Corona Regional Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Corona, California.
- Location
- 730 Magnolia Avenue, Corona, California 92879
- CMS Provider Number
- 555390
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Corona Regional Medical Center D/p Snf during CMS and state inspections, most recent first.
Two residents with respiratory failure and documented ROM limitations did not receive ordered ROM devices and splinting. One resident, who had orders for towel rolls in both hands each day shift, was observed in bed without the hand rolls; the RNA stated she had provided a shower and forgot to replace them, despite being responsible for their application. Another resident, with an order for a left elbow extension splint to be applied daily, was observed without the splint; the RNA reported being unaware of the order and noted no elbow splint was present in the resident’s splint storage bag. Facility policy states that RNAs must carry out restorative programs, including splinting and orthotic application, according to the written plan of care.
A nurse failed to administer a resident’s scheduled 10:00 a.m. medications within the facility’s required one‑hour before/after window, instead giving multiple routine drugs (including vitamin supplements, benztropine, esomeprazole, and quetiapine) via gastric tube at 12:08 p.m. The nurse reported being behind on the med pass due to attending to other residents’ dressing changes and PRN needs, and stated that all other licensed nurses were busy and unable to assist. The DON confirmed that facility policy requires medications to be administered within one hour before and one hour after the scheduled time.
A resident with multiple complex conditions and no decision-making capacity had a physician order for Tylenol #3 for pain while the resident’s responsible party was present and involved in requesting pain management. After the pharmacy reported that Tylenol #3 was not recommended due to a documented hydrocodone allergy, the RN contacted the physician, who changed the order to tramadol 50 mg via G-tube as needed. The RN and nurse manager confirmed that the resident’s representative was not informed of this medication change, contrary to facility policy requiring notification of representatives about changes in care and services.
A resident with multiple complex conditions, including chronic respiratory failure, tracheostomy with ventilator dependence, hemiplegia, and vascular dementia, had a documented sacral pressure area that had reopened and was being treated per physician orders with cleansing, Triad cream, and dry dressings. However, the Quarterly MDS assessment for the same time frame recorded that the resident had no unhealed pressure ulcers and was not receiving pressure ulcer care. During an interview and record review, the NM confirmed the discrepancy between the wound care documentation and the MDS, acknowledging that the assessment did not accurately reflect the resident’s pressure ulcer status as required by the RAI Manual.
A resident with complex medical conditions and impaired decision‑making capacity was given a shower and skin check by a CNA/RNA, who documented routine care and application of triad barrier cream to abdominal folds but reported no abnormal findings. Later that day, an ER photograph showed a skin tear on an abdominal fold covered with cream, and a subsequent hospital admission assessment documented a left abdominal fold skin tear present on arrival. The CNA/RNA and nurse manager acknowledged that this skin tear met the facility’s criteria for an abnormal finding that should have been identified and reported under the CNA job description and the facility’s skin care policy, but it was not reported at the time of care.
A resident with chronic respiratory failure, tracheostomy, and ventilator dependence had multiple months of IDT Monthly Meeting Notes documenting use of two locked bedrails for "seizure activity" and whole body jerking while coughing or during suctioning, despite no seizure diagnosis in the medical record. During interviews, the Director of Subacute and the Nurse Manager confirmed there was no documented seizure diagnosis and that the notes inaccurately described restraint use. The Director reported that the MDS nurse did not adequately customize the IDT notes to reflect the resident’s actual clinical status, resulting in medical record documentation that did not accurately represent the resident’s condition, contrary to facility policy requiring accurate records.
Surveyors found that the facility did not provide documentation of annual fuel quality testing for its emergency generators, with the last available record being nearly two years old. This deficiency affected all residents and multiple smoke compartments, and had been previously cited during a prior survey.
Surveyors found that the facility did not provide documentation of required emergency preparedness exercises, including an annual full-scale community-based exercise and an additional annual exercise, as required by federal regulations. This deficiency affected all residents in the facility and was identified during a Life Safety Code recertification survey.
The facility did not conduct required monthly inspections of its automatic sprinkler system components, with 8 out of 12 inspection records missing and only quarterly inspections being performed. Additionally, a corroded sprinkler head was found in a dining area, and facility leadership was unaware of its condition. These deficiencies affected all residents and smoke compartments in the facility.
The facility did not conduct or document quarterly fire drills for all required shifts, with missing records for certain AM and PM shifts. Staff confirmed that while drills were performed in various departments, some were not properly recorded, affecting all residents.
The facility did not correct or document resolution of deficiencies found during the annual inspection of its medical gas and vacuum system, including leakage, loose outlets/inlets, a zone valve box needing cleaning, and missing caution labels, affecting all residents and smoke compartments.
The facility did not review or update its Emergency Operations Plan within the required annual timeframe, as the last update was over a year prior. The Director of Plant Operations believed the review was required every two years, following hospital guidelines, rather than annually as required for LTC facilities. This deficiency affected all patients in the facility.
A smoke detector in a hallway near Nurse Station 1 and resident rooms failed to activate the fire alarm system during a functional test using smoke detector test spray. The Director of Subacute was unable to provide an explanation for the failure, which affected 24 of 59 residents in one smoke compartment.
Surveyors found that corridor doors, including those to the SNF Nurse Manager office and a storage room, did not latch upon self-closing as required. This deficiency affected multiple residents and a smoke compartment, and facility leadership was unaware of the issue at the time of the survey.
A LVN did not verify nasogastric tube (NGT) placement before administering medication to a resident with a history of postpartum cardiac arrest. The LVN attempted to aspirate for gastric residual but, finding none, proceeded to give medications without further placement verification, contrary to facility policy and care plan instructions.
A vial of Ativan 2 mg was found stored in the medication refrigerator past its expiration date. The NM confirmed expired medications should be removed to prevent administration, and the DON acknowledged staff failed to identify and remove the expired vial as required by facility policy.
Surveyors observed two expired fruit cups and one unlabeled fruit cup stored in the kitchen refrigerator, all readily available for use. The DNS confirmed that these items should have been labeled and discarded according to facility policy. At the time, two residents were on an oral diet.
An LVN did not follow the required two-minute contact time when disinfecting a shared glucometer with Sani cloth wipes before and after use on a resident. The LVN acknowledged not adhering to the manufacturer's instructions, and both the DSD and DON confirmed that staff are expected to follow these guidelines for proper infection control.
The facility failed to implement necessary interventions for turning and repositioning a dependent resident, leading to an increased risk of pressure injuries. Documentation showed significant gaps in repositioning, and interviews confirmed that if it was not documented, it was not done. The resident had a pressure injury that required consistent care, highlighting a deficiency in the facility's practices.
Failure to Follow Physician Orders for ROM Devices and Splinting
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for range of motion (ROM) and positioning devices for two residents with significant functional limitations. One resident, initially admitted with respiratory failure and documented functional limitations in ROM of both upper and lower extremities, had physician orders for a left and right towel roll in each hand every day shift. On observation, this resident was in bed with upper extremities flexed on the chest and no hand rolls in either hand. During interview, the Restorative Nursing Assistant (RNA) confirmed the resident was supposed to have towel rolls in each hand and stated she had given the resident a shower that morning and forgot to replace the towel rolls, acknowledging she was responsible for placing them. The second resident, also admitted with respiratory failure and documented functional limitations in ROM of all extremities, had a physician order for nursing/RNA to manage a left elbow extension splint up to four hours as tolerated each day shift. On observation, this resident was in bed with the left upper extremity extended at the side and no elbow splint in place. During interview, the RNA stated she was not aware the resident had a left elbow splint and reported that all splints were kept in a mesh bag, but there was no elbow splint present. Review of the facility’s Restorative Nursing Assistant Program policy indicated the facility is responsible for providing maintenance and restorative programs and that the RNA carries out programs according to the written plan of care, including splinting and application of orthotics and braces.
Late Administration of Scheduled Medications Outside Required Time Window
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the facility’s required 60‑minute window around the scheduled time for one resident. During a medication pass observation on March 11, 2026, at 11:18 a.m., LVN 1 prepared multiple 10:00 a.m. medications for Resident 3, including ascorbic acid 500 mg, benztropine mesylate 0.5 mg, cranberry 250 mg, esomeprazole 40 mg, lactobacillus, a multivitamin and mineral 15 ml, and quetiapine 100 mg. These medications, ordered for administration at 10:00 a.m. per the resident’s Order Summary Report and March 2026 MAR, were not actually administered via gastric tube until 12:08 p.m., more than two hours after the scheduled time and outside the facility’s one‑hour before/after administration window. Resident 3’s face sheet showed an admission with diagnoses including respiratory failure, and the medications observed were part of her routine 10:00 a.m. regimen. During interview, LVN 1 stated that nurses are expected to administer medications within one hour before and one hour after the scheduled time and acknowledged being behind on the 10:00 a.m. med pass due to attending to other residents who required a dressing change and PRN medication. LVN 1 reported that if falling behind, he would ask other licensed nurses for help but that they were all busy. In a separate interview, the DON confirmed that licensed nurses are expected to administer medications within one hour before and one hour after the scheduled time, consistent with the facility’s written Medication Administration – General Guidance policy dated July 2025.
Failure to Notify Resident Representative of Pain Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to have their designated representative informed of significant changes in care, specifically a change in prescribed pain medication. Resident 1, who lacked decision-making capacity and had her daughter designated as responsible party, was admitted with multiple serious medical conditions including chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, ventilator dependence, hemiplegia, hemiparesis, and vascular dementia. On one date, a physician made rounds while the responsible party was at the bedside and, at the responsible party’s request for pain management, ordered Tylenol #3 (acetaminophen-codeine) for pain. This order was faxed to the pharmacy. The pharmacy notified the RN that Tylenol #3 was not recommended due to the resident’s documented allergy to hydrocodone. The RN then contacted the physician, who changed the order from Tylenol #3 to tramadol 50 mg via G-tube every 12 hours as needed for moderate to severe pain. The RN acknowledged that the responsible party was not notified of this change in medication from Tylenol #3 to tramadol, despite the facility’s process and policy requiring that resident representatives be informed of changes in condition, care, and services, and the policy on patient rights stating that patients and their designated representatives have the right to participate in decisions regarding care and to receive information necessary for informed consent or refusal.
Inaccurate MDS Documentation of Pressure Ulcer Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Comprehensive MDS assessment accurately reflected the resident’s current pressure ulcer status. The resident had been admitted with multiple serious medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia/hemiparesis, and vascular dementia, and lacked capacity to make decisions, with a daughter designated as responsible party. A wound care note dated May 19, 2025 documented a sacral fragile skin scar tissue reopening, measuring 3 cm in length, 1 cm in width, and 0.1 cm in depth, and included a physician’s order to cleanse with normal saline, apply Triad cream, and cover with a dry dressing for 30 days. Despite this documented wound and active treatment orders, the Quarterly MDS assessment for the same period indicated that the resident had no unhealed pressure ulcer injuries and was not receiving pressure ulcer care. During a concurrent interview and record review on February 18, 2026, the Nurse Manager confirmed that the wound care note showed a reopened pressure ulcer with specific treatment orders, and acknowledged that the MDS assessment did not reflect the resident’s actual pressure ulcer status. The Nurse Manager also stated that the facility follows the federal mandate for MDS assessments, and the cited RAI Manual language emphasized that MDS information must cover the specified observation period and be validated for accuracy by the IDT, which did not occur in this case.
Failure to Identify and Report Abdominal Skin Tear During CNA Skin Check
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a non‑pressure related skin impairment received appropriate treatment and services in accordance with professional standards of practice. The resident had multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia, hemiparesis, and vascular dementia, and lacked decision‑making capacity, with her daughter designated as responsible party. On the day of transfer to an acute care hospital, CNA documentation in the electronic medical record indicated that the resident received a complete linen change, face care, peri care, and a shower. During a concurrent interview and record review, the CNA/RNA who assisted with the shower stated that facility process requires CNAs to perform skin checks during incontinent care, bed baths, and showers, and to report abnormal findings to the wound care nurse or charge nurse. The CNA/RNA reported that she performed a skin check during the shower and noted no abnormal findings to report, and that she applied triad barrier cream to the resident’s abdominal folds. However, a photograph taken later that day in a general acute care hospital emergency room showed a skin tear covered with white cream on an abdominal fold, which the CNA/RNA acknowledged would have been an abnormal finding that should have been reported to the wound care nurse and that she had not identified during the shower. Subsequent review with the SNF nurse manager and the wound/ostomy nurse from a second acute care hospital confirmed that the resident arrived at the hospital with a left abdominal fold skin tear. The second hospital’s admission process included a skin assessment and photograph of the left abdominal fold skin tear, and the wound/ostomy nurse identified it as such. The SNF nurse manager, after reviewing the hospital photographs, stated that the photos indicated a left abdominal skin tear and that CNAs are expected to identify and report such abnormalities during routine skin checks. The facility’s CNA job description and the skin care and pressure injury prevention policy both require CNAs to monitor and report noticeable changes in residents’ skin condition and to routinely assess for signs of irritation or breakdown, which did not occur in this instance.
Inaccurate IDT Documentation of Restraint Use and Clinical Status
Penalty
Summary
The facility failed to ensure that Interdisciplinary Team (IDT) notes accurately reflected a resident’s current status, resulting in discrepancies in the medical record. The resident was initially admitted with chronic respiratory failure with hypoxia, a tracheostomy, and ventilator dependence, and was later discharged to a general acute care hospital. Review of the IDT Monthly Meeting Notes for multiple months showed documentation of restraints described as two bedrails raised and locked while in bed for seizure activity and whole body jerking while coughing or while being suctioned. However, there was no documented evidence in the medical record that the resident had a diagnosis of seizures from admission through discharge. During an interview and concurrent record review with the Director of Subacute and the Nurse Manager, it was confirmed that the medical record did not contain a seizure diagnosis for the resident, despite the repeated references to seizure activity in the IDT Monthly Meeting Notes. The Director of Subacute stated that the IDT notes inaccurately reflected the resident’s restraint usage by citing a seizure diagnosis instead of documenting the use of two locked bedrails for ventilator-dependent whole body jerking while coughing or during suctioning. The Director further stated that the MDS nurse failed to adequately customize the IDT Monthly Meeting Notes to reflect the resident’s correct clinical status, resulting in documentation that did not accurately represent the resident’s specific condition, contrary to the facility’s policy requiring accurate completion of medical records for patient safety.
Failure to Perform and Document Annual Fuel Quality Testing for Emergency Generators
Penalty
Summary
The facility failed to maintain the Emergency Power Supply System (EPSS) as required by NFPA 101 and NFPA 110 standards. During a facility tour, record review, and interviews with facility leadership, it was found that documentation was not provided to show that a fuel quality test had been performed at least annually on the 200-kilowatt diesel generator for the subacute area and the 125-kilowatt diesel generator for the annex building. The last available documentation for the subacute generator was from nearly two years prior, and no current or previous year's report was provided by the deadline set by surveyors. The Plant Operations Manager stated that a recent fuel quality test had been performed, but the report was not available for review at the time of the survey. This deficiency affected all 59 residents and four smoke compartments within the facility. The lack of current fuel quality testing documentation could impact the operational reliability of the emergency power system. This issue had also been previously cited during a prior Life Safety Code Recertification Survey, indicating a repeated failure to comply with required maintenance and testing protocols for the facility's emergency generators.
Plan Of Correction
The contracted company to take samples for fuel quality testing on 5/15/25. The Director of Plant Operations contacted the company for the results. Both generators will be tested for fuel quality on an annual basis. Action plans are generated with findings and deadlines for completion. The Plant Operations Manager or qualified designee will be maintaining the record of preventive maintenance of the electrical system, including the generator fuel quality test. The Director of Plant Operations will do a random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Maintain Emergency Preparedness Testing Requirements
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness testing requirements as outlined in federal regulations. During a record review and interviews with the Director of Subacute and the Director of Plant Operations, surveyors requested documentation of the facility's Emergency Operations Plan and evidence of participation in required emergency preparedness exercises. The facility was unable to provide documentation showing participation in an annual full-scale community-based exercise or an additional annual full-scale exercise to test the emergency plan. The Director of Plant Operations indicated that they needed to locate the after-action report for an actual emergency event that had occurred in the past year, but this documentation was not provided by the deadline given by surveyors. The lack of documentation meant that the facility could not demonstrate compliance with the requirement to conduct at least two emergency preparedness exercises per year, including unannounced staff drills using emergency procedures. This deficiency affected all 59 residents in the facility at the time of the survey. The survey findings were based on the absence of required records and the inability of facility leadership to produce evidence of compliance with emergency preparedness testing standards during the annual Life Safety Code recertification survey.
Plan Of Correction
E 039 Facility was compliant with frequency of drills/actual events as evidenced by the following documents: On 5/30/2024, incident command was set up internally for a water pipe ruptured in the ceiling of a non-patient care hallway. This is contiguous to a supply room and near the kitchen. Code Triage Internal was called and facility engineers were already on-site mitigating the issue. Water was shut off to the building at the street. County and state were notified. (Please see the attachment) On 2/19/2025, incident command was set up due to phone outage and inability to receive incoming calls or make outgoing calls. Internal unit to unit and employee mobile phones being utilized to support communication. First information from IT is that is not a switch issue, but more widespread and involves AT&T. In addition, Pyxis is on critical override. Intermittent computer down. (Please see the attachment). PLAN: Facility will continue to perform mock disaster drills as scheduled per our Environment of Care (EOC)/Emergency Management (EM)/Life Safety (LS) in accordance with state and county guidelines and participate in tabletop exercises with the county and other agencies. All documents will be maintained by the disaster coordinator. A scheduled tabletop exercise is planned for October 16th, 2025 in collaboration with local and State agencies, "The great California shakeout".
Failure to Perform Required Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 requirements. Specifically, the facility did not perform monthly inspections of the sprinkler system components, such as gauges and valves. During the survey, it was found that 8 out of 12 required records documenting these monthly inspections were not provided. The Plant Operations Manager confirmed during an interview that only quarterly visual inspections were being conducted, rather than the required monthly inspections. This deficiency had been previously cited during a prior Life Safety Code Recertification Survey. Additionally, a corroded sprinkler head was observed in Dining Room C of the main building. The Director of Subacute stated during the interview that they were unaware of the corroded sprinkler head. The presence of corrosion on the sprinkler head is a direct violation of NFPA 25, which requires that sprinkler heads be free from corrosion, leakage, and other physical damage. These failures affected all 59 residents in the facility, as well as all four smoke compartments. The lack of proper inspection and maintenance of the sprinkler system and its components, as well as the presence of a corroded sprinkler head, were identified through observation, record review, and staff interviews during the survey.
Plan Of Correction
The sprinkler located by dining room C was replaced by contracted company. (Please see the attachment.) Scheduled recurring preventative maintenance was implemented to occur monthly to visually inspect the sprinklers PM schedule. MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the sprinklers on a semi-annual basis. 2. Added monitoring is a visual inspection to be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations. K 353
Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct required quarterly fire drills for each shift, as evidenced by missing documentation for specific shifts and quarters. During a record review and interview with the Director of Subacute and Plant Operations Manager, it was found that there were no records of a fire drill for the AM shift in the first quarter and third quarter, nor for the PM shift in the fourth quarter. The Plant Operations Manager stated that fire drills were performed quarterly per shift in various departments, but some fire drill reports did not record subacute staff responses. This deficiency affected all 59 residents in the facility.
Plan Of Correction
The director of plant operations updated the current fire drill matrix to reflect a separate Subacute fire drills that will occur monthly for each shift (Main Building and Annex). The director of plant operations provided in-service to the plant operation staff for the new process with the updated fire matrix. (Please see the attachments). MONITORING: 1. The Plant Operations Manager or qualified designee will be inspecting the fire drill record and fire drill process on a quarterly basis. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Correct Deficiencies in Medical Gas and Vacuum System Maintenance
Penalty
Summary
The facility failed to maintain its Piped Medical Gas and Vacuum System as required by NFPA 99 standards. During a review of records and interviews with the Plant Operations Manager, it was found that the annual inspection and testing report for the medical gas and vacuum system identified several deficiencies, including leakage when an adapter was inserted, loose outlet/inlet, a zone valve box that required cleaning, and a missing caution label. The report did not include documentation of any corrective actions taken to address these issues. These deficiencies affected all 59 residents and all four smoke compartments in the facility. The lack of timely correction and documentation of the identified discrepancies in the medical gas and vacuum system constituted a failure to comply with required inspection, testing, and maintenance protocols. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Plan Of Correction
The contracted company repaired medical gas equipment according to the inspection report on 6/13/25. MONITORING: 1. The Plant Operations Manager or qualified designee will be maintaining the preventive maintenance of the piped gas and vacuum system. 2. The Director of Plant Operations will do random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Annually Review and Update Emergency Operations Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring the annual review and update of its Emergency Operations Plan (EOP). During a record review and interview with the Director of Subacute and the Director of Plant Operations, it was found that the EOP had last been reviewed and updated on 11/29/22. This was confirmed when the Director of Plant Operations stated that they believed the plan only needed to be reviewed every two years, following the hospital's review schedule, rather than annually as required for long-term care facilities. This deficiency affected all 59 patients in the facility, as the EOP had not been reviewed or updated within the required annual timeframe. The lack of timely review and update of the emergency preparedness plan could result in the facility being unprepared in the event of an emergency or disaster, as the plan may not reflect current procedures, resources, or risks.
Plan Of Correction
E 004 The director of plant operations revised the emergency operations plan. The emergency management committee approved the revised emergency operations plan and will be presented to the Subacute Quality Assurance and Performance Improvement committee for final approval. The Director of plant operations will be revising the emergency operations plan on an annual basis (within the first quarter of the year).
Smoke Detector Failed to Activate During Functional Test
Penalty
Summary
During a facility tour and interview, surveyors observed that a smoke detector located in the hallway near Nurse Station 1 and resident rooms 730 and 743 failed to activate the fire alarm system when tested. The test involved spraying the smoke detector three times with smoke detector test spray, but the device did not trigger an alarm. The Director of Subacute, present during the test, was unable to explain why the smoke detector did not respond. This deficiency affected 24 out of 59 residents in one of four smoke compartments. Records of system acceptance, maintenance, and testing were expected to be readily available and the fire alarm system was required to be maintained in reliable operating condition in accordance with NFPA 70 and NFPA 72 standards.
Plan Of Correction
Smoke detector located in the hallway by nurse station 1 and resident rooms 730 and 743 was repaired by contracted company (Please see the attachment). MONITORING: 1. The plant operations team, headed by the plant operations director or qualified designee, will be inspecting all smoke detectors on a semi-annual basis. Monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Corridor Doors Failed to Latch Upon Closing
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. During a facility tour, it was found that the corridor door to the SNF Nurse Manager office and the corridor door to the storage room by resident room 732 did not latch upon self-closing. These doors are required to resist the passage of smoke and have positive latching hardware to ensure proper containment in the event of a fire. The deficiency affected 14 of 59 residents and one of four smoke compartments. During the interview, the Director of Subacute stated they were unaware that the doors did not latch. The report does not mention any specific medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
The contracted company repaired the corridor door to the SNF nurse manager office and storage room by resident room 732. (Please see the attachment). MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the doors on an annual basis. Additional monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Verify NGT Placement Prior to Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to verify the placement of a nasogastric tube (NGT) prior to administering medication to a resident. During a medication administration observation, the LVN prepared the resident's medications, verified the resident's identity, and attempted to aspirate for gastric residual from the NGT, but no residual was obtained. Despite this, the LVN proceeded to administer the medications through the NGT without further verification of tube placement. When questioned, the LVN stated that checking tube placement was unnecessary for an NGT, as opposed to a G-tube. The resident involved had a history of postpartum cardiac arrest and was care planned to have an NGT, with instructions to check tube placement and gastric contents per facility protocol. The facility's policy required verification of NGT placement by aspirating for gastric contents and, if none were obtained, by injecting air and listening for a swooshing sound with a stethoscope. The Director of Nursing confirmed that all licensed nurses were expected to follow this protocol for both NGT and G-tube placements prior to administering feedings or medications.
Expired Ativan Vial Not Removed from Medication Storage
Penalty
Summary
During an inspection of the medication storage room, one vial of Ativan 2 mg was found stored in the medication refrigerator beyond its manufacturer's recommended discard date. The Nurse Manager confirmed that expired medications should be removed from use to prevent administration to residents. The Director of Nursing acknowledged that staff are responsible for checking medication expiration dates and that the expired Ativan vial was overlooked and not removed or returned to the pharmacy as required. Facility policy states that discontinued, outdated, or deteriorated drugs must not be used and should be returned to the dispensing pharmacy or destroyed.
Expired and Unlabeled Food Items Stored in Kitchen Refrigerator
Penalty
Summary
During an initial kitchen tour with the Director of Nutritional Services (DNS), two fruit cups labeled with a use-by date that had already passed and one fruit cup with no label or date were found stored in the refrigerator and readily available for use. The DNS confirmed that all items stored in the refrigerator should be labeled with a use-by date and that expired or unlabeled items should not be stored or available for use. A review of the facility's policy indicated that all prepared salads must be covered, labeled, and dated with a use-by date before being placed in the refrigerator. At the time of the observation, two residents in the facility were on an oral diet.
Improper Disinfection of Shared Glucometer by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to properly disinfect a shared glucometer during medication administration. The LVN was observed wiping the glucometer with a Sani cloth disposable wipe but did not adhere to the manufacturer's specified contact time of two minutes. Instead, the LVN allowed the glucometer to air dry while still wet, but not for the required duration. This process was performed before and after checking a resident's blood sugar, and the LVN acknowledged not following the manufacturer's instructions regarding contact time during an interview. Interviews with the Director for Staff Development (DSD) and the Director of Nursing (DON) confirmed that staff are expected to sanitize the glucometer before and after each use, following the manufacturer's instructions for a two-minute contact time. A review of the facility's policy and the manufacturer's instructions both indicated that all patient care equipment should be disinfected between uses and that surfaces must remain wet for two minutes to ensure proper disinfection. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Implement Turning and Repositioning Interventions
Penalty
Summary
The facility failed to implement the necessary interventions for turning and repositioning a dependent resident, leading to an increased risk of pressure injuries. Resident 1, who was nonverbal and noncommunicative, had a care plan that required turning and repositioning every two hours and at specific times requested by the family. However, documentation from January 17-21, 2024, showed that Resident 1 was not turned or repositioned as required, with significant gaps in the records indicating a lack of adherence to the care plan. Interviews with CNAs and the DON confirmed that if repositioning was not documented, it was not done, highlighting a failure in the facility's care practices. Further interviews with treatment nurses revealed that Resident 1 had a pressure injury on the buttocks, which was improving but still required consistent turning and repositioning to promote healing and prevent further injuries. The facility's policy on skin care and prevention of pressure injuries emphasized the importance of changing positions regularly to maintain skin integrity. The lack of documentation and adherence to the care plan for Resident 1 indicates a significant deficiency in the facility's care practices, putting the resident at risk for developing and worsening pressure injuries.
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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