Desert Mountain Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indio, California.
- Location
- 47-763 Monroe Avenue, Indio, California 92201
- CMS Provider Number
- 555742
- Inspections on file
- 35
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Desert Mountain Care Center during CMS and state inspections, most recent first.
A resident with respiratory failure, muscle weakness, CHF on diuretics, impaired mobility, and a tracheostomy was care planned for occasional bladder incontinence with use of briefs and checks "as required," but had no toileting program despite being frequently incontinent and able to ambulate and make her own decisions. The resident reported delays in staff response to call lights, attempted to toilet independently, lost balance, fell, and soiled herself. Documentation showed she had balance problems, decreased coordination, and required assistive devices, yet a bowel and bladder evaluation labeled her an unlikely candidate for retraining, and the MDS reflected no toileting program. The DON later acknowledged the resident should have been re-evaluated for a bowel and bladder toileting program, despite a facility policy requiring bowel/bladder retraining and care plan inclusion for residents with potential to benefit.
A resident with chronic pain from osteoarthritis and fibromyalgia received PRN Dilaudid despite a documented pain score of 0/10, contrary to the physician’s order limiting use to pain levels of 4–10. The MAR showed multiple such administrations, and the ADON confirmed staff should not give PRN opioids when pain is 0/10. Additionally, a physician-ordered pain management consult for uncontrolled pain was not successfully scheduled for months, with progress notes reflecting repeated calls that only reached voicemail and no completed appointment, while the resident reported ongoing pain and an unmet request to see a pain specialist.
Surveyors found that two mechanical lifts with identified or suspected problems remained on the floor and one was used for resident transfers despite visible Coban wrapped around its casing and another being labeled as not working. CNAs and an LVN reported they used one of the lifts without noticing or questioning the Coban, and the DON acknowledged the lift should not have been in use and that this posed a safety problem. The Director of Maintenance confirmed there were no TELS work orders or maintenance requests for either lift, even though facility policy requires routine inspection, documentation, and removal from service when equipment is not working properly.
Surveyors found that the facility did not maintain a safe and sanitary environment when laminate flooring in a main hallway was deformed with multiple raised areas, which staff, including a CNA and the DON, acknowledged as a tripping hazard. A maintenance staff member stated the bubbles in the flooring could result from inadequate glue during installation. In addition, a resident room previously affected by roof leaks had a cracked, lumpy ceiling with possible water damage and cracked, chipped paint directly above a resident’s bed. These conditions did not comply with the facility’s maintenance policy requiring smooth, dry, and cleanable floor, wall, and ceiling surfaces without cracks.
Surveyors found that discontinued IV fluids, antibiotics, and oral medications remained accessible in medication storage areas, and that staff did not consistently follow physician orders for medication administration and lab testing. For example, a resident received midodrine despite blood pressure parameters indicating the dose should be held, and another resident did not receive Hgb A1c testing at the ordered intervals for diabetes management. These issues were confirmed by staff interviews and record reviews.
Wooden shelves in the kitchen's dry goods supply area were found to be chipped, splintered, and had peeling varnish, exposing bare wood. Staff and dietary leadership acknowledged the risk of staff injury and possible cross-contamination of food, and the Registered Dietician had previously reported the issue to facility management. The facility's food storage policy requiring cleanable shelving was not followed.
A resident was found with two open containers of zinc oxide ointment on the overbed table and reported self-applying the ointment as needed. Review of records showed no documented assessment for safe self-administration, despite facility policy requiring interdisciplinary evaluation and physician authorization. Nursing staff confirmed the absence of assessment and acknowledged that medications should not be kept at bedside without proper evaluation.
A saline nasal spray was discovered on a medication cart without any labeling to identify the intended resident. An LVN confirmed the absence of a name or room number on the bottle or box and stated that proper labeling was required to ensure correct administration. Facility policy requires all prescription medications to be labeled with the resident's name and prohibits sharing medications between residents.
A resident with missing upper teeth and a tracheostomy requested upper dentures on multiple occasions, but the facility failed to follow up on her dental needs. Despite documentation of her requests and recommendations from the dentist, there was no evidence that Social Services or Nursing pursued her eligibility for dentures, and staff interviews confirmed the lack of follow-up.
Two residents with documented dislikes for pork were served meals containing pork, despite their preferences being clearly indicated on their dietary meal tickets. Both residents were cognitively intact and had relevant medical conditions, including end-stage renal disease, diabetes, and dysphagia. Dietary staff and the RD confirmed that food preferences should have been honored, and facility policy required alternate menu items to be provided for disliked foods.
Two residents with complex medical needs were affected by lapses in infection control practices: a stand fan in one room was found with accumulated dust, and a used plastic urinal was improperly stored in another resident's closet. Staff interviews confirmed that these actions did not follow facility policies for cleaning and storage, increasing the risk of contamination.
Two residents used wheelchairs with unresolved safety and maintenance issues, including non-functioning brakes, loose wheels, and cracked upholstery. Despite reports and assessments by staff, the necessary repairs and replacements were not completed, resulting in continued use of unsafe equipment and potential infection control concerns.
A resident with respiratory failure and hypoxia experienced critically abnormal vital signs, including elevated pulse and low O2 saturation, but staff did not promptly notify the physician or closely monitor the resident as required. Despite repeated abnormal findings and refusal of oxygen therapy, there were significant gaps in assessment and escalation, and no timely follow-up to ensure physician evaluation, contrary to facility policy and staff expectations.
Housekeeping staff, without prior training in behavioral health or 1:1 supervision, were assigned to monitor a resident with severe cognitive impairment and wandering behavior. Despite physician orders and care plan interventions requiring 1:1 supervision, these staff members were not trained before being assigned, and the facility lacked a policy for managing residents needing sitters. The DON and DSD confirmed the lack of training and policy.
A resident with severe dementia and a history of wandering did not consistently receive the required 1:1 supervision as ordered by the physician and outlined in the care plan. Staff interviews and documentation revealed multiple shifts where no assigned sitter was present, and supervision was informally shared among staff or assigned to non-clinical personnel. Facility records confirmed gaps in direct supervision, and leadership acknowledged the lack of a formal policy for managing residents needing a sitter.
During an infectious disease outbreak, a CNA was observed exiting a resident's room, removing gloves, touching a linen cart, and re-entering the room without performing hand hygiene. Staff interviews and policy review confirmed that hand hygiene was required before and after resident contact and after touching potentially contaminated surfaces, but these procedures were not followed.
A resident with diabetes had a blood sugar reading of 403 mg/dl, which exceeded the threshold in the physician's order requiring notification. The physician was not notified as required, and this was confirmed through record review and staff interview. The resident also expressed dissatisfaction with their care.
During an unannounced visit, surveyors found that three direct care staff members, including a CNA and two LVNs, were wearing artificial nails, contrary to the facility's infection control policy. The staff acknowledged the risk of bacterial transmission associated with artificial nails, and the Infection Preventionist confirmed that such nails are prohibited for staff providing direct care. This breach occurred despite the facility's policy discouraging artificial nails to prevent infection spread.
A resident with a history of altered mental status and high risk for elopement was able to leave the facility undetected due to a door alarm not being activated. The Director of Staff Development forgot to turn on the alarm after using the door, and staff interviews confirmed the alarm should always be on to prevent such incidents. The resident had previously attempted to leave the facility, highlighting the importance of maintaining active alarms.
A resident with intact cognition eloped from the facility unsupervised to visit a bank and post office, resulting in minor injuries. The facility failed to report the incident to the CDPH within the required 24-hour timeframe, as per their policy on unusual occurrences.
The facility failed to maintain a comfortable environment as room temperatures exceeded acceptable levels due to malfunctioning air conditioning units. Despite temporary cooling measures, residents experienced discomfort, and the issue was not reported to the California Department of Public Health as required. Additionally, the facility's carpets were observed to be dirty with persistent stains, affecting the overall cleanliness and homeliness of the environment.
Two residents experienced delays in receiving incontinent care, with one resident left wet for over 10 minutes and another waiting over 30 minutes for assistance. Both residents had the capacity to make decisions and expressed dissatisfaction with the care delays. The facility's policies on timely care were not followed, as observed during the survey.
The facility failed to maintain environmental conditions to prevent insects from entering, as observed during an unannounced visit. Issues included a missing window screen, tears and gaps in other screens, and entrance and exit doors with gaps. The Maintenance Supervisor and Director of Nursing confirmed these deficiencies, which violate the facility's policy requiring intact window screens and properly functioning doors.
A resident's wounds were not assessed and treated within the required timeframe, leading to a delay in care. The facility's policy requires a comprehensive admission assessment and timely wound assessment and treatment, but the resident's wounds were not measured and treated until the third day after admission.
Failure to Implement Toileting Program for Continent/Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to restore or maintain bladder continence for a resident who was frequently incontinent and able to make her own decisions. The resident, admitted with respiratory failure with hypoxia, muscle weakness, and a tracheostomy, had care plans noting diuretic therapy for CHF with increased fall risk and occasional bladder incontinence related to COPD, respiratory failure, impaired mobility, and obesity. Her care plan interventions included use of a brief per her request, maintaining an unobstructed path to the bathroom, and checking her when incontinent "as required." A Bowel and Bladder Evaluation documented that she was an unlikely candidate for bowel and bladder retraining, and the MDS later documented that she did not have a toileting program and was frequently incontinent with bladder. The resident reported that it could take a while for staff to respond when she called for assistance, and that she attempted to take herself to the bathroom, lost her footing, fell, and soiled herself. A Change in Condition Evaluation documented that she was found on the floor after attempting to go to the bathroom unassisted, with pain in her lower back and right wrist, and that she stated she lost her balance and landed on her backside. A Fall Risk Evaluation identified balance problems while walking, decreased muscular coordination, and the need for assistive devices. The DON acknowledged that the resident fell when she went to the bathroom by herself and stated that the resident should be re-evaluated for a toileting program, as she had been in the facility a long time, could ambulate, and could be a candidate for a bowel and bladder toileting program. The facility’s own toileting program policy required bowel and bladder retraining for residents with potential to benefit and directed that toileting programs be addressed on the care plan and reassessed at least quarterly and as needed.
Failure to Follow PRN Pain Orders and Arrange Timely Pain Management Consult
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain conditions, including bilateral hip osteoarthritis with artificial hip joints and fibromyalgia. The physician had ordered pain to be monitored using a 0–10 scale, Dilaudid 8 mg PO every three hours as needed for moderate to severe pain rated 4–10, and Morphine ER 15 mg PO twice daily for pain management. The resident’s care plan identified acute pain with interventions to give medications as ordered and monitor pain levels. However, review of the Medication Administration Record showed that Dilaudid, which was ordered only for pain levels of 4–10, was administered on multiple occasions when the documented pain level was 0/10, indicating no pain at the time of administration. The ADON confirmed that licensed staff should evaluate pain before administering PRN pain medication and that the resident should not receive PRN pain medication when pain is 0/10. The facility also failed to ensure timely follow-through on a physician’s order for a pain management consultation due to uncontrolled pain. The order for a pain consult was written in late October 2025, but the resident had not yet been seen by a pain management specialist at the time of the survey. Progress notes showed repeated attempts to contact the pain clinic, with staff reaching only voicemail on several occasions and no documented successful scheduling of an appointment. During interview, the resident reported generalized pain, difficulty moving, and stated she was supposed to receive Dilaudid every three hours but felt it was not being given as ordered, and that her request to see a pain doctor had not yet been fulfilled. The ADON acknowledged that the pain management consult ordered months earlier had not resulted in an appointment and that the resident’s pain management needed to be re-evaluated.
Unsafe Mechanical Lifts Left in Use Without Maintenance or Removal From Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure mechanical lifts used for resident transfers were maintained in safe operating condition and removed from service when potentially unsafe. During an unannounced complaint visit focused on the physical environment, surveyors observed mechanical lift #7 with Coban wrapped around its casing while it remained in use on the unit. A CNA stated the lift might be broken and should not be used, and the DON confirmed the lift should not be wrapped with Coban or in use and identified this as a safety problem. Another mechanical lift in the same hallway was labeled with a sign stating it was “not working,” yet it remained on the floor rather than being removed from service. Staff interviews showed that CNAs and an LVN had recently used mechanical lift #7 for resident transfers without noticing or questioning the Coban wrapped around the equipment. CNA 3 and LVN 1 both acknowledged the lift should not have been used and that they did not investigate the Coban or report a potential problem. The Director of Maintenance later reviewed monthly inspection logs and the TELS work order system and confirmed there were no work orders or maintenance requests for either of the two lifts in question, despite the facility’s written policy requiring routine inspections, documentation in the preventive maintenance log or TELS, and daily review of maintenance requests. This sequence of observations and interviews demonstrated that two lifts with identified or suspected problems remained on the floor and in use without being removed from service or entered into the maintenance system as required by facility policy.
Failure to Maintain Safe Flooring and Intact Ceilings After Water Damage
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, and sanitary environment in Hallway 100 and in a resident room. During an unannounced complaint investigation, staff interviews and observations revealed that the flooring in Hallway 100 was deformed with multiple raised areas or “bumps.” A CNA stated the floor was not safe for residents or staff because someone could trip and fall. The DON also observed the hallway flooring and acknowledged that it should not have bumps and that this condition was a safety hazard. The Maintenance Assistant explained that the laminate flooring could develop bubbles if insufficient glue was used during installation and agreed that this condition posed a tripping hazard, indicating that the affected tiles would need to be removed and replaced. Surveyors also observed a ceiling defect in a resident room that had previously experienced water damage from roof leaks. The DON and Director of Maintenance reported that there had been multiple roof leaks in the facility in November and December, with one leak affecting a resident room where drywall had been cut and repaired. During observation with the Maintenance Assistant, the ceiling in the identified room was noted to have a crack from prior water damage and was described as needing to be repatched, while a resident lay in bed beneath the cracked area. In a later observation with the resident, the ceiling was described as lumpy with possible water damage, and the paint was cracked and chipped. The facility’s maintenance policy required maintaining a clean and safe facility, including floor, wall, and ceiling surfaces that are smooth, dry, and cleanable, and stated that any cracks may harbor bacteria, which was not met in these observed conditions.
Failure to Remove Discontinued Medications and Follow Physician Orders for Medication Administration and Lab Testing
Penalty
Summary
The facility failed to ensure proper provision of pharmaceutical services to meet the needs of residents, as evidenced by the improper storage and handling of discontinued medications and failure to follow physician orders. During inspections, surveyors observed four discontinued bags of 0.45% normal saline and one discontinued IV bag of vancomycin stored in the medication room and refrigerator, respectively, despite being no longer needed for the residents for whom they were ordered. Additionally, a discontinued blister card of ondansetron and a discontinued blister card of generic Norco were found in the medication cart, available for use, even though both medications had been discontinued by physician order. Staff interviews confirmed that these medications should have been removed and stored separately or discarded according to facility policy. Further review of medication administration practices revealed that midodrine was administered to a resident with heart failure, chronic kidney disease, and hypertension, even when the resident's systolic blood pressure exceeded the physician-ordered parameter to hold the dose if above 120 mmHg. The Medication Administration Record showed that the medication was given on two occasions when the blood pressure was above the specified threshold, contrary to the physician's instructions. The Assistant Director of Nursing acknowledged that these doses should not have been administered. Additionally, the facility failed to consistently obtain laboratory tests as ordered for a resident with adult-onset diabetes mellitus. The physician had ordered Hgb A1c tests every three months to monitor diabetes management, but there were missed intervals where the test was not completed as required. The Assistant Director of Nursing confirmed that the tests were not performed every three months as ordered. These findings demonstrate failures in medication management, adherence to physician orders, and compliance with facility policies.
Unsanitary Food Storage Shelving in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen's dry goods supply area. Specifically, wooden storage shelves were found to be chipped, splintered, and had peeling lacquered varnish, exposing bare wood. During an observation with the Dietary Supervisor (DS), it was noted that staff wore gloves to avoid splinters when accessing food items, indicating an awareness of the risk of staff injury. The Plant Director (PD) confirmed that the shelves should not be in such a condition due to the potential for staff injury and cross-contamination of food. The Registered Dietician (RD) reported being aware of the damaged shelving and had previously notified both the PD and the Administrator about the issue. The facility's policy on food storage requires that all food items be stored on shelves that facilitate thorough cleaning, which was not met due to the condition of the shelves. No specific residents were mentioned as being directly affected at the time of the deficiency, but the report notes the potential for food-borne illness in a highly susceptible resident population.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A facility failed to ensure that an assessment for safe self-administration of medication was conducted for a resident when two open containers of topical ointment were found on the resident's overbed table. During observation and interview, the resident stated she applied the ointment to her lower legs when she felt itchy and would use more if she wanted. The containers were labeled as zinc oxide 25%. Review of the resident's admission record showed a history of infectious and parasitic diseases, and a history and physical indicated the resident was mentally capable of making decisions. However, there was no documented evidence that a self-administration assessment had been completed. A registered nurse confirmed that no assessment for self-administration of medications had been conducted for the resident, and stated that it was not safe for the resident to have medications at the bedside without such an assessment. The assistant director of nursing stated that licensed nurses were expected to follow the facility's policy and procedure regarding self-administration assessment and medication administration. Facility policy required an interdisciplinary team assessment and periodic re-evaluation for residents wishing to self-administer medications, and that self-administration was only allowed when specifically authorized by the attending physician. These procedures were not followed in this instance.
Unlabeled Medication Found on Medication Cart
Penalty
Summary
During an inspection of Medication Cart Rx 2, a saline nasal spray was found that was not labeled with the name or room number of the resident for whom it was intended. The LVN present confirmed that there was no identifying information on either the spray bottle or its manufacturer box and acknowledged that the medication should have been labeled with the resident's name. The LVN also stated that, without the name on the medication, she would not know which resident the medication was for. Review of the facility's policies confirmed that prescription medication labels are required to include the resident's name and that medications supplied for one resident are never to be administered to another resident.
Failure to Follow Up on Dental Needs for Resident Requesting Dentures
Penalty
Summary
The facility failed to follow up on the dental needs of a resident who was missing upper teeth and expressed a desire to receive dentures. The resident, who had a tracheostomy and was able to make her own decisions, reported that she had requested to be seen by the facility dentist but was not updated on whether she would receive dental services. Record review showed that the resident's oral assessment at admission indicated she was unable to function without natural teeth and dentures, and subsequent nutrition evaluations noted several missing teeth. Dental notes documented that the resident requested upper dentures on two separate occasions, with recommendations to check eligibility for a full upper denture, but there was no documented evidence of follow-up by Social Services or Nursing regarding her eligibility. Interviews with facility staff, including a registered nurse, the Social Service Director, and the Director of Nursing, confirmed that no follow-up was conducted for the resident's dental requests. Staff acknowledged that the dental requests should have been followed up and that failure to do so could delay dental care services. Review of facility policies indicated that the facility is responsible for ensuring residents have access to needed dental services and that Social Services is responsible for scheduling such appointments, but these procedures were not followed in this case.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to honor the documented food preferences of two residents during a lunch meal service. One resident, who had a documented dislike of pork on his meal ticket, was observed eating a substitute burrito after being served a main entrée containing pork. The resident stated he disliked pork and frequently received it despite his preference being noted. Review of his record showed he was cognitively intact and had diagnoses including end-stage renal disease and diabetes. An LVN confirmed that pork should not have been served, and the kitchen staff should have followed the diet slip instructions. Another resident, also with a documented dislike of pork and a history of dysphagia, was observed eating a meal that included chopped pork. The resident consumed only a few bites of the pork and stated a dislike for it. Both residents' meal tickets clearly indicated their dislike for pork, and the facility's policy required adherence to food preferences and provision of alternate menu items as dictated by resident dislikes. The Registered Dietician confirmed that residents' preferences and dislikes are to be printed on meal tickets to guide dietary staff, and that the residents should not have been served pork.
Infection Control Lapses in Equipment Cleaning and Urinal Storage
Penalty
Summary
The facility failed to implement proper infection control practices in two separate instances. In the first case, a black stand fan in a resident's room was observed with accumulated black and gray dust on both the front and back guard covers. Both a CNA and a respiratory therapist confirmed that the fan was dusty and should have been cleaned. The resident in this room had a history of respiratory failure with a tracheostomy and was on enhanced barrier precautions due to a gastric tube and trach. Facility staff, including the infection preventionist and assistant director of nursing, acknowledged that dust on equipment could contribute to the spread of germs and potentially cause respiratory infections, especially for residents with tracheostomies. In the second instance, a used plastic urinal was found inside another resident's personal belongings storage closet. The CNA present stated that the urinal should not have been placed on the closet shelves and should have been stored in a urinal holder or discarded if not in use. The resident involved had diagnoses including kidney failure, malignant melanoma, and abdominal surgical dehiscence, and also had a trach. Both the LVN and infection preventionist confirmed that improper storage of urinals could lead to surface contamination and the spread of infection. The DON stated that proper storage procedures were expected to be followed according to facility policy. Facility policies reviewed indicated requirements for maintaining clean and sanitary equipment and resident rooms, including damp wiping surfaces with germicidal solution and proper storage of bedpans and urinals. The observed failures to clean the fan and properly store the urinal were not in accordance with these policies and procedures.
Failure to Maintain Safe Wheelchair Equipment for Residents
Penalty
Summary
The facility failed to maintain wheelchairs in safe operating condition for two residents. For one resident with spinal stenosis, joint replacement aftercare, and diabetic neuropathy, the wheelchair had multiple issues including a non-functioning left brake, a loose and wobbly left armrest, and a right wheel with a missing metal hand rim that left sharp edges exposed. The resident reported these problems, describing the situation as dangerous. The Plant Director confirmed the need for parts replacement and acknowledged that the cracked upholstery posed an infection control risk and that the broken metal and inoperative brake could result in injury. The Physical Therapy Assistant also confirmed the issues and stated that a work request had been submitted for repairs, but a suitable replacement wheelchair was not available. Another resident with osteoarthritis, right knee pain, and hemiplegia reported that their wheelchair, though previously repaired, remained shaky with a loose left wheel and cracked, peeling upholstery on the left armrest. The resident had reported these issues, and the Plant Director, upon assessment, agreed that parts replacement was needed. The cracked upholstery was again identified as an infection control issue, and the loose wheel was recognized as a risk for injury. Facility policy requires equipment to be maintained in good working order for resident safety and for staff to communicate specific accommodation needs, but these requirements were not met in these cases.
Failure to Provide Timely Care and Physician Notification for Change in Condition
Penalty
Summary
A resident with a history of respiratory failure and hypoxia experienced a significant change in condition, including an elevated pulse rate and decreased oxygen saturation. On multiple occasions, the resident was found with abnormal vital signs, such as a pulse ranging from 107 to 163 beats per minute and oxygen saturation levels as low as 65%. Despite these findings, there was no timely notification to the physician regarding the resident's deteriorating condition, and vital signs were not closely monitored at the recommended intervals. Documentation shows gaps in monitoring, with several hours passing between assessments, and a lack of consistent follow-up on the resident's status. The nursing staff did not notify the physician when the resident was found unresponsive with critically low oxygen levels and an elevated pulse. Subsequent assessments continued to show abnormal vital signs, but the physician was still not informed in a timely manner. The resident also refused oxygen therapy and transfer to the emergency room, but there was no evidence of persistent or immediate escalation to the physician or further intervention until much later. The facility's own policy required prompt assessment, physician notification, and close monitoring in the event of a change in condition, but these steps were not followed as documented in the records and confirmed by staff interviews. Interviews with facility leadership and nursing staff confirmed that the expected protocol was not followed. Staff acknowledged that the physician should have been notified, vital signs should have been monitored every 10–15 minutes, and 911 should have been called when the resident's oxygen saturation and pulse were critically abnormal. There was also no documentation that the physician came to evaluate the resident as promised, nor was there follow-up to ensure the physician's timely assessment. The failure to provide timely care and treatment according to orders and facility policy had the potential to delay necessary interventions and affect the resident's overall health condition.
Untrained Staff Assigned to 1:1 Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that staff members assigned to provide one-on-one (1:1) supervision for a resident with wandering behavior were properly trained and competent to meet the resident's behavioral health needs. Housekeeping staff were utilized as sitters for a resident with severe cognitive impairment and a history of wandering, despite not having received training on how to manage residents with such behaviors. Interviews with both a CNA and the Director of Staff Development confirmed that housekeepers were assigned to provide 1:1 supervision for the resident throughout April, and that these staff members had not been trained for this responsibility prior to their assignment. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and unspecified dementia, with a severely impaired cognition score on the most recent assessment. Physician orders and the care plan specified the need for 1:1 supervision due to wandering risk. Despite this, the facility did not have a policy for managing residents requiring a sitter, and the Director of Nursing acknowledged that housekeeping staff should have received proper training before being assigned as sitters. Documentation and staff interviews confirmed that the housekeepers did not receive relevant training until after they had already been assigned to supervise the resident.
Failure to Provide Required 1:1 Supervision for Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide one-on-one (1:1) supervision for a resident with severe cognitive impairment and a history of wandering, as required by the physician's order and the resident's care plan. Multiple staff interviews and record reviews revealed that there were several occasions when no assigned sitter was present for the resident, and the responsibility to monitor the resident was informally distributed among all available staff. Assignment sheets and sitter schedules showed blank entries for numerous shifts, indicating the absence of a designated sitter during those times. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and dementia, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The care plan specifically identified the resident as an elopement risk and required 1:1 supervision due to wandering behaviors. Despite this, staff reported that when no sitter was available, they were instructed to "keep an eye" on the resident while also attending to their other assigned duties, and sometimes non-clinical staff such as housekeepers were assigned as sitters. Documentation reviewed for the month showed multiple periods where no staff signatures were present to confirm 1:1 supervision, and staff confirmed that these blank periods meant the resident was not being directly supervised as required. The Director of Nursing acknowledged that the resident should not have been left without a sitter at any time while the order was in place, and the facility did not have a specific policy for managing residents who require a sitter.
Failure to Perform Hand Hygiene During Infectious Disease Outbreak
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection prevention and control practices during an infectious disease outbreak. Specifically, the CNA was observed exiting a resident's room, removing gloves outside the room, and touching the linen cart in the hallway without performing hand hygiene. The CNA then re-entered the resident's room without using hand sanitizer or washing hands. This lapse in protocol was acknowledged by the CNA during a concurrent interview, where she admitted she should have used hand sanitizer to prevent the spread of germs. Further interviews with other staff, including another CNA, the Infection Prevention Nurse, and the Director of Nursing, confirmed that facility policy and standard precautions require hand hygiene before and after entering a resident's room and after contact with potentially contaminated surfaces. A review of the facility's infection prevention and control policy, as well as CDC guidelines, reinforced the importance of hand hygiene in preventing the spread of infection. The failure to adhere to these procedures was observed during an unannounced visit investigating an infectious disease outbreak.
Failure to Notify Physician of Critically High Blood Sugar
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus had a blood sugar reading of 403 mg/dl, which exceeded the threshold specified in the physician's order for notifying the physician. The physician's order required staff to call the physician if the resident's finger-stick blood sugar was less than 60 or greater than 400. On the specified date, the resident's bedtime blood sugar was recorded as 403 mg/dl, but there was no documented evidence that the physician was notified as required by the order. During a review of the resident's record and an interview with the Assistant Director of Nursing (ADON), it was confirmed that the physician was not notified of the elevated blood sugar level. The facility's policy on physician orders outlines procedures for timely implementation and follow-up of orders, but in this instance, the required notification did not occur. The resident expressed dissatisfaction with their care during an interview conducted as part of the investigation.
Infection Control Breach Due to Artificial Nails
Penalty
Summary
The facility failed to adhere to proper infection prevention and control standards when three direct care staff members were observed with artificial nails, which is against the facility's infection control policy. During an unannounced visit to investigate a complaint regarding quality of care and infection control, as well as a reported gastrointestinal outbreak, surveyors observed a Certified Nursing Assistant (CNA) and two Licensed Vocational Nurses (LVNs) with long artificial nails. Each staff member acknowledged that wearing artificial nails was against the facility's policy due to the risk of collecting bacteria and potentially transmitting infections to residents. The facility's Infection Preventionist confirmed that staff members providing direct patient care should not have artificial nails, as they pose an infection control risk. The facility's policy on infection prevention and control, as well as hand hygiene, explicitly discourages artificial nails among staff with direct resident-care responsibilities and prohibits them for those caring for severely ill or immunocompromised residents. Despite these policies, the presence of artificial nails on staff members was noted, indicating a lapse in adherence to infection control protocols.
Failure to Activate Door Alarm Leads to Elopement Risk
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident at high risk for elopement when the door alarm was not activated. During an unannounced visit, it was observed that the door alarm on the exit door in hallway 200 was not functioning because it had not been turned on. The Director of Staff Development admitted to forgetting to activate the alarm after using the door to enter the facility. This oversight was confirmed by a Registered Nurse who stated that the door alarm should always be on, regardless of its use as an entrance or exit, to prevent residents from leaving undetected. The resident involved had a history of altered mental status and unspecified psychosis, and was identified as having a high risk for wandering and elopement. The resident had previously attempted to leave the facility, as noted in an evaluation indicating active exit-seeking behavior. Interviews with the Maintenance Supervisor and the Assistant Director of Nursing revealed that the responsibility for ensuring the alarm was activated fell on the staff, and failure to do so could lead to repeated elopement incidents, posing a risk of accidents or injuries to the resident.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an unusual occurrence to the California Department of Public Health (CDPH) in a timely manner, as per their policy and procedure, when a resident eloped from the facility. The incident occurred when the resident, who had intact cognition and was able to walk using a walker, left the facility unsupervised to go to the bank and post office. The resident was later found at a bus stop by facility staff and returned to the facility with minor abrasions on the forehead and shin. The Assistant Director of Nursing (ADON) acknowledged that the incident was initially debated as either an elopement or leaving against medical advice. It was eventually classified as an elopement, which required reporting to the CDPH within 24 hours. However, the report was submitted later than the required timeframe. The facility's policy on unusual occurrences mandates that such incidents be reported within 24 hours to the local health officer and the Department, which was not adhered to in this case.
Facility Fails to Maintain Comfortable Environment and Cleanliness
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by excessively high temperatures in resident rooms and hallways, which exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This issue was observed during an unannounced visit, where multiple residents expressed discomfort due to the heat. The facility's air conditioning units had been malfunctioning for approximately three weeks, and despite the provision of portable fans and AC units, the temperatures remained high, reaching up to 87 degrees Fahrenheit in some areas. The Plant Director confirmed the malfunction and acknowledged that the internal temperature should be within the specified range. Additionally, the facility did not report this disruption of services to the California Department of Public Health as an unusual occurrence, which is required when events threaten the welfare, safety, or health of residents. The Administrator admitted awareness of the air conditioning issues but believed the situation was manageable with the temporary cooling solutions provided. However, the failure to report the incident in a timely manner was acknowledged as a lapse in protocol. The facility also failed to maintain clean and sanitary conditions, as evidenced by dirty carpets with black circular stains in various areas, including the entrance, nurse's station, and resident hallways. Despite weekly cleaning efforts by the Plant Director and a previous attempt by an outside agency, the stains persisted, leading to dissatisfaction among residents and visitors. The Administrator recognized the poor condition of the carpets and acknowledged the need for improvement, as the facility's policy requires a safe, functional, and comfortable environment for all residents and staff.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for two residents, resulting in a delay of care needs. Resident 11, who had been at the facility for two weeks, reported being left wet for over 10 minutes before receiving assistance. Resident 11's medical history included myocardial infarction, pneumonia, cirrhosis of the liver, heart failure, hypertension, and anxiety, and she was cognitively intact with the capacity to make decisions. During an observation, Resident 11 was found lying in bed and expressed dissatisfaction with the delay in care. Resident 12, who had diagnoses including Wernicke's Encephalopathy and dysphonia, also experienced delays in receiving care. She reported that staff took 30 minutes to an hour to change her brief and was observed waiting for 15 minutes with the call light on, which remained unanswered for an additional 20 minutes. The CNA assigned to Resident 12 acknowledged being occupied with another client and informed the nursing staff, but the call light was still on when she returned. The DON stated that the facility's call system should alert staff to assist residents promptly, but was unaware of Resident 12's prolonged wait time. The facility's policies emphasized providing necessary care to maintain residents' well-being, but these were not adhered to in these instances.
Facility Fails to Maintain Environmental Conditions to Prevent Insect Entry
Penalty
Summary
The facility failed to maintain environmental conditions that prevent insects from entering the building, as observed during an unannounced visit. A missing window screen, tears and gaps in other screens, and entrance and exit doors with gaps large enough for insects to enter were noted. These deficiencies were confirmed through observations and interviews with the Maintenance Supervisor (MS) and the Director of Nursing (DON). The MS acknowledged that the front door was not completely closed or latched due to it being locked, which was supposed to be unlocked by the charge nurse. The DON also verified the presence of gaps in the front lobby door and other areas, which could allow insects to enter the facility. Further observations revealed additional issues with window screens and doors throughout the facility. The lunch staff lounge had a window screen with a large gap, the small dining room had no screen on the window, and a fly was noted inside. Rooms with window screens containing holes and hallway exit doors with gaps were also identified. The facility's policy, revised in December 2019, requires window screens to be intact and doors to fully close and latch, with no daylight visible on the door frame. These findings indicate a failure to adhere to the facility's policy, potentially allowing insects to enter areas frequented by residents.
Failure to Provide Timely Wound Treatment
Penalty
Summary
The facility failed to ensure treatments were provided upon admission for a resident's wounds located on the right lower extremity and left achilles. The resident was admitted with multiple wounds, including an unstageable pressure injury to the sacrococcyx, a surgical incision to the sternum, scabs on the upper abdomen, discolorations on both arms, an AV shunt to the left upper arm, a diabetic ulcer to the left achilles, and a diabetic ulcer to the posterior right lower extremity. The physician orders for wound treatment were not initiated until two days after admission, leading to a delay in care. Interviews with staff revealed that admission skin assessments are expected to be completed within 24 hours, and treatments should be initiated promptly. However, the wound nurse did not complete the wound measurements until the third day, and the treatment orders were not clarified until then. The delay in documenting and clarifying the wound measurements resulted in a delay in the initiation of the prescribed treatments. The facility's policy requires a comprehensive admission assessment and timely wound assessment and treatment. Despite this policy, the resident's wounds were not assessed and treated within the required timeframe, leading to a delay in care. The Director of Nursing and other staff confirmed that the admission assessment and treatment orders were not completed as per the facility's policy, resulting in a deficiency in the care provided to the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
