Cedar Crest Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunnyvale, California.
- Location
- 797 E Fremont Avenue, Sunnyvale, California 94087
- CMS Provider Number
- 555790
- Inspections on file
- 15
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Cedar Crest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including a dusty oxygen concentrator filter for a resident with COPD, failure by two LVNs to perform hand hygiene before administering eye and nasal medications, and the presence of unlabeled personal care items in a bathroom shared by four residents. Staff confirmed these practices were not in line with facility policies.
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. The care plans lacked specific activities and measurable objectives, despite known preferences. This was confirmed by both the AD and RNS during interviews and record reviews.
The facility failed to maintain kitchen utensils and equipment in good condition, as ten baking pans and a magnetic knife holder were found dirty and rusty. The dietary supervisor verified the condition and removed the baking pans, while the registered dietitian confirmed the need for cleanliness and maintenance according to the facility's sanitation policy.
The facility's QAPI program was found ineffective in identifying and preventing medication administration errors. Observations revealed multiple instances where LVNs deviated from prescribed dosages and manufacturer guidelines, leading to improper administration of Flonase, Alphagan, and MiraLAX. The Assistant Administrator was unaware of these issues, and no performance improvement projects were in place to address them.
The facility failed to implement proper infection control practices when a laundry staff member did not perform hand hygiene before handling clean linens and a CNA did not change gloves or perform hand hygiene during a resident's wound treatment. These actions were confirmed by the maintenance director and the infection preventionist, as well as the CNA and LVN involved in the treatment.
A resident with dysphagia was fed by a CNA who was standing, contrary to facility policies requiring staff to sit at eye level to promote dignity. This was confirmed by both the CNA and an LVN present.
The facility failed to document a resident's advance directive, leaving section D of the POLST form blank and not including a care plan. Both the Social Service Director and Registered Nurse Supervisor verified the lack of documentation.
The facility failed to accurately complete the discharge MDS for a resident, who was discharged to home with home health services. The MDS incorrectly indicated that the resident was discharged to a short-term general hospital. This error was confirmed by the social service director, the MDS Coordinator, and the registered nurse supervisor.
A resident with chronic respiratory failure was prescribed oxygen at 2 LPM, but observations revealed the oxygen concentrator was set at 4 LPM. Staff confirmed the discrepancy and acknowledged the need to follow the physician's order.
The facility failed to consistently complete the dialysis communication form for a resident with end-stage renal disease, leading to incomplete documentation of vital signs and blood sugar levels. This failure was confirmed by the nurses involved and was against the facility's policy for the care of dialysis residents.
The facility reported a medication error rate of 13%, with errors observed in the administration of Flonase, Alphagan, and MiraLAX by LVNs. Errors included incorrect dosages, failure to follow manufacturer guidelines, and incomplete administration.
Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Labeling of Personal Care Items
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. The filter of a resident's oxygen concentrator was observed to be dusty, and both the licensed vocational nurse and the infection preventionist consultant confirmed that the filter should be kept clean and cleansed weekly, as per the user manual. Additionally, during medication administration, a licensed vocational nurse did not perform hand hygiene before donning gloves to administer eye drops to a resident, contrary to facility policy. In another instance, a different licensed vocational nurse did not cleanse her hands or change gloves before administering nasal spray to a resident after repositioning him, which was also against facility policy. Furthermore, during room rounds, multiple unlabeled personal care items, including wash basins, bed pans, urinals, and a kidney-shaped basin with a toothbrush and toothpaste, were found in a shared bathroom used by four residents. A certified nursing assistant confirmed that these items were in use and not labeled with resident names or room numbers, increasing the risk of cross-use. The infection preventionist consultant stated that these items should have been labeled before use, in accordance with facility policy requiring all bed pans and urinals to be marked for individual use.
Failure to Develop Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. For Resident 37, the care plan did not include specific activities that would be provided, such as daily room visits and watching television, despite the resident's preferences being known. This lack of detail in the care plan was confirmed by both the Activity Director (AD) and the Registered Nurse Supervisor (RNS) during interviews and record reviews. Similarly, Resident 1's care plan was found lacking in specific activities, such as watching television, going outside daily, and smoking outside, which were known preferences. The AD and RNS both verified that the care plan was not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the resident's needs. This was also the case for Resident 53, whose care plan did not include activities like room visits, aroma therapy, blessings, and prayers, despite these being part of the resident's routine. The same deficiencies were observed for Residents 71, 41, and 2. Resident 71's care plan did not include specific activities like watching television and daily room visits. Resident 41's care plan missed activities such as talking to staff, socialization, and watching movies. Resident 2's care plan did not include activities like current events, watching television, and using an iPad. In all cases, the AD and RNS confirmed that the care plans were not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs.
Failure to Maintain Kitchen Utensils and Equipment in Good Condition
Penalty
Summary
The facility failed to ensure that kitchen utensils and equipment were maintained in good condition and stored in accordance with professional standards for safety. During an initial kitchen tour, ten baking pans were observed with brownish to dark colored spots that appeared dirty and rusty. Additionally, a magnetic knife holder with attached kitchen knives was found to have brownish discolorations that also looked dirty and rusty. These observations were made in the presence of the dietary supervisor (DS), who verified the condition of the items and removed the baking pans immediately. The DS also acknowledged the condition of the magnetic knife holder and stated that it would be cleaned. The registered dietitian (RD) later confirmed that baking pans and the magnetic knife holder should be kept clean and free of rust. The facility's undated policy and procedures on sanitation indicated that all utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. The failure to maintain these items in good condition had the potential to cause the growth of microorganisms and cross-contamination of food, which could affect the 81 residents residing and consuming food at the facility.
Medication Administration Errors and Ineffective QAPI Program
Penalty
Summary
The Quality Assessment Performance Improvement (QAPI) program at the facility was found to be ineffective in identifying and preventing medication administration errors. During a medication pass observation, a 13% medication error rate was noted. Specifically, a Licensed Vocational Nurse (LVN A) administered Flonase to a resident but deviated from the prescribed dosage by spraying two sprays in each nostril instead of one. Additionally, LVN A did not follow the manufacturer's guidelines for administering the nasal spray, such as instructing the resident to blow their nose or closing the opposite nostril during administration. LVN A admitted to the errors and attributed them to initial confusion and forgetfulness about the proper guidelines. Further observations revealed that LVN A also improperly administered Alphagan ophthalmic solution to the same resident by allowing the tip of the eye drop bottle to contact the eyelashes, increasing the risk of contamination. LVN A did not instruct the resident to keep their eyes closed or press their index finger against the inner corner of the eye after administration, as recommended by the manufacturer. LVN A acknowledged these errors during an interview and expressed a commitment to improving their practices. Additional deficiencies were observed with other nurses. LVN B administered MiraLAX to a resident but did not mix it thoroughly, resulting in the resident not consuming the full dose. Similarly, LVN C administered MiraLAX to another resident, who only took a small sip, and LVN C left without ensuring the medication was fully consumed. The Assistant Administrator, involved with the QAPI program, was unaware of any medication administration issues and confirmed that the program had not identified or addressed such concerns. There was no documented evidence that medication administration errors were being reviewed or that performance improvement projects were in place to address these errors.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a laundry staff member did not perform hand hygiene before handling clean linens and residents' personal clothing. This was observed during an interview with the maintenance director, who confirmed that all laundry staff should wash their hands before handling clean items. The infection preventionist emphasized the importance of hand hygiene in preventing the spread of infections. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene is the primary means to prevent the spread of infections and should be performed before and after coming on duty. In the second instance, staff failed to perform hand hygiene during the treatment of a resident with a pressure ulcer and a surgical wound. The certified nurse assistant did not change gloves or perform hand hygiene between different stages of the wound treatment, despite handling both the resident and the wound dressings. This was confirmed by both the CNA and the licensed vocational nurse involved in the treatment. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene should be performed before and after direct contact with residents and before handling clean or soiled dressings.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat Resident 390 with respect and dignity when Certified Nurse Assistant E (CNA E) was observed standing while feeding the resident. Resident 390, who had been admitted with a diagnosis of dysphagia (difficulty swallowing), was being fed by CNA E while CNA E was standing over him. This observation was confirmed by both CNA E and Licensed Vocational Nurse J (LVN J), who was present in the room for medication administration. The facility's policies and procedures on dignity and assistance with meals explicitly state that residents should be fed in a manner that promotes their well-being and dignity, including not standing over them while feeding. However, these guidelines were not followed in this instance, leading to a deficiency in the care provided to Resident 390.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to document the status of a resident's advance directive (AD) for one of seven residents investigated. Resident 2 was admitted with diagnoses including angioneurotic edema, unspecified heart failure, and unspecified hyperlipidemia. The clinical records for Resident 2 did not contain documentation verifying or obtaining an advance directive, nor was there a care plan regarding the advance directive. Additionally, the Physician Orders for Life-Sustaining Treatment (POLST) form for Resident 2 had all options in section D, which pertains to advance directives, left blank. During a concurrent record review and interview with the Social Service Director (SSD) and the Registered Nurse Supervisor (RNS), both verified that section D of Resident 2's POLST was left blank and that there was no documentation or care plan regarding the advance directive. The facility's policy and procedures on advance directives state that information about whether or not the resident has executed an advance directive should be prominently displayed in the medical record, which was not done in this case.
Incorrect Discharge MDS Coding
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) for one resident, which had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions. Specifically, Resident 79 was admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, atrial fibrillation, and essential primary hypertension. The resident was discharged to home with home health services, but the MDS incorrectly indicated that the resident was discharged to a short-term general hospital. Interviews and record reviews confirmed the incorrect coding. The social service director, the Minimum Data Set Coordinator, and the registered nurse supervisor all verified that the discharge MDS was incorrectly coded. The error was identified during a review of the resident's face sheet, interdisciplinary team planned discharge summary report, and section A of the MDS. The coding error was acknowledged by the staff, who confirmed that the resident was indeed discharged to home with home health services, not to a short-term general hospital.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for Resident 390. The resident, who had a diagnosis of chronic respiratory failure, was prescribed oxygen at 2 liters per minute (LPM) via a nasal cannula. However, during observations on two separate occasions on the same day, the oxygen concentrator was set at 4 LPM, which was confirmed by Licensed Vocational Nurse J. The nurse acknowledged that the oxygen should have been administered at the prescribed rate of 2 LPM as per the physician's order. Further interviews with the Registered Nurse Supervisor confirmed that staff should ensure oxygen is administered at the prescribed rate. A review of the facility's policies and procedures indicated that a physician's order is required for therapies and treatments, including oxygen administration. The failure to adhere to the physician's order for oxygen administration had the potential to compromise the resident's health and safety.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to consistently complete the dialysis communication form for a resident who required dialysis services. The resident, who had end-stage renal disease and received dialysis on specific days, had incomplete documentation on the dialysis communication forms. Specifically, there was no documentation of vital signs on one occasion and no documentation of blood sugar on another occasion. These forms were supposed to be filled out by the licensed nurse receiving the resident from dialysis, but this was not done consistently, as confirmed by the nurses involved during interviews and record reviews. The facility's policy and procedure for the care of dialysis residents required that vital signs be taken upon the resident's return from dialysis. However, this policy was not followed, as evidenced by the incomplete forms. The nurses involved acknowledged that they should have completed the forms as required. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis for the resident involved.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a reported error rate of 13%. During a medication pass, four medication errors were observed out of thirty opportunities for three of seven residents. One incident involved a Licensed Vocational Nurse (LVN A) administering two sprays of Flonase in each nostril to a resident instead of the prescribed one spray, and not following the manufacturer's guidelines for proper administration. LVN A admitted to the discrepancy and acknowledged the error during an interview. Another incident involved LVN A administering Alphagan ophthalmic solution to the same resident but failing to follow the manufacturer's guidelines, including allowing the tip of the eye drop bottle to contact the eyelashes and not instructing the resident to keep their eyes closed for 1 to 2 minutes after administration. LVN A admitted to forgetting the proper procedure during the administration. Additionally, two separate incidents involved LVNs B and C administering MiraLAX to two different residents. LVN B did not thoroughly mix the MiraLAX solution, resulting in the resident consuming less than half of the mixture, while LVN C did not ensure that the resident fully consumed the MiraLAX mixture, leaving most of it in the glass. Both LVNs admitted to their respective oversights and acknowledged the need for improvement in their administration practices.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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