed, and the privacy curtain was not drawn. The CNA admitted to preferring to stand to see the resident's face and acknowledged that the resident had requested the CNA to sit, but the CNA refused, citing a lack of available chairs. The CNA then sat on the resident's bed to continue feeding, which was also not in accordance with facility expectations. The Director of Staff Development (DSD) confirmed that staff should be seated in front of residents during meal assistance and should not sit on residents' beds. In the second instance, a restorative nurse assistant (RNA) was observed standing at the bedside while feeding another resident who was sitting on the bed. This resident had a cognitive communication deficit and dysphagia but was cognitively intact. The RNA stated it was acceptable to stand while feeding, but both the DSD and the Director of Nursing (DON) later confirmed that staff are required to sit while feeding residents. The facility's policy on dignity, revised in 2021, specifies that residents are to be treated with dignity and respect at all times, including being provided with a dignified dining experience.
Lack of Comprehensive Care Plan for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with schizophrenia. The resident was admitted with a diagnosis of schizophrenia and had a physician's order for Aripiprazole to treat the condition. Upon review of the clinical record, it was found that there was no care plan addressing the resident's schizophrenia, including target symptoms, measurable objectives, or interventions. During an interview and record review, the DON confirmed the absence of a care plan for this active diagnosis. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident's needs.
Failure to Administer and Document Enteral Feeding and Oral Care as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, hemiplegia, aphasia, and type 2 diabetes mellitus was not administered enteral feeding in accordance with the physician's order. The resident was prescribed a continuous tube feeding of Jevity 1.2 at 75 ml/hr for 20 hours per day, totaling 1500 ml, and was also ordered to receive oral care every shift. Observations revealed that the feeding tube was disconnected, and the amount of feeding solution administered was insufficient compared to the prescribed amount. Staff interviews confirmed that the feeding was stopped prematurely and that there was no documentation of the specific amount of enteral feeding given. Further observations showed that the resident had whitish buildup and tartar in the mouth, indicating that oral care had not been performed as ordered. The CNA responsible for the resident stated that oral care had not yet been provided that morning, and there was no toothbrush available at the bedside. Instead, lemon glycerin swab sticks and foam-tipped swab sticks were used for oral care, but these were not utilized during the observed period. Record reviews and staff interviews confirmed that there was no hourly, per shift, or daily documentation and monitoring of the resident's enteral feeding intake. The DON, RN, and dietician all verified the lack of accurate monitoring and documentation, and acknowledged that the resident did not receive the prescribed amount of enteral feeding. Facility policy required documentation of the amount and type of enteral feeding, as well as monitoring for adequate nutrition, but these procedures were not followed.
Failure to Administer Oxygen Therapy at Physician-Ordered Flow Rate
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy was administered oxygen at a flow rate of 1.5 liters per minute (lpm) via nasal cannula, instead of the physician-ordered rate of 1 lpm. This discrepancy was observed during multiple visits to the resident's room, and was confirmed by a licensed vocational nurse (LVN) who acknowledged that the oxygen flow rate being delivered did not match the physician's order. The LVN stated that the correct procedure would have been to follow the doctor's order for oxygen therapy. The resident involved had a medical history including chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF). The facility's policy on oxygen administration requires verification and adherence to physician orders, as well as proper adjustment of the oxygen delivery device. The director of nursing (DON) confirmed that nurses are expected to review and follow physician orders for oxygen therapy and to ensure accurate flow rate administration.
Failure to Obtain Order, Consent, and Care Plan Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed prior to the installation and use of bilateral quarter upper bed rails for a resident diagnosed with Alzheimer's disease. Specifically, the bed rails were observed in use without a physician's order, and there was no timely development of a care plan addressing their use. Additionally, informed consent for the bed rails was not obtained from the resident's representative before the rails were installed. These actions were confirmed through observation, record review, and staff interviews, which revealed that the required assessment, order, care plan, and consent were all completed only after the bed rails had already been put in place. The resident's clinical record indicated that the bed rails were in use at all times while the resident was in bed to enhance mobility, but documentation showed that the necessary physician's order, care plan, and informed consent were not present at the time of installation. Staff interviews further confirmed that facility policy requires these steps to be completed prior to bed rail use, but they were not followed in this instance. The facility's own policies also specify that residents or their representatives must be informed of the risks and benefits and alternatives to bed rails, and that a comprehensive care plan must be developed, neither of which occurred before the bed rails were put in use.
Failure to Provide Planned Menu Meals and Alternatives According to Resident Preferences
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 15, did not receive the planned menu meal or the appropriate food alternative on multiple occasions. During a dining observation, the resident received a beef patty and salad, which was the same meal served the previous day, despite the posted menu listing soft tacos and salad. The resident confirmed he had not requested an alternative for that meal and expressed a preference for the soft tacos, which he did not receive. Additionally, the resident reported that on a previous occasion, after requesting barbecue chicken from the alternative menu, he was instead served chicken nuggets, which were not listed as an alternative option. Review of the resident's tray ticket showed a documented dislike of all pork, and the dietary manager confirmed that the soft tacos were made with beef, not pork, indicating the planned menu item was appropriate for the resident's preferences. The dietary manager acknowledged that the resident received a vegetable patty instead of the planned menu item and that the requested alternative meal was not provided as listed. The facility's policy requires that menus be prepared in advance and followed, but these requirements were not met in this instance.
Call Light System Not Accessible to Dependent Residents
Penalty
Summary
Surveyors observed that the facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for activities of daily living. In one instance, a resident with cerebral palsy, who was cognitively intact but fully dependent for mobility and self-care, was found lying in bed without the call light within reach; it was instead hanging on a feeding tube pole. A Certified Nursing Assistant confirmed that the call light was not accessible to the resident and acknowledged it should not have been placed on the feeding tube pole. The Director of Nursing also confirmed that the resident was dependent on staff and that the call light should always be within reach. In another case, a resident with hemiplegia and hemiparesis, and moderate cognitive impairment, was observed lying in bed with the call light clipped to the privacy curtains, out of reach. A Registered Nurse confirmed the call light was not accessible and stated it should not have been placed on the curtains. Both residents' clinical records indicated they were dependent on staff for all activities of daily living, including mobility and personal care. The facility's policy required that each resident have a means to call staff for assistance from their bed, but this was not followed in these instances.
Failure to Communicate Lab Results to Physician
Penalty
Summary
The facility failed to ensure that laboratory results were communicated to the physician for one of three sampled residents. The resident in question had a history of pneumonia and urinary tract infection and was admitted with symptoms including vomiting, decreased appetite, reduced fluid intake, and low urine output. A physician's order was placed for a repeat CBC and CMP, and the blood was collected and results received the same day, with multiple abnormal findings noted. Despite the receipt of these lab results, there was no documentation in the resident's medical record that the results were communicated to the physician as required. During an interview, a registered nurse confirmed that the results had not been documented as reported to the physician. Facility policy requires that such communication be documented in the Progress Notes section of the medical record, but this was not done in this instance.
Inadequate Infection Control in Shower Rooms
Penalty
Summary
The facility failed to implement proper infection control practices in four out of six shower rooms, as observed during a survey. In shower room [ROOM NUMBER], a brown substance identified as feces was found on the floor, which the Maintenance Director (MD) confirmed should have been cleaned and disinfected by staff after use. In another shower room, cotton swabs and a shaver cover were left on the floor drain, which the MD acknowledged should have been disposed of after use. Additionally, a used white towel was found on the shower handlebar in a different shower room, and the MD confirmed that the room should have been cleaned for the next resident. Further observations revealed a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub of another shower room, which the MD confirmed should have been removed to maintain cleanliness for subsequent use. The Director of Nursing (DON) acknowledged these observations and stated that shower rooms should not be left dirty to prevent infection. The facility's policies and procedures, which were reviewed, indicated that environmental surfaces should be cleaned and disinfected according to CDC recommendations and OSHA standards, and that bathrooms should be cleaned daily to maintain a safe and sanitary environment.
Failure to Notify Responsible Party of Resident's Injury
Penalty
Summary
The facility failed to notify a responsible party regarding a change in condition when a resident sustained an injury to his left elbow. A physician's order was obtained to treat the injury, but the clinical record lacked documentation that the responsible party was informed of the wound. During an interview, the director of nurses reviewed the resident's clinical record and confirmed the absence of documentation for notifying the responsible party. The facility's policy required a nurse to notify the resident's representative when there was a significant change in the resident's status, which was not adhered to in this case.
Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for Resident 1, who was admitted with diagnoses including diabetes mellitus and malnutrition, and was at risk for dehydration. The resident had a wound on the left lower leg infected with MRSA, for which physician's orders for treatment were obtained late and implemented three days after admission. Additionally, there was a failure to obtain a physician's order for a wound on the right third toe, which was noted to have 10% slough and 90% granulation, and the resident was not seen by a podiatrist. The facility also failed to document a change in condition for Resident 1 when a STAT lab was ordered, which revealed a critically high sodium level, leading to a diagnosis of severe dehydration. Furthermore, there was a lack of documentation regarding a left elbow wound, for which a physician's order was obtained to cleanse and dress the wound. However, there was no corresponding change of condition note, despite a surgical procedure being performed to remove necrotic tissue from the wound. The facility's documentation practices were inadequate, as evidenced by the lack of weekly skin status documentation and failure to record changes in the resident's condition. The facility's policies required documentation of all services provided and communication between the interdisciplinary team regarding the resident's condition and response to care, which was not adhered to in this case.
Failure to Monitor Lasix Side Effects
Penalty
Summary
The deficiency involved a failure by the consultant pharmacist (CP) to report drug irregularities for a resident who was prescribed Lasix, a diuretic with a black box warning (BBW) from the FDA due to its potential serious side effects. The CP did not address the need for monitoring the side effects of Lasix, such as signs and symptoms of dehydration, in the resident's clinical record. This oversight was identified during a review of the resident's medication orders and clinical records, which lacked documentation indicating that the side effects of Lasix were being monitored. The resident had been admitted to the hospital with severe dehydration and hypernatremia, conditions that could be related to the side effects of Lasix. Despite the critical nature of these conditions, the Medication Record Review (MRR) conducted shortly after the prescription of Lasix did not result in any recommendations for monitoring. Interviews with the CP and the director of nurses (DON) confirmed the absence of documentation and monitoring for Lasix's side effects. Additionally, the facility's policy on Medication Regiment Review, which should have guided the monitoring of adverse consequences, was not adhered to, and the specific policy for handling medications with black box warnings was not provided upon request.
Delay in STAT Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to ensure timely acquisition of a STAT laboratory result for a resident, which led to a delay in necessary medical intervention. The resident, who was at risk for dehydration, had a STAT lab order placed for a comprehensive metabolic panel. However, the results were not obtained until the following day, revealing a critical high sodium level that required immediate medical attention. This delay resulted in the resident being sent to the hospital with a diagnosis of severe dehydration. Interviews with facility staff and the lab company revealed that the lab specimen took approximately 9 hours to reach the lab, which was considered too long for a STAT order. The facility's policy indicated that STAT results should be released within 4 to 6 hours from the time of the blood draw. The director of nurses and the administrator acknowledged ongoing issues with obtaining timely lab results, which contributed to the delay in addressing the resident's critical condition.
Failure to Notify Physician of Abnormal Lab Result
Penalty
Summary
The facility failed to promptly notify a physician or nurse practitioner of an abnormal lab result for one of the residents, leading to a delay in the adjustment of the resident's diabetic medication. The resident, who was admitted with a diagnosis of diabetes mellitus, had a lab test drawn on December 29, 2022, which showed an elevated A1c level of 9.1%. This result was not documented as reviewed by licensed nurses, nor was there any indication that the physician or nurse practitioner was notified in a timely manner. The facility's policy required nursing staff to review test results and notify the physician if the results met certain criteria. However, there was no documentation to show that the nursing staff followed this protocol. The director of nurses confirmed the lack of documentation during an interview, indicating a failure in the facility's process for handling lab results. This oversight resulted in a delay in the resident's medication adjustment, as changes were only made after the physician was eventually informed of the elevated A1c level.
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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