Crystal Cove Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport Beach, California.
- Location
- 1445 Superior Avenue, Newport Beach, California 92663
- CMS Provider Number
- 055929
- Inspections on file
- 35
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Crystal Cove Care Center during CMS and state inspections, most recent first.
The facility failed to maintain confidentiality of residents’ PHI when a medical records assistant allowed a non-employee family member to sit inside the medical records office for an extended period while discharged records were being filed. Facility policies and HIPAA training prohibited unauthorized access to resident information and limited medical record access to designated staff. However, the non-employee was permitted to remain in the office, where open bookshelves contained medical record folders with visible resident names, and some showed admission and discharge dates and medical record numbers. The DON and Medical Records Director confirmed that unauthorized persons, including volunteers, were not allowed in the medical records area and that the family member was not an employee.
During wound care for a resident with a Stage 3 pressure injury, an RN and an LVN failed to wear required isolation gowns and did not post EBP signage, despite the resident's care plan specifying these precautions. The facility's infection control policy and staff interviews confirmed that EBP protocols were not followed during this high-contact care activity.
A resident with PTSD, anxiety, and hypertension was discharged without being provided with prescribed medications, including Verapamil, Ambien, and oxycodone-acetaminophen. Medical records confirmed these medications were ordered at discharge but not given to the resident, as verified by staff and documentation review.
A resident with a history of hypertension had an elevated blood pressure reading that was not retaken, and the physician was not notified as required. Additionally, the resident did not receive prescribed antihypertensive medication, and there was no documentation of physician notification regarding the missed dose or abnormal vital sign.
Two residents did not receive proper pharmaceutical services: one was not administered prescribed Verapamil and Ambien, and for another, required controlled medication count sheets for Roxicodone and oxycodone were missing from the medical record. Staff confirmed the omissions and lack of documentation.
A nurse failed to follow infection control protocols while providing catheter care to a resident, including allowing a urine drainage bag to touch the floor, making contact between a shoe and the drainage bag, and not performing hand hygiene between glove changes. These actions were not in accordance with facility policies for hand hygiene and catheter care.
A resident did not receive timely bowel management interventions as required by facility policy, resulting in more than three days without a BM, signs of distress, and eventual transfer to acute care for disimpaction. Nursing staff delayed implementing prescribed interventions and notifying the physician, despite daily monitoring requirements and clear evidence of constipation.
A resident with severe cognitive impairment and a history of falls experienced multiple falls, but the facility did not update the care plan with new or different interventions as required. The care plan remained unchanged despite repeated incidents, and documentation failed to address the resident's ongoing behaviors and fall risk. Facility leadership confirmed that no updates or additional interventions were made following the falls.
An LVN left three unlabeled medications in a clear cup unattended on a resident's bedside table, contrary to facility policy requiring safe administration and storage of medications. The DON confirmed that medications should not be left in a resident's room, and the resident was not assessed as capable of self-administering medication.
A resident returned from the hospital with a new order for Zyprexa, an antipsychotic medication, to be administered for psychosis. The facility's care plan addressed the medication but failed to include non-pharmacological interventions, which are required before or alongside psychotropic medications. Despite multiple episodes of psychosis, there was no documentation of non-pharmacological interventions being provided, as confirmed by the DON.
A facility failed to provide timely catheter care and bladder training for a resident with an indwelling urinary catheter, leading to a risk of CAUTIs. Catheter care and urine output monitoring were delayed by seven days, and despite requests, bladder training was not provided. A urology consultation was requested but not documented as followed up, indicating a lack of adherence to the resident's care plan.
The facility failed to provide information and maintain copies of advance directives for two residents. One resident expressed interest in having an advance directive but was not approached by staff, while another resident's advance directive was not documented in the medical record despite being requested. The SSD confirmed these oversights, which were against the facility's policy.
A resident at high risk for pressure injuries was left in a wheelchair for several hours without repositioning, contrary to facility policy. Staff interviews revealed a lack of adherence to care plans and communication issues. Observations showed the resident had redness on the sacral area and was found with soiled incontinence products, indicating inadequate care. The DON acknowledged the deficiency and clarified repositioning protocols.
A facility failed to monitor a resident's fluid intake as per physician's orders for fluid restriction. The resident's MAR showed fluid intake from the nursing department but lacked documentation from the dietary department. Interviews with staff revealed a lack of awareness and documentation regarding the resident's fluid intake during meals, leading to incomplete records and potential health risks.
A facility failed to provide appropriate dialysis care for a resident by not maintaining a dialysis emergency kit at the bedside and not consistently assessing the dialysis access site. The resident, with a permacath access for hemodialysis, lacked necessary emergency supplies, and staff failed to document assessments before and after dialysis treatments. The DON acknowledged these lapses in protocol.
A resident was found to have duplicate medication orders for guaifenesin with different dosages, posing a risk of medication errors. The attending physician confirmed that only one order was intended, and the previous order was not discontinued. The pharmacist received only one order, while the other was a stock item. The DON acknowledged the findings.
The facility failed to ensure proper storage and labeling of medications and supplies, including single-use dressings and expired Covid testing kits. A resident was found with medications in their nightstand without physician's orders. Staff confirmed these deficiencies, indicating a lack of oversight.
The facility failed to provide necessary care for two residents, impacting their well-being. A resident's pacemaker was not monitored, and their surgical wound was not properly assessed or documented. Another resident did not receive ordered lab tests, and their orthostatic blood pressure was incorrectly monitored. Staff interviews confirmed these deficiencies.
The facility failed to provide necessary respiratory care for three residents. A resident was using oxygen without a physician's order, another was receiving oxygen at an incorrect rate and without proper signage or care plan, and a third resident's nebulizer tubing was unlabeled. These deficiencies were confirmed by staff and highlighted non-compliance with facility policies.
The facility failed to ensure the competency of two licensed nurses regarding bladder training for a resident with an indwelling urinary catheter. Additionally, the facility did not provide training materials for in-service trainings, and the annual performance evaluation for an LVN was not completed as required by policy.
The facility failed to ensure proper informed consent and monitoring for psychotropic medications for two residents. A resident's zolpidem consent lacked a physician's signature, and sleep monitoring documentation was inconsistent. Another resident's clonazepam consent was not renewed as required, despite continued administration. These issues were confirmed by staff interviews and record reviews.
The facility failed to maintain sanitary conditions in the kitchen, with several utensils found dirty and in poor condition, posing a risk of cross-contamination and foodborne illnesses. The Registered Dietitian confirmed the deficiencies, which affected 80 out of 86 residents consuming food prepared in the facility's kitchen.
The facility failed to maintain accurate and complete medical records for several residents, leading to potential care gaps. Issues included incorrect advance directive information, missing medication administration records, and incomplete monitoring documentation. These deficiencies were confirmed by facility staff, indicating systemic record-keeping issues.
The facility failed to maintain an effective infection control program, with deficiencies in infection surveillance, hygiene practices, and equipment handling. The infection control data was inaccurate, and mapping was incomplete. A laundry aide transported uncovered linen, and an LVN did not perform hand hygiene during wound care. Additionally, a resident's nasal cannula tubing was improperly handled, posing an infection risk.
A facility failed to provide a resident with a copy of their personal inventory list upon admission, as required by policy. The inventory list, which was meant to document the resident's belongings, was not given to the resident, leaving their personal items potentially unaccounted for. Interviews with staff confirmed the oversight, and the DON acknowledged the requirement for residents to receive a copy of the inventory list.
The facility failed to maintain the specimen refrigerator at the required temperature range of 36-46 degrees F, with an observed temperature of 28 degrees F and ice build-up in the freezer compartment. This was confirmed by an RN and acknowledged by the DON.
A resident was not provided privacy during a medication administration procedure when an LVN failed to pull the privacy curtain and sliding door curtain, leaving the resident exposed. The LVN lifted the resident's gown, exposing the stomach and part of the diaper, before being reminded to ensure privacy. The DON acknowledged the importance of maintaining privacy during such procedures.
A facility failed to notify a resident or their representative of the bed hold policy upon transfer to a hospital. Although the resident's representative signed the notification form upon admission, the sections for confirmation of transfer and bed hold provision were left blank, indicating a lack of notification at the time of transfer. The resident was alert and capable of making decisions, but there was no documented evidence of notification in the medical record. The ADON confirmed that licensed nurses were responsible for this notification.
A resident with a fracture of the right humerus refused to wear a physician-ordered sling, and the facility failed to update her care plan to reflect this refusal. Despite observations showing the resident without the sling, the care plan was not revised, posing a risk of inconsistent care. The ADON confirmed the oversight, acknowledging the resident's tendency to remove the sling.
The facility did not complete annual performance evaluations for a CNA rehired in 2022, as required by policy. The DSD, responsible for these evaluations, had not reviewed all personnel records since starting in January 2025. The DON confirmed the necessity of these evaluations to assess work performance and identify improvement needs.
A resident's care plan was not fully implemented, as the facility failed to ensure the use of dental appliances and coordinate a dental consult after readmission. The resident lacked lower dentures, impacting their ability to eat, and no dental consult was arranged. Additionally, the facility did not develop a care plan for the resident's hard of hearing status, despite documented evidence of hearing difficulties.
A resident in an LTC facility did not receive necessary dental services after readmission, as the facility failed to assist in obtaining lower dentures. Despite the resident's care plan indicating the need for dental appliances, the lower dentures were missing, and no investigation or dental consult was conducted. The resident expressed difficulty eating without the dentures, and the facility's policies for dental services and theft investigation were not followed.
Unauthorized Individual Allowed Access to Visible Medical Records
Penalty
Summary
The facility failed to protect residents’ confidential personal and health information by allowing an unauthorized individual into the medical records office where protected health information (PHI) was openly accessible. Facility policies titled “Resident Rights” and “Protected Health Information (PHI), Management and Protection of,” both dated 2001, stated that unauthorized release, access, or disclosure of resident information was prohibited and that PHI shall not be used or disclosed except as permitted by federal and state laws. The HIPAA compliance training described by a medical records assistant (MRA 1) included instruction not to release or share resident information with anyone other than the resident or the resident’s durable power of attorney. The DON and the Medical Records Director both stated that only designated staff (medical records staff, licensed nurses, therapists, physicians, admissions, administrator, activities staff, DSD, dietary supervisor, and registered dietician) were authorized to access medical records, and that no volunteers or other unauthorized persons were permitted in the medical records department. Despite these policies and training, MRA 1 reported that on a specific date she allowed a family member (Family Member 1), who was her means of transportation and not an employee of the facility, to sit inside the medical records office with her for approximately one to two hours while she put away discharged residents’ 2025 medical records. MRA 1 acknowledged that she knew she was not supposed to bring anyone into the office and stated she asked Family Member 1 to stay inside because it was hot outside. Surveyor observation of the medical records office showed two large open bookshelves with three rows of medical record folders containing visible resident names, and some folders also showed admission dates, discharge dates, and medical record numbers. MRA 1 confirmed that from the chair where Family Member 1 sat, the resident names on the medical record folders were visible. The DON verified that Family Member 1 was not an employee and reiterated that unauthorized persons were not allowed in the medical records office due to the easily accessible medical records that needed protection.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement infection control practices as outlined in its Enhanced Barrier Precautions (EBP) policy during wound care treatment for a resident with a Stage 3 pressure injury. During an observed wound care procedure, an RN and an LVN provided care to the resident without wearing the required isolation gowns, using only gloves. Additionally, there was no EBP signage posted near the resident's room doorway or bedside to alert staff and visitors of the necessary precautions. Both staff members acknowledged during the observation that EBP should have been followed, including the use of gowns and appropriate signage. The resident involved had moderate cognitive impairment and was on hospice care, with a sacrococcyx wound that had been reclassified as a Stage 3 pressure injury following debridement. The resident's care plan specifically required EBP during high-contact care activities, including wound care, and listed interventions such as ensuring the availability of PPE and posting EBP signage. The facility's Infection Preventionist, DON, and Quality Assurance Nurse all confirmed that EBP protocols were not followed during the observed incident.
Failure to Provide Complete Discharge Medication List
Penalty
Summary
The facility failed to ensure that a resident's discharge medication list was complete and that all necessary medications were provided upon discharge. Specifically, the discharge medication list for one resident did not include Verapamil (for blood pressure), Ambien (for insomnia), and oxycodone-acetaminophen (for pain relief). Medical record review confirmed that these medications were ordered for the resident up to and including the day of discharge, but were not marked as given to the resident upon leaving the facility. The omission was verified during an interview with a registered nurse, who confirmed that the medications were not provided at discharge. The resident, who had diagnoses including PTSD, anxiety, and high blood pressure, reported leaving the facility because she did not receive her Verapamil or Ambien medications. The facility's records showed active orders for these medications, as well as for oxycodone-acetaminophen, at the time of discharge. The failure to provide these medications was identified through a complaint and subsequent review of the resident's medical and discharge records.
Failure to Notify Physician and Administer Antihypertensive Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a diagnosis of high blood pressure, PTSD, and anxiety. On review of the resident's medical record, it was found that only one blood pressure reading was obtained, which was 142/86 mmHg—above the normal range. There was no documentation that the blood pressure was retaken or that the physician was notified of this abnormal result, despite facility policy and physician orders requiring such actions for elevated readings. Additionally, the resident had physician orders for Verapamil to be administered for hypertension, with specific instructions to hold the medication if the systolic blood pressure was greater than 110 mmHg. The medication was not administered as ordered, and there was no documentation that the physician was notified of the missed dose or the elevated blood pressure. Interviews with facility staff confirmed that these actions were not taken and not documented in the resident's record.
Failure to Provide Medications and Maintain Controlled Substance Documentation
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in medication administration and documentation deficiencies. One resident, with diagnoses including high blood pressure and PTSD, was not administered prescribed Verapamil and Ambien medications during their stay. The resident reported that the facility did not provide these medications and was told a physician visit was required before administration. Medical record review confirmed that the medications were ordered but not given, and facility staff acknowledged the omission. For another resident, who had a history of a fall with a left lower extremity fracture and mild cognitive impairment, the facility did not maintain required controlled medication count sheets for administered Roxicodone and oxycodone. Although the medication administration records showed that these controlled substances were given as ordered, the corresponding count sheets were missing from the medical record. The Medical Records Director verified that these documents were not on file.
Infection Control Lapses During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for one resident with a suprapubic catheter. During an observation of urinary catheter care, a nurse's shoe was seen touching the resident's urine drainage bag, and the drainage bag itself was observed resting on the floor. The nurse removed dirty gloves after cleaning the catheter surgical site and immediately donned clean gloves without performing hand hygiene in between. The nurse acknowledged both the improper placement of the drainage bag and the failure to perform hand hygiene. Review of facility policies confirmed that hand hygiene should be performed after glove removal and before donning new gloves, and that catheter tubing and drainage bags must be kept off the floor.
Failure to Implement Timely Bowel Management Interventions
Penalty
Summary
The facility failed to provide necessary care and services for a resident who did not have a bowel movement (BM) for more than three days. According to the facility's bowel regimen management policy, nursing staff are required to review bowel records daily, monitor for no BM for more than 72 hours, and implement interventions as needed, including notifying the physician. In this case, the resident had no BM from 6/1 to 6/6, but interventions were not implemented until 6/6, despite daily monitoring requirements. The resident's medical record showed orders for various laxatives and interventions, but these were not administered in a timely manner according to the policy. The resident exhibited signs of constipation, including abdominal distention, increased agitation, and distress, and required multiple interventions, including enemas and oral laxatives, which were ultimately ineffective. The physician was notified after 72 hours without a BM, and a KUB x-ray confirmed moderate constipation. The resident was subsequently sent to an acute care hospital for disimpaction after seven days without a sufficient BM. The delay in implementing appropriate interventions as outlined in the facility's policy contributed to the deficiency.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was at risk for falls, despite multiple incidents of falling. The resident, who had severe cognitive impairment and a history of falls, experienced two falls within a short period. The care plan in place included general fall prevention interventions such as participation in a fall prevention program, reminders to call for assistance, keeping the call light within reach, and supervision. However, after the resident's falls, there was no evidence that the care plan was reviewed or revised to include additional or different interventions tailored to the resident's specific behaviors and needs. Documentation in the medical record and interdisciplinary team (IDT) notes did not address the resident's repeated attempts to transfer without assistance or the falls that occurred. The facility's policy required staff to implement new or different interventions if falls recurred, but this was not done. During interviews, facility leadership confirmed that the care plan was not updated following the falls, and no new interventions were implemented to address the resident's ongoing fall risk.
Unattended Medications Left at Bedside by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) left three unlabeled medications in a clear cup unattended on a resident's bedside table, as observed during a medication pass. The LVN confirmed that the medications should not have been left on the bedside table and acknowledged that they should have been taken back and administered when the resident was ready. Facility policy requires medications to be administered safely and not left unattended, and the Director of Nursing (DON) confirmed that medications should not be left in a resident's room. A self-administration assessment had been completed for the resident, indicating the resident was not capable of self-administering medication.
Failure to Implement Non-Pharmacological Interventions for Antipsychotic Use
Penalty
Summary
The facility failed to provide non-pharmacological interventions for a resident who was prescribed Zyprexa, an antipsychotic medication, upon returning from an acute care hospital. The resident was admitted with a physician's order for Zyprexa to be administered every six hours as needed, which was later changed to four times a day for psychosis manifested by episodes of striking out. Despite the care plan addressing the use of Zyprexa, it did not include any non-pharmacological interventions, which are required to be attempted before or alongside the use of psychotropic medications. The medical record review showed multiple episodes of psychosis, evidenced by striking out, on consecutive days, yet there was no documentation of non-pharmacological interventions being provided. During an interview, the Director of Nursing confirmed the absence of documentation for such interventions and acknowledged that the care plan did not include them. This oversight had the potential to lead to the unnecessary use of psychotropic medications for the resident.
Failure to Provide Timely Catheter Care and Bladder Training
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident was admitted with a catheter, and the facility did not begin documenting catheter care and urine output until seven days after admission, despite physician orders to monitor the catheter every shift. The resident's plan of care included recording the catheter's output, but this was not initiated promptly, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Additionally, the facility did not provide bladder training for the resident, despite a request from the resident's responsible party. The responsible party was informed that bladder training was not possible with the catheter in place, and a urology consultation was requested but not documented as followed up. Interviews with facility staff confirmed the delay in catheter care and the absence of bladder training, highlighting a lack of adherence to the resident's care plan and communication with the responsible party.
Failure to Provide and Maintain Advance Directives
Penalty
Summary
The facility failed to provide information regarding the rights to formulate advance directives and did not obtain or maintain copies of advance directives for two residents. For Resident 586, there was no documentation in the medical record indicating whether an advance directive existed. The resident, who had moderate cognitive impairment, expressed interest in having an advance directive but stated that no one from the facility had discussed this with her. The Social Services Director (SSD) confirmed that the social services staff had not discussed advance directives with Resident 586, despite the facility's policy requiring such discussions upon admission. For Resident 10, the facility did not maintain a copy of the advance directive in the medical record, even though the resident had stated that an advance directive existed and a copy was requested. The SSD acknowledged that the copy should have been in the medical record and admitted to not following up within 48 hours to obtain it, as required by the facility's policy. The absence of the advance directive in the medical record was verified during interviews and concurrent medical record reviews with the SSD.
Failure to Prevent Pressure Injuries Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure injuries for a resident identified as high risk. The resident, who had short and long-term memory problems and was dependent on mobility, was observed sitting in a wheelchair for several hours without being repositioned. The facility's policy required residents in chairs to be repositioned every hour, but this was not adhered to, as the resident remained in the wheelchair from 0745 hours to 1145 hours without repositioning. Interviews with staff revealed a lack of communication and adherence to the care plan. A CNA admitted to placing the resident in the wheelchair and not checking or cleaning the resident for incontinence during this period. The CNA also stated that residents who were total care should be turned every two hours, but this was not done for the resident. An LVN was unaware that the resident had been placed in the wheelchair early and confirmed that the resident should not have been left in the wheelchair for such a long period without repositioning. Further observations showed the resident had blanchable redness on the sacral area and was found with dry fecal matter and a wet diaper, indicating a lack of timely incontinence care. The DON acknowledged the findings and stated that repositioning should be done every two hours or as needed for residents who require assistance with ADL care. The DON also clarified that repositioning on the side is not feasible in a wheelchair, contradicting the LVN's earlier statement about shifting the resident in the wheelchair.
Failure to Monitor Resident's Fluid Intake
Penalty
Summary
The facility failed to adequately monitor the fluid intake of Resident 45, who was under a physician's order for fluid restriction. The medical records and interviews revealed that the facility did not document the resident's fluid intake from the dietary department, which was supposed to be part of the total daily fluid intake. The facility's policy required detailed documentation of fluid intake, including the type and amount of liquid consumed, but this was not adhered to for Resident 45. The resident's Medication Administration Record (MAR) showed fluid intake from the nursing department but lacked records from the dietary department, indicating a gap in monitoring and documentation. Interviews with facility staff, including a CNA and an LVN, confirmed the lack of documentation and awareness regarding the resident's fluid intake from meals. The CNA was unaware of the fluid restriction order and did not report the resident's fluid intake during meals to the nurses. The LVN acknowledged that the MAR only reflected fluid intake from the nursing department and not from the dietary department, leading to incomplete records of the resident's total daily fluid intake. This oversight had the potential to result in fluid overload, negatively impacting the resident's well-being.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, specifically by not maintaining a dialysis emergency kit at the bedside. The resident, who had a permacath access for hemodialysis, did not have the necessary emergency kit available, which is crucial in case of complications such as accidental dislodgement or bleeding. The facility's protocol mandates that a dialysis emergency kit be provided upon admission and maintained at the resident's bedside, a responsibility that falls on the nursing staff. Additionally, the facility did not consistently assess and monitor the resident's dialysis access site. There were multiple instances where the licensed staff failed to document assessments of the dialysis access site before the resident was transported to the dialysis center and upon their return. This lack of documentation included missing assessments from the dialysis center itself. The nursing staff also incorrectly documented the type of dialysis access, either leaving it blank or incorrectly identifying it as a catheter instead of a permacath. Interviews with the LVN and DON revealed that the facility's procedures were not followed, as the dialysis emergency kit was not checked or maintained, and the necessary assessments were not conducted. The DON acknowledged the importance of having the emergency kit available and the need for accurate and timely assessments to prevent confusion and ensure the resident's safety.
Duplicate Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically involving duplicate medication orders with different dosages. Resident 67 had two active orders for guaifenesin, one for a 400 mg oral tablet and another for a 100 mg/5 ml oral liquid, both to be administered as needed for cough and congestion. This duplication posed a risk of medication errors. The issue was identified during a medical record review conducted on February 19, 2025. Interviews with facility staff and the resident's attending physician revealed that the duplicate orders were not intended. The attending physician confirmed that only one order was desired and suggested that the previous order was not discontinued as it should have been. The pharmacist also noted that they had only received the order for the guaifenesin oral tablet and not for the geri-tussin, which was a stock item. The Director of Nursing was informed of these findings and acknowledged the issue.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
The facility failed to ensure the safe and proper storage and labeling of medications and medical supplies. During an inspection of the treatment cart, it was observed that single-use dressings, such as Steri-Strips, hydrocolloid dressings, hydrofera blue, and xeroform gauze, were opened and partially used, despite being intended for single use only. Additionally, a used Santyl ointment, which belonged to a discharged resident, was found without a label. The treatment cart also contained drawers with dark brownish residue and dust-like particles. These findings were confirmed by LVN 9, who acknowledged that the unused supplies should have been discarded. The facility also failed to discard expired Covid testing kits, with several boxes found to have passed their expiration dates. RN 1 confirmed the presence of these expired kits. Furthermore, Resident 54 was found to have a medication cup with a white pasty cream and a bottle of Adapt stoma powder in their nightstand, without any physician's orders for their use. CNA 8 and RN 6 verified these findings, indicating a lack of proper oversight and documentation for the use of these medications.
Deficiencies in Monitoring and Care for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 336 and Resident 45, which impacted their physical well-being. For Resident 336, the facility did not monitor the resident's pacemaker, as there was no documented evidence of follow-up on the pacemaker information. Additionally, the facility did not accurately assess and document the resident's skin condition upon admission, as the resident was admitted with a surgical wound with staples that were not properly assessed. The facility also failed to obtain a physician's order before applying Steri-Strips to the surgical site after staple removal and did not develop a care plan to monitor the surgical site or address the removal of the staples. Resident 336's medical record lacked documentation of monitoring after the removal of the staples, and there was no follow-up with the appointment clinic for further orders. Interviews with LVNs 9 and 10 confirmed these findings, revealing that the initial skin assessment was incomplete and that the application of Steri-Strips was done without a physician's order. Furthermore, RN 4 verified that the pacemaker was not monitored, and there was no follow-up on the pacemaker information. For Resident 45, the facility failed to complete laboratory tests for CBC, Chem 7, and magnesium levels as ordered by the physician. The medical record showed no evidence of these tests being conducted or followed up. Additionally, the facility did not correctly monitor Resident 45's orthostatic blood pressure, as the same blood pressure readings were documented for different positions. LVN 12 confirmed that the laboratory tests were not signed off in the MAR and that there was no documentation of follow-up for the tests or the orthostatic blood pressure readings.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents, as observed during a survey. Resident 686 was found using oxygen via nasal cannula at a rate of 4 liters per minute without a physician's order. This was confirmed by LVN 6, who acknowledged the absence of a physician's order in the resident's electronic health record or paper medical record, despite the resident receiving continuous oxygen therapy since the morning. Resident 336 was observed receiving continuous oxygen at a rate of 2 liters per minute via nasal cannula, also without a physician's order. Additionally, there was no 'Oxygen In Use' sign posted outside the resident's room, and the resident's care plan did not address the use of oxygen. MDS Coordinator 2 confirmed these findings. A follow-up observation revealed that the oxygen was being administered at a rate of 2.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute. Resident 67's nebulizer tubing was not labeled with the resident's name and date, as required by the facility's policy. The nebulizer mask and tubing were found inside a plastic bag on the nightstand without proper labeling. LVN 4 verified the lack of labeling and acknowledged the need for replacement and labeling. The DON was informed of these findings, which highlighted the facility's failure to adhere to its own policies and procedures regarding respiratory care.
Deficiencies in Staff Competency and Training Documentation
Penalty
Summary
The facility failed to ensure the competency of two licensed nurses, LVN 12 and the ADON, regarding bladder training for a resident with an indwelling urinary catheter. Despite a physician's order for bladder training, the facility did not provide such training, and the staff were not able to demonstrate competency in this area. The ADON and LVN 10 both stated that bladder training was not conducted at the facility, and the ADON was unsure why it was not done. The DON mentioned that if there was a physician's order for bladder training, it should be done by clamping and unclamping the catheter, but this was not implemented. Additionally, the facility failed to provide training materials for in-service trainings, which are essential for ensuring staff competency. The Education/Training Attendance Record showed that LVN 12 attended the training, but the ADON did not. The facility's policy and procedure for the Bowel and Bladder Training Program did not include procedures for bladder training with an indwelling urinary catheter. The DSD confirmed that there were no training materials available, which should have included teaching objectives and competency assessment methods. Furthermore, the facility did not complete the annual performance evaluation for LVN 5, as required by their policy. LVN 5's last performance appraisal was over a year ago, and the DSD verified that the evaluation was not conducted. The DON acknowledged that performance evaluations are necessary to assess the quality of an employee's work and determine if improvement is needed.
Failure to Ensure Proper Informed Consent and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 336, the facility did not obtain the physician's signature on the informed consent for zolpidem, a hypnotic medication prescribed for insomnia. Additionally, there was a discrepancy in the monitoring documentation for hours of sleep related to zolpidem use, as the records showed zero hours of sleep but also zero episodes of inability to fall asleep on the same date. This inconsistency was verified by RN 4 during an interview and medical record review. For Resident 1, the facility did not renew the informed consent for clonazepam, an antianxiety medication, as required by their policy and state regulations. The last consent was obtained in August 2024, and the medication continued to be administered daily without a renewed consent. This oversight was confirmed by RN 3 and the Director of Nursing (DON) during interviews. The failure to renew informed consent and ensure proper documentation could lead to unnecessary use and ineffective monitoring of psychotropic medications, potentially affecting the residents' well-being.
Sanitation Deficiencies in Kitchen Utensils and Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by unclean kitchen utensils and equipment. During an inspection, it was observed that several kitchen utensils, including cutting knives, a serving fork, a slotted serving scoop, and a dough cutter, were dirty with dry food residue and fuzzy stains. These findings were confirmed by the Registered Dietitian (RD), who acknowledged that the utensils should have been stored clean to prevent infection. The facility's policy on dishwashing, which requires all dishes to be properly sanitized and free of gross food particles, was not adhered to, posing a risk of cross-contamination and foodborne illnesses to the residents. Additionally, the facility did not ensure that kitchen utensils were in good condition. A white basting brush was found to be worn out with frayed bristles, which was verified by the RD. According to the USDA Food Code, utensils must be maintained in a state of good repair and should not allow the migration of deleterious substances to food. The failure to replace the worn-out basting brush with a new one, despite having it available, further highlights the facility's non-compliance with sanitary standards. These deficiencies affected the majority of the residents, as 80 out of 86 consumed food prepared in the facility's kitchen.
Inaccurate and Incomplete Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to potential gaps in care. For instance, Resident 2's Advance Directive Acknowledgement contained incorrect information, and the POLST did not reflect the absence of an advance directive. Similarly, Resident 40's medical records were incomplete, with missing documentation for medication administration and advance directive details. These inaccuracies were acknowledged by the facility's staff, including the SSD and DON, during interviews. Resident 10's MAR lacked documentation for monitoring adverse reactions to anticoagulant use, Covid symptoms, and pain scale assessments. This oversight was confirmed by LVN 12, who admitted to missing the documentation. Resident 20's MAR was also incomplete, missing records of monitoring for adverse reactions to various medications and the application of prescribed treatments. LVN 3 confirmed the monitoring was done but not documented. Additional deficiencies were noted for other residents, such as Resident 68, whose TAR did not show evidence of completed perineal treatment, and Resident 586, whose IV site monitoring was not documented. Resident 336's records contained incorrect personal information, and Resident 51's narcotic sheet was inaccurately recorded. These documentation failures were verified by facility staff, including LVNs and the DON, highlighting a systemic issue with record-keeping practices at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in their infection control practices. The facility did not implement their infection control surveillance program for three consecutive months, failing to accurately identify healthcare-associated infections (HAIs) and community-acquired infections (CAIs) according to the McGeer criteria. The infection control data presented to the infection control meeting was neither accurate nor complete, and the facility's mapping of infections was incomplete, only including influenza and RSV infections. Additionally, the Fourth Quarter Microbiology Report was incomplete, missing data from one of the acute care hospitals and the facility itself. The facility also failed to adhere to proper hygiene and infection control practices in several instances. A laundry aide was observed transporting an uncovered linen cart with residents' clothing and blankets, contrary to the facility's policy requiring clean linen to be protected during transport. Furthermore, an LVN did not perform hand hygiene during a wound care treatment for a resident, failing to wash hands between glove changes and after moving from a soiled to a clean body site, which is against the facility's hand hygiene policy. Additionally, a resident was observed using oxygen via a nasal cannula, with the tubing touching the inside of a trash can and the floor, posing a risk for infection. This was confirmed by an LVN, who acknowledged that the nasal cannula tubing should not be in contact with the floor. These failures collectively posed a risk for not identifying infections and controlling the transmission of communicable diseases within the facility.
Failure to Provide Personal Inventory List to Resident
Penalty
Summary
The facility failed to ensure that a resident's personal belongings inventory process was completed accurately for one of the sampled residents. Specifically, the facility did not provide a copy of the personal inventory list to the resident upon admission. The facility's policy and procedure, dated 2001, required that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. However, during a medical record review for the resident, it was found that the triplicate copies of the inventory form, which included a pink copy meant for the resident, were still intact and not given to the resident. Interviews with facility staff, including MDS 2 and the DON, confirmed that the personal inventory list was completed during admission to keep track of the resident's belongings. MDS 2 verified that the pink copy of the inventory list, dated 1/8/25, was not provided to the resident. The DON acknowledged that the facility's process required the resident to receive a copy of the inventory list upon admission, readmission, and when new belongings were received. This oversight had the potential to result in the resident's personal belongings not being accurately accounted for.
Specimen Refrigerator Temperature Deficiency
Penalty
Summary
The facility failed to maintain the resident's specimen refrigerator in safe operating condition. During an inspection and interview with an RN, it was observed that the specimen refrigerator's temperature was 28 degrees F, which is below the required range of 36-46 degrees F. Additionally, there was ice build-up in the freezer compartment of the refrigerator. The facility's Specimen Refrigerator Temperature Log for February 2025 indicated that the temperature should be between 36F-46F, and the latest recorded temperature on 2/19/25 was 36 degrees F. The RN acknowledged and confirmed these findings. The Director of Nursing (DON) was informed and acknowledged the findings during a subsequent interview.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy for Resident 40 during a medication administration procedure. On February 20, 2025, at 0830 hours, an observation was conducted where LVN 5 administered medication via a gastrostomy tube (GT) to Resident 40 without pulling the privacy curtain by the bed or the curtain of the sliding door. This left Resident 40 exposed to the outside patio and rooms across the patio. During the procedure, LVN 5 lifted Resident 40's gown, exposing the stomach area and a portion of the diaper. LVN 5 acknowledged the oversight when reminded to provide privacy. Resident 40 had short and long-term memory problems, as noted in the medical record review. The Director of Nursing (DON) was informed of the incident and acknowledged the findings, emphasizing the importance of maintaining resident privacy during such procedures.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was provided with a written or verbal notice of the facility's bed hold policy upon transfer to an acute care hospital. This deficiency was identified during a review of closed records for a resident who was transferred to the hospital. The facility's policy requires that residents and their representatives be informed of the bed hold policy in writing at least twice: once in advance of any transfer and again at the time of transfer. However, in this case, the documentation showed that while the resident's representative signed the bed hold notification form upon admission, the sections for confirmation of transfer and bed hold provision were left blank, indicating a failure to notify at the time of transfer. The resident involved was admitted to the facility and later transferred to an acute care hospital. The resident was noted to be alert and capable of making her own decisions prior to the transfer. Despite this, there was no documented evidence in the medical record that the resident or her representative was notified of the bed hold provision when the transfer occurred. An interview with the Assistant Director of Nursing (ADON) confirmed these findings, and it was stated that the licensed nurses were responsible for notifying the resident and/or their representative of the bed hold provision and completing the notification form at the time of transfer.
Failure to Revise Care Plan for Resident Refusing Sling
Penalty
Summary
The facility failed to revise the care plan for a resident who refused to wear a physician-ordered sling on her right upper extremity (RUE). The resident, who was admitted with a diagnosis of an unspecified fracture of the upper end of the right humerus, had a physician's order dated December 22, 2024, to wear a sling while out of bed. Despite this order, observations on February 18 and 19, 2025, showed the resident sitting in a wheelchair without the sling. During an interview on February 24, 2025, the resident confirmed she was aware of the order but chose not to wear the sling, stating that the physician had told her it was not necessary. The Assistant Director of Nursing (ADON) verified the physician's order and acknowledged that the resident should have been using the sling. However, the ADON noted that the resident had a tendency to remove it. The facility's policy and procedure (P&P) require that care plans be revised as residents' conditions change, but the resident's care plan was not updated to reflect her refusal to wear the sling. This oversight posed a risk of not providing appropriate, consistent, and individualized care to the resident.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to ensure that performance evaluations were completed every 12 months for one of the two Certified Nursing Assistants (CNAs) whose employee files were reviewed. Specifically, CNA 7, who was rehired on October 18, 2022, did not have documented performance evaluations for the past two years. This oversight was confirmed during an interview and personnel record review with the Director of Staff Development (DSD), who acknowledged the lapse and stated that it was her responsibility to conduct these evaluations. The DSD, who began her role in January 2025, had not yet reviewed all CNAs' personnel records. The Director of Nursing (DON) also confirmed that performance evaluations were supposed to be conducted annually to assess the quality of employees' work performance and identify areas needing improvement.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, specifically regarding the use of dental appliances and coordination of a dental consult. The resident, who was readmitted to the facility, did not have his lower dentures, which were necessary for eating. Despite the care plan indicating the need for dental appliances to be in good repair and in place for meals, and for social services to follow up on dental consults, these actions were not taken. The Director of Nursing (DON) confirmed that the resident's lower dentures were missing since readmission and that a dental consult had not been arranged. Additionally, the facility did not develop a care plan to address the resident's hard of hearing status. The resident expressed difficulty hearing and a desire to try hearing aids. Documentation in the medical record indicated the resident's hearing issues, but no specific care plan was initiated to address this. The DON acknowledged that a care plan should have been created when the speech-language pathologist documented the resident's hearing difficulties.
Failure to Provide Dental Services and Investigate Missing Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident, specifically in assisting with obtaining lower dentures after the resident's readmission. The resident, who was at risk for nutritional issues due to recent infection and hospitalization, had a care plan that included ensuring dental appliances were in good repair and in place for meals. Despite this, the resident did not have his lower dentures since readmission, which were noted to be ill-fitting and a choking hazard during a hospital evaluation. The facility did not conduct a loss or theft investigation regarding the missing lower dentures, nor did it coordinate a dental consult for the resident. Interviews with the resident and staff confirmed that the lower dentures were missing since the resident's readmission, and the resident expressed difficulty eating without them. The social services staff, responsible for coordinating dental services, acknowledged awareness of the missing dentures but had not initiated an investigation or dental consult. The facility's policies and procedures for dental services and investigating theft or misappropriation of resident property were not followed. The social services staff did not interview relevant parties or attempt to locate the dentures, and there was no documentation of efforts to ensure the resident could eat adequately while awaiting dental services. These oversights had the potential to negatively impact the resident's well-being.
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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