Country Drive Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fremont, California.
- Location
- 2500 Country Drive, Fremont, California 94536
- CMS Provider Number
- 055885
- Inspections on file
- 24
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Country Drive Post Acute during CMS and state inspections, most recent first.
Surveyors found that multiple self-responsible residents did not receive or sign admission agreements at or near the time of admission, contrary to facility policy. One resident’s agreement was signed eight days after admission, another resident had no signed agreement on file, a third resident’s agreement was only provided on the day of discharge and the family reported being unaware of the care and services provided, and a fourth resident signed the agreement more than a month after admission. The admission agreement, which includes resident rights, advance directives, facility and Ombudsman information, arbitration terms, and expectations, was required by policy to be signed at admission and filed in the clinical record.
A resident with anxiety, depression, and intact cognition was assigned a new roommate after the prior roommate was transferred to the hospital, but did not receive advance written notice of this roommate change. The ADON reported that the facility only gives written notice when residents move rooms, not when they receive a new roommate, despite a policy requiring timely advance notice for room or roommate changes. Only undocumented verbal notice was given, and the failure was noted as having the potential to cause avoidable psychosocial distress.
A resident with intact cognition and multiple chronic conditions entrusted a wallet containing cash to the SSD for safekeeping. The SSD stored the wallet in an unlocked office drawer instead of securing it per the facility’s personal funds policy. When the resident’s family later requested a portion of the money, most of the cash was missing, and documentation showed the issue was discussed with the family but not directly with the resident, even though the facility’s policy required proper safeguarding and accounting of resident funds.
A resident admitted with multiple fractures, dementia, gait difficulty, and delirium did not receive a summary of the baseline care plan within 48 hours of admission. The ADON could not confirm that either the resident or the resident’s representative had been given this summary, and the ICC documentation listed only facility staff as attendees and left the section on providing a copy of the care plan summary blank. The resident’s representative reported that the admission agreement was only received on the day of planned discharge and that the family was unaware of the care and services to be provided. The facility’s baseline care plan policy described IDT development of person-centered care but did not specify when or how to provide a care plan summary to the resident or representative.
The facility did not meet the required minimums for Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) DHPPD on ten weekend days, as confirmed by staff interviews and payroll record reviews. Staffing levels on these days fell below both the 3.5 DHPPD and 2.4 CNA DHPPD thresholds, in violation of facility requirements.
Surveyors found multiple prescription medications, including insulin and oral tablets, stored in a medication cart without proper labeling or resident identification, and not separated from other medications. Additionally, insulin vials and pens were stored in a medication refrigerator operating at a temperature far below the required range, with staff unaware of the issue prior to inspection.
A resident with cognitive and physical impairments was not provided with individualized activities according to their assessment and care plan. The resident was observed awake in bed without engagement in any activities, and staff could not specify what activities were offered. No activity care plan or assessment of preferences was found in the record, and required follow-up with the family was not completed. Facility policy requiring individualized activity planning was not followed.
A resident with severe kidney disease did not have current physician orders or a medication list in the dialysis communication binder, and there was no follow-up on a recommendation to discontinue a prescribed medication. Facility staff also recorded inconsistent assessments of the resident's dialysis access site, documenting findings inconsistent with the actual type and location of the access. These failures resulted in a lack of proper coordination and documentation with the dialysis center.
A registered nurse failed to follow proper insulin pen injection technique for two different insulin medications administered to a resident, withdrawing the needle too soon and resulting in two medication errors. This led to a medication error rate of 8%, surpassing the allowable federal threshold.
A resident with a right leg immobilizer and moderate risk for pressure ulcers developed an unstageable, facility-acquired pressure ulcer on the right lower leg due to lack of documented skin checks and failure to update the care plan with appropriate interventions. Despite physician orders and facility policy requiring daily monitoring, staff did not assess or document the condition of the skin under the immobilizer, resulting in delayed identification and management of the wound.
Failure to Provide Timely Admission Agreements and Notice of Rights
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with notice of rights, rules, services, and charges prior to or upon admission, as required by facility policy. The Admissions Director stated that the admission agreement is very important because it includes information on resident rights, advance directives, facility and Ombudsman information, arbitration, and expectations, and that it should be signed within 72 hours of admission. However, record review showed that one resident, who was self-responsible and had an emergency contact listed, was admitted on a specified date and transferred to the hospital after a medical emergency, yet the state-specific admission agreement was not signed by the resident representative until eight days after admission. Another self-responsible resident with an emergency contact listed had no signed admission agreement in the clinical record, as confirmed by the ADON during concurrent interview and record review. For a third self-responsible resident, records showed admission on a specified date and discharge home on another date, with the emergency contact listed; the resident’s representative reported that the admission agreement was only given on the day of discharge, and that the resident and family were unaware of the care and services provided while at the facility. The state-specific admission agreement for this resident was dated the day the resident went home. For a fourth self-responsible resident, the admission agreement was signed more than one month after admission. Review of the facility’s policy and procedure titled “Admission Agreement,” last revised December 2025, indicated that each resident must have an admission agreement signed and dated by the resident or resident representative at the time of admission and filed in the clinical record, which did not occur for these four of five sampled residents.
Failure to Provide Required Advance Notice of Roommate Change
Penalty
Summary
The facility failed to honor a resident’s right to receive advance notice of a roommate change when a new roommate was assigned to Resident 2’s room. Resident 2 had been admitted with diagnoses including encounter for removal of an internal fixation device, anxiety disorder, and depression, and had an MDS BIMS score of 13, indicating intact cognition. Resident 2 initially shared a room with Resident 6 until Resident 6 was transferred to the hospital. On a later date, Resident 2 was given a new roommate without advance written notice, and only verbal notice was reportedly provided. During interviews, the ADON stated that the facility does not provide written notice when a resident acquires a new roommate and only provides written notice when a resident is moved to a new room. Review of the facility’s “Room or Roommate Change” policy, effective 6/27/22, showed that residents or their representatives are to receive timely advance notice before a room or roommate change, and that this notice can be verbal, written, or both. The ADON confirmed that when Resident 2 received a new roommate, only verbal notice was given and it was not documented in the clinical record, contrary to the facility’s policy. The report stated this failure had the potential to result in avoidable psychosocial distress.
Failure to Safeguard Resident Personal Funds
Penalty
Summary
The facility failed to safeguard a cognitively intact resident’s personal funds that had been entrusted to staff for safekeeping. The resident, who was self-responsible and had diagnoses including diabetes mellitus, benign prostatic hyperplasia, and chronic gout, had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. According to the Administrator, the resident gave a wallet containing $180 in cash to the Social Services Director (SSD) for safekeeping. The SSD placed the wallet in an unlocked drawer in the SSD office, contrary to the facility’s policy and procedure for management of residents’ personal funds, which required the facility to hold, safeguard, manage, and account for residents’ personal funds when the facility manages them. Later, when the resident’s family requested $140 from the resident’s money, only $40 remained in the wallet, indicating that $140 was missing. The SSD no longer worked at the facility at the time of the investigation. A review of the Social Services Progress Notes from October through December did not show that the resident was informed about the missing $140, although the SSD had discussed the issue with the resident’s family. During an interview, the resident stated that the facility still had the wallet and that a man had visited his room and provided a number to call regarding the missing money. The facility’s policy required written authorization and proper safeguarding of funds when the facility manages a resident’s personal funds, but the wallet and cash were not secured in accordance with these procedures.
Failure to Provide Baseline Care Plan Summary to Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a resident received a summary of the baseline care plan within 48 hours of admission, as required. The resident was admitted with multiple significant diagnoses, including fractures of the left pubis, sacrum, and upper end of the left humerus, as well as dementia, difficulty in walking, and delirium. The admission record indicated the resident was self-responsible and identified a representative as the emergency contact. During review of the resident’s Interdisciplinary Care Conference (ICC) documentation, the Assistant Director of Nursing (ADON) stated she was unsure whether a summary of the baseline care plan had been provided to the resident or the representative, noting that the notes did not indicate this. The ICC form listed only facility staff as attendees, did not identify which representative participated, and left blank the section indicating whether a copy of the care plan summary was provided. In a telephone interview, the resident’s representative reported that the admission agreement was only received on the day the resident was to be discharged and that the resident and family were unaware of the care and services to be provided at the facility. Review of the facility’s policy and procedure titled “Care Plan-Baseline” showed that it described the baseline care plan as including instructions for effective, person-centered care to be developed and implemented by the Interdisciplinary Team for each resident, but the policy did not specify when or how a summary of the baseline care plan should be provided to the resident or their representative. This lack of clear documentation and policy guidance contributed to the failure to provide the required baseline care plan summary to the resident or the representative.
Failure to Meet Minimum Direct Care and CNA Staffing Requirements
Penalty
Summary
The facility failed to provide the required minimum of 3.5 Direct Care Service Hours Per Patient Day (DHPPD) and 2.4 Certified Nursing Assistant (CNA) DHPPD on ten weekend days, as evidenced by interviews and record reviews. Staff responsible for scheduling and staffing, including the Staff Developer Assistant and Director of Staff Development, confirmed awareness of the minimum staffing requirements. Payroll records reviewed with the Payroll Coordinator showed that on multiple dates, both overall DHPPD and CNA DHPPD fell below the mandated levels. Specific staffing data from the facility's census and DHPPD reports indicated that on several days, the DHPPD ranged from 3.07 to 3.49 and CNA DHPPD ranged from 1.79 to 2.23, all below the required minimums. The facility's staffing waiver also stipulated that no less than 3.5 direct care service hours per patient day should be provided, which was not met on the identified dates. This deficiency was identified through interviews and review of staffing records, but no information about specific residents or their conditions was provided in the report.
Improper Medication Labeling and Storage, Including Unsafe Refrigeration of Insulin
Penalty
Summary
During an inspection of a medication cart, multiple prescription medications were found without proper labeling or resident identification. Items included a Humalog (insulin lispro) KwikPen, a pill organizer containing various oral tablets, and an Albuterol Sulfate Inhaler, none of which had prescription labels or clear identifiers. These medications were not separated from other facility-stocked medications and were stored in a manner that did not prevent potential medication administration errors. A registered nurse acknowledged that these medications were brought in by a resident and admitted they had not been properly labeled or verified for use. Additionally, a medication refrigerator in the facility's medication storage area was observed to be operating at 14°F, well below the required refrigeration range. Multiple insulin vials and pens were stored inside, all labeled to be refrigerated but not frozen. The nursing supervisor confirmed that staff had not previously identified or addressed the unsafe storage condition, and there was no indication that the affected insulin had been evaluated for safety or removed from use.
Failure to Provide Individualized Activities Based on Assessment and Preferences
Penalty
Summary
The facility failed to provide individualized activities for one resident, as required by assessment and care plan, based on the resident's preferences and needs. The resident, who was admitted with diagnoses including pneumonia, weakness, and difficulty walking, was observed lying in bed awake and alert on multiple occasions, with no TV or music playing and no evidence of engagement in any activities. The resident was unable to speak but responded to greetings with a smile. Staff interviews revealed that in-room visits were conducted, but the Activity Director could not specify what activities were provided and acknowledged that activities were anticipated rather than planned according to an individualized assessment. A review of the resident's records showed no activity care plan or individualized activity assessment was present at the time of the observations. The MDS assessment did not document the resident's choices or preferences for activities. The Activity Director admitted that the assessment and care plan had not been completed within the required timeframe and that follow-up with the resident's family regarding preferences had not occurred as needed. Facility policy requires individualized activities and care plans to be developed based on assessment, but this was not done for the resident in question.
Failure to Ensure Consistent Dialysis Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure ongoing and consistent collaboration with the dialysis center for a resident requiring dialysis services. The resident, who had severe kidney disease and a hypertensive emergency, was admitted with physician orders for Clonidine transdermal patches to manage hypertension. The dialysis communication binder for this resident did not contain the current physician's orders or a medication list, despite a request from the dialysis center. Additionally, there was no follow-up on the dialysis center's recommendation to discontinue the Clonidine patches, and the medication continued to be administered. Facility staff also documented inconsistent assessments of the resident's dialysis access site. While the resident had a left chest permacatheter, records incorrectly noted the access site as the right upper arm with findings (bruit and thrill) that would not be present with a permacatheter. The resident confirmed the location of her access site and the ongoing use of Clonidine patches, and staff acknowledged the absence of required documentation and communication in the dialysis binder. These lapses were contrary to the facility's policy, which required regular written communication and collaboration with the dialysis provider and attending physician.
Medication Error Rate Exceeds Federal Threshold Due to Improper Insulin Administration
Penalty
Summary
During a medication administration observation, a registered nurse administered Lantus Insulin and Novolog Insulin to a resident but failed to follow the manufacturer-recommended technique for insulin pen injections. Specifically, the nurse did not hold the insulin pen in place for the required 5 to 10 seconds after injection, instead withdrawing the needle after only 2 to 3 seconds. This incorrect technique was observed for both types of insulin administered to the resident. Each instance of improper administration was counted as a separate medication error, resulting in a medication error rate of 8%, which exceeds the federal threshold of 5%. The nurse acknowledged the error during a follow-up interview, stating she forgot the correct technique.
Failure to Monitor and Prevent Pressure Ulcer Under Immobilizer
Penalty
Summary
A resident with a periprosthetic fracture around an internal prosthetic right hip joint was admitted with a right leg-knee immobilizer and was identified as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 13. The care plan acknowledged the resident's higher risk for pressure ulcers but did not include specific interventions to monitor or protect the skin under the immobilizer. There was no documentation of skin checks under the immobilizer, and the care plan was not updated when a pressure ulcer was later identified on the right lower leg. Despite physician orders to monitor the skin under the right leg brace daily and notify the physician of any changes, there was no evidence in the clinical record or treatment administration record that these checks were performed. Interviews with nursing staff and review of skin monitoring forms confirmed that the skin under the immobilizer was not routinely assessed. When a pressure ulcer was eventually discovered, there was no initial measurement or detailed documentation of the wound, and the care plan was not promptly updated to reflect the new condition. The lack of monitoring and timely intervention led to the development of an unstageable, facility-acquired pressure ulcer on the resident's right lower leg, which caused pain and extended the resident's stay. The facility's own policy required regular risk evaluation, skin inspection, and documentation, but these procedures were not followed in this case. The failure to implement and document appropriate preventive measures and wound assessments directly contributed to the deficiency.
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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