Desert Springs Healthcare & Wellness Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Indio, California.
- Location
- 82262 Valencia Avenue, Indio, California 92201
- CMS Provider Number
- 555084
- Inspections on file
- 32
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Desert Springs Healthcare & Wellness Centre during CMS and state inspections, most recent first.
A resident with severe cognitive impairment passed away, and the facility did not provide the legal representative with timely disbursement of personal funds or itemized financial statements, despite multiple requests. Staff interviews and record reviews confirmed that required policies for prompt refunds and transparent accounting were not followed.
A resident with a chronic skin condition refused a bed bath due to concerns about soap residue and was not offered any alternative hygiene options when regular showers were unavailable. CNAs were unaware of further steps to take, and documentation did not show that alternatives were provided or that the reason for refusal was addressed, despite facility policy requiring person-centered care.
A facility failed to conduct proper orthostatic blood pressure monitoring for a resident with a history of falls and Alzheimer's disease. The care plan required monitoring every Thursday due to medication use, but records showed only lying and sitting blood pressures were recorded, omitting standing measurements. Staff interviews revealed a lack of adherence to correct procedures, with the DON admitting the failure to identify the appropriate position for monitoring.
Two residents at the facility experienced multiple falls, and the care plans were not updated with new interventions despite recommendations from the IDT. Resident 7, with conditions like dementia and difficulty walking, and Resident 8, with a history of falls and multiple health issues, both had high fall risk scores. The facility's policy required care plan updates post-fall, but this was not done, as confirmed by the RN.
A resident who underwent spine surgery experienced severe pain due to the facility's failure to administer prescribed pain medications in a timely manner. Despite the resident's repeated requests and high pain levels, necessary medications were delayed due to authorization and delivery issues. The facility's staff did not adhere to the pain management policy, resulting in the resident being transferred to a hospital for pain management.
The facility failed to respect the rights of two residents by opening their mail and packages without consent. Both residents, who were cognitively intact, reported that staff opened their packages and removed items without permission. The facility's protocol involved processing mail through various departments before delivery, contradicting the policy that mail should remain unopened unless requested by the resident.
A resident admitted after spine surgery did not receive timely pharmaceutical services, resulting in significant pain and distress. The facility failed to acquire prescribed medications, including narcotic pain medications and a nicotine patch, in a timely manner. Despite follow-ups, the medications were delayed, impacting the resident's care and treatment.
A resident's wheelchair at the facility had a non-functioning left brake, which was not addressed, posing a risk of injury. The resident reported difficulties in transferring to the wheelchair due to the broken brake. Interviews with staff revealed that the facility had protocols for maintaining equipment, but these were not followed in this case.
A resident with a history of stroke and epilepsy experienced a fall and subsequent symptoms such as altered consciousness and abnormal vital signs. Despite these changes, CNAs and LVNs failed to communicate and document the resident's condition properly, leading to a deficiency in care. The facility's protocols for post-fall evaluation and change of condition notification were not followed, resulting in the resident's transfer to the hospital with cardiac issues.
A resident with a history of stroke and epilepsy experienced a fall and subsequent abnormal vital signs, which were not adequately addressed by the facility staff. Despite elevated blood pressure and pulse rate being recorded, there was a lack of communication and failure to follow protocols for reporting changes in the resident's condition. The resident was eventually transferred to the hospital, where further complications were identified.
A resident with severe cognitive impairment and a history of falling was found unresponsive after becoming stuck in a sunken dirt area on the facility's patio. The resident was later hospitalized for syncope and elevated D-dimer levels. The facility lacked specific accident prevention policies, contributing to the unsafe environment.
The facility failed to provide information on Advance Directives (AD) to three residents or their representatives. A resident with severe cognitive impairment signed an AD form without RR involvement, another resident did not receive AD information upon admission, and a third resident capable of making decisions was not informed about AD formulation. These oversights were confirmed through record reviews and staff interviews.
A facility failed to develop a comprehensive care plan for a resident prescribed apixaban for atrial fibrillation, neglecting to address the risk of bleeding. The DON confirmed that a care plan should have been completed within seven days of admission, as per facility policy.
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during monthly medication regimen reviews. A resident was given aripiprazole without monitoring for hallucinations, and three residents on anticoagulants were not monitored for bleeding. The Director of Nursing confirmed the lack of monitoring and absence of recommendations from the Consultant Pharmacist. The facility also lacked specific policies for anticoagulant medications.
The facility failed to monitor three residents for adverse effects while on anticoagulant medications, such as apixaban and enoxaparin. Despite having conditions like atrial fibrillation and a history of falls, these residents were not observed for signs of bleeding. The DON and Administrator confirmed the absence of specific monitoring policies for these medications.
The facility failed to follow the prescribed menu and portion sizes during meal preparation, affecting three residents with specific dietary needs. A resident on a renal diet received an incorrect portion of tacos, another resident on a large portion renal diet was served a regular portion, and a third resident on a pureed diet received a smaller portion than required. These discrepancies were due to the use of incorrect measuring tools and lack of clarity on portion sizes, potentially impacting the residents' nutritional status.
The facility failed to implement proper Infection Prevention and Control practices, as staff were unaware of which residents required Enhanced Barrier Precautions (EBP). A CNA incorrectly practiced EBP on a resident not listed for it, and two residents were inappropriately roomed together despite one being colonized with C. diff. The facility's policy on EBP was not followed, leading to potential infection risks.
Two residents were not treated with dignity during meal times as CNAs fed them while standing, contrary to facility policy requiring staff to sit at eye level. One resident required extensive assistance due to severe impairment, while the other had severe cognitive impairment and needed limited assistance. The facility's policy emphasizes promoting dignity and respect, which was not upheld in these instances.
Two residents were not provided necessary assistance during mealtime, resulting in incomplete meal setups. One resident, with severe cognitive impairment and other health issues, was unable to open food items, while another resident, with multiple health conditions, could not access her drink. Facility policies require proper meal preparation and assistance, which were not followed.
A resident with a history of hip fracture and malnutrition experienced a delay in treatment due to the facility's failure to address abnormal chest x-ray results in a timely manner. The x-ray, showing bilateral infiltrates, was not acted upon until two days after the results were received, and the prescribed antibiotic was not administered until four days later. This delay was due to a lack of communication between the physician, DON, and nursing staff, contrary to the facility's policy for timely notification of significant changes in a resident's condition.
A resident with severe cognitive impairment and blindness experienced multiple falls due to the facility's failure to implement necessary interventions, such as a 1:1 sitter and frequent monitoring. Despite being at high risk for falls, the resident was often left alone, leading to injuries. Staff interviews confirmed the lack of appropriate fall prevention measures, and the DON acknowledged the ineffectiveness of the current care plan.
A facility failed to accurately account for controlled medications for a resident when Norco was signed out but not documented on the MAR. During a survey, it was found that the medication was not recorded as administered on two occasions. The LVN acknowledged the discrepancy, and the DON confirmed the facility's process for medication administration, which includes immediate documentation in the MAR. The facility's policies require accurate documentation of controlled substances.
A resident with schizoaffective disorder was given aripiprazole without adequate behavioral monitoring for hallucinations. The facility's policy lacked guidelines for such monitoring, and the DON confirmed the absence of documented monitoring over a year.
A resident was inappropriately prescribed and administered Macrobid for a UTI despite not meeting McGeer's criteria. The physician's order to discontinue Macrobid and switch to Avelox was not followed, leading to non-compliance with the facility's antibiotic stewardship program.
Failure to Timely Disburse and Account for Deceased Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that the personal funds of a deceased resident were provided to the resident's legal representative within the required timeframe. After the resident, who had severe cognitive impairment due to dementia, passed away, the legal representative made multiple attempts to obtain information and the remaining funds from the facility. Despite repeated calls and requests, the facility did not provide timely callbacks, accurate information about the account balance, or an itemized breakdown of the funds. The legal representative received checks at different times, but these were not accompanied by the required itemized statements or invoices, and in one instance, an invoice was sent requesting payment without a breakdown of the amount due. Interviews with facility staff, including the DON, SSD, and BOM, confirmed that the facility's policy required refunds and final accountings to be processed and provided within 30 days of a resident's death, and that requests for itemized statements should be fulfilled immediately. However, the facility did not adhere to these policies, resulting in delays and lack of transparency regarding the resident's personal funds. The deficiency was identified through interviews, record reviews, and policy examination during a complaint investigation.
Failure to Offer Alternative Hygiene Options After Bath Refusal
Penalty
Summary
The facility failed to ensure that a resident who refused a bed bath was offered an alternative option for personal hygiene. During a period when regular showers could not be provided due to a plumbing issue, the resident, who has eczema and a physician's order for topical cream to manage skin dryness and scabs, was offered a bed bath as an alternative to a shower. After initially accepting, the resident refused a subsequent bed bath, expressing concern that soap would not be rinsed off properly, potentially aggravating his skin condition. There was no documented evidence that any other alternative was offered after the refusal, nor was there documentation that the reason for refusal was explored or addressed. Interviews with CNAs revealed a lack of awareness regarding alternative options when a resident refuses a bed bath, with staff indicating they would simply notify licensed nurses but did not know what further steps to take. The DON confirmed that staff were expected to offer alternatives, such as coordinating with family for a shower at home, but this was not done. Facility records and policy review confirmed the absence of documented alternative options or follow-up actions to support the resident's hygiene needs in a person-centered manner.
Failure in Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to conduct appropriate orthostatic blood pressure monitoring for a resident, identified as Resident 6, who was at risk for falls due to a history of multiple falls and a diagnosis of Alzheimer's disease and osteoporosis. The resident's care plan required orthostatic blood pressure monitoring every Thursday due to the use of Escitalopram, as recommended by a pharmacist. However, the facility's records showed that only lying and sitting blood pressures were recorded, with no standing blood pressure measurements taken, which are crucial for accurate orthostatic blood pressure monitoring. Interviews with the facility's staff, including two Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that the nurses were not following the correct procedure for orthostatic blood pressure monitoring. The LVNs acknowledged that standing blood pressure should have been taken instead of sitting blood pressure, especially since the resident was ambulatory and had a tendency to stand and walk abruptly. The DON admitted that the facility failed to identify the appropriate position for obtaining orthostatic blood pressure, which was a deviation from the facility's policy and procedure for managing orthostatic hypotension.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to adequately assess and revise interventions for two residents who experienced multiple falls. Resident 7, who was admitted with conditions including cellulitis, hypertension, anxiety disorder, difficulty walking, and dementia, was identified as being at high risk for falls. Despite having a care plan in place, Resident 7 experienced falls on several occasions, and no new interventions were added to the care plan following these incidents. The Interdisciplinary Team (IDT) recommended activities to prevent further falls, but these were not incorporated into the care plan. Similarly, Resident 8, who had a history of repeated falls and was admitted with conditions such as atrial fibrillation, hydrocephalus, hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease, also experienced multiple falls. The care plan for Resident 8 did not include new interventions after the falls, despite recommendations from the IDT for more frequent checks. The facility's policy required that interventions be documented and updated in the care plan following falls, but this was not done for Resident 8. The Registered Nurse (RN) confirmed that no new interventions were added to the care plans of Residents 7 and 8 after their falls, despite the facility's policy and the IDT's recommendations. The RN acknowledged the importance of updating interventions to prevent recurring falls. The facility's policy on fall management emphasized the need for care plans to be updated with interventions following falls, but this was not adhered to in these cases.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who had undergone spine surgery, resulting in severe pain and a decline in the resident's quality of life. Upon admission, the resident required specific pain medications, including Methadone, Fentanyl, and other analgesics, which were not administered as ordered due to delays in obtaining authorization from the physician and delivery from the pharmacy. The resident expressed severe pain and distress, with pain levels consistently reported as high as 10 out of 10, indicating excruciating pain. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) acknowledged that the necessary medications were not available upon the resident's arrival and were still pending delivery two days later. Despite the resident's repeated requests for pain relief and the facility's awareness of the situation, the medications were not administered in a timely manner. The resident's care plan and physician's orders clearly outlined the need for specific pain management interventions, which were not followed, leading to the resident experiencing severe pain and muscle spasms. The facility's policy on pain management emphasized the importance of assessing and managing pain to maintain residents' well-being. However, the staff failed to adhere to these guidelines, resulting in the resident being transferred to an acute hospital for pain management. The lack of timely medication administration and inadequate communication between the facility, pharmacy, and physician contributed to the deficiency in care provided to the resident.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to respect the rights of two residents, identified as Residents B and C, by opening their mail and packages without their prior consent. Resident B, who was cognitively intact with a BIMS score of 13, expressed dissatisfaction with the staff opening his packages, which he perceived as a violation of his rights. Similarly, Resident C, also cognitively intact with a BIMS score of 14, reported that staff opened his packages, including health plan letters and supply catalogs, and removed items he ordered without his permission. Both residents did not recall giving consent for their mail or packages to be opened by the facility staff. The Director of Staff Development (DSD) explained the facility's protocol, which involved mail and packages being received at the nurse's station, processed through the business office, and then divided between the case manager and the activities department before being delivered to residents. The DSD stated that staff would open all packages in front of the residents to conduct an inventory. However, this practice contradicted the facility's policy, which clearly stated that residents' mail should be delivered unopened unless the resident requested assistance. The facility's policy on resident rights also emphasized the right to receive unopened mail and packages, highlighting the failure to adhere to established procedures.
Delay in Medication Delivery for Resident Post-Surgery
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, identified as Resident A, who was admitted after spine surgery. Upon admission, Resident A was prescribed several medications, including narcotic pain medications and a nicotine patch for smoking cessation. However, the facility did not acquire these medications in a timely manner, resulting in Resident A experiencing significant pain and distress. Interviews with the Director of Nursing (DON) and Resident A revealed that the resident was in pain and had not received the necessary medications, leading to a delay in care and treatment. Resident A's medical records indicated that several prescribed medications, such as Gabapentin, Diclofenac Sodium, Baclofen, Methadone, and Fentanyl, were not administered as ordered by the physician. Progress notes documented multiple instances where medications were pending delivery from the pharmacy, and the facility was awaiting authorization from the physician. Despite efforts to follow up with the pharmacy and the physician, the medications were not delivered promptly, leaving Resident A without adequate pain management for nearly 48 hours after admission. The facility's policy on medication ordering and receiving from the pharmacy was not effectively implemented, as evidenced by the delay in obtaining the necessary medications for Resident A. The DON acknowledged the delay and the potential for withdrawal symptoms due to the lack of pain management. The report highlights the facility's failure to ensure timely pharmaceutical services, which impacted Resident A's overall health condition and had the potential to affect other residents similarly.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition for one of the residents, identified as Resident A, whose wheelchair had a non-functioning left brake. This deficiency was discovered during an announced visit to investigate a complaint regarding quality of care. Resident A reported difficulties in transferring herself to the wheelchair due to the broken brake, which made it challenging for her to go to the bathroom. The observation confirmed that the left brake of the wheelchair would not lock, posing a potential risk of injury to the resident. Interviews with the Physical Therapist (PT) and the Director of Nursing (DON) revealed that the facility had several wheelchairs available for residents, and all equipment was expected to be maintained in a safe and working order. The PT stated that any wheelchair with non-functioning brakes should be tagged and a maintenance request should be submitted. The DON acknowledged that equipment should be in working order before a resident is assigned to a room and that any broken equipment should be set aside and repaired. Despite these protocols, the facility failed to ensure that Resident A's wheelchair was safe for use, as evidenced by the broken brake.
Failure to Monitor and Respond to Resident's Condition Post-Fall
Penalty
Summary
The facility failed to ensure that there were sufficient licensed nurses with the appropriate competencies and skill sets necessary to care for Resident A, as identified through resident assessments and described in the plan of care. Resident A, who was admitted with diagnoses including cerebral infarction, epilepsy, and aphasia, experienced a fall on August 6, 2024. Following the fall, Resident A exhibited symptoms such as altered level of consciousness, edema, and discoloration on the left side of the face, and abnormal vital signs, including elevated blood pressure and heart rate. Despite these symptoms, there was a lack of appropriate response from the nursing staff. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) failed to adequately communicate and document the changes in Resident A's condition. CNA 4 did not inform the charge nurse about Resident A's high heart rate and blood pressure, and LVN 1 did not take further action after being informed of the abnormal vital signs. LVN 2, who was responsible for monitoring Resident A during the night shift, was unaware of the irregular heart rate and high blood pressure until after Resident A was transferred to the hospital. The facility's policies and procedures, including the Fall Management Program and Change of Condition Notification, were not followed. The staff did not perform the necessary post-fall evaluations or notify the attending physician of the significant changes in Resident A's condition. This lack of adherence to established protocols contributed to the deficiency in care provided to Resident A, ultimately leading to the resident's transfer to the hospital with a diagnosis of sinus tachycardia and other cardiac issues.
Failure to Address Abnormal Vital Signs After Resident Fall
Penalty
Summary
The facility failed to consistently assess and provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall and subsequent abnormal vital signs. The resident, who had a history of cerebral infarction, epilepsy, and aphasia, was found on the floor by staff with no immediate injuries noted. However, the resident's vital signs, including elevated blood pressure and pulse rate, were not adequately addressed following the fall. On multiple occasions, the resident's abnormal vital signs were recorded but not acted upon. Certified Nursing Assistants (CNAs) reported the abnormal readings to the licensed nurse, but there was no documentation of any intervention or notification to the physician. The resident's condition worsened, with altered consciousness and abnormal vital signs persisting without appropriate medical response. Interviews with staff revealed a lack of communication and failure to follow protocols for reporting changes in the resident's condition. Despite being aware of the abnormal vital signs, the CNAs and licensed nurse did not ensure that the necessary medical attention was provided. The resident was eventually transferred to the hospital, where further complications were identified, including sinus tachycardia and incomplete right bundle branch block.
Resident Safety Compromised Due to Patio Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident when an outside patio had an open sunken area of dirt approximately two inches below the surrounding concrete pavement. This deficiency resulted in the resident becoming stuck in the dirt between a tree and the edge of the concrete pavement. The resident, who had a history of falling and severe cognitive impairment, was found unresponsive in his wheelchair with his head and shoulder leaning on a gate. The resident was later admitted to the hospital due to syncope and elevated D-dimer levels. The incident occurred after the resident had finished lunch and was wheeling around the facility. Another resident noticed the resident struggling with his wheelchair through a glass door and informed the LVN. Upon investigation, the LVN found the resident slumped in his wheelchair with all four wheels stuck in the dirt area. The resident was assessed for injuries and sent to the hospital for further evaluation. The facility did not have specific policies or procedures regarding accident prevention unless related to a specific incident, as stated by the DON.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that information regarding the formulation of Advance Directives (AD) was provided to residents or their representatives, affecting three residents. Resident 29, who had severe cognitive impairment and was unable to make healthcare decisions, signed an AD Acknowledgement Form without the involvement of her resident representative (RR). Despite the resident's incapacity, there was no documented evidence that the RR was informed about the AD, as confirmed by interviews with the Activities Director (ACD) and Case Manager (CM). Resident 52, who was cognitively intact with a BIMS score of 13, did not receive information about formulating an AD upon admission. The ACD acknowledged that it was her responsibility to provide this information but failed to do so until two days into the survey. This oversight was identified during a review of the resident's record and an interview with the ACD. Resident 6, who had the capacity to make medical decisions, also did not receive information on formulating an AD. The Director of Nursing (DON) and ACD confirmed that the absence of documentation indicated a failure to follow up with the resident regarding AD formulation. The facility's policy required that residents be provided with information about ADs upon admission and during the Social Services Assessment process, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure a comprehensive care plan was initiated for a resident prescribed apixaban, an anticoagulant medication, for atrial fibrillation. The resident was admitted with a diagnosis of atrial fibrillation and a telephone order for apixaban was documented. However, there was no evidence of a care plan addressing the resident's risk for bleeding due to the medication. An interview with the Director of Nursing (DON) confirmed that a care plan should have been developed within seven days of admission to monitor for signs and symptoms of bleeding. The facility's policy requires a comprehensive person-centered care plan to be developed within seven days from the completion of the comprehensive assessment. The DON acknowledged that the care plan was not completed as required.
Failure to Monitor Medication Effects and Report Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for four out of five residents reviewed for unnecessary medications. Specifically, Resident 9 was administered aripiprazole, an anti-psychotic medication, without adequate behavioral monitoring for hallucinations, which was the target behavior for the medication. The Director of Nursing (DON) acknowledged that the facility did not monitor the target behavior of visual hallucinations for Resident 9 while receiving aripiprazole for approximately one year. The facility's policy and procedure on Behavior/Psychoactive Drug Management did not include guidelines for behavioral monitoring. Additionally, the facility failed to monitor three residents (Residents 6, 40, and 52) for signs and symptoms of adverse effects related to the use of anticoagulants. Resident 6, who was on apixaban for atrial fibrillation, was not monitored for signs of bleeding. Similarly, Resident 40, also on apixaban, and Resident 52, on Lovenox, were not monitored for potential adverse effects, including bleeding. The DON confirmed that there were no recommendations from the CP regarding the need for monitoring adverse effects for these residents during the use of anticoagulants. The facility lacked a policy and procedure for anticoagulant medications, and the existing policy on Medication Monitoring and Management did not mention apixaban or Lovenox. The CP's monthly MRRs for the residents did not include recommendations related to monitoring for adverse effects. The facility's policy on Consultant Pharmacist Reports required the CP to perform a comprehensive review of each resident's medication regimen monthly and to identify irregularities, including monitoring for adverse consequences, but this was not adhered to in practice.
Failure to Monitor Anticoagulant Adverse Effects
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary medications due to inadequate monitoring for adverse effects associated with anticoagulant medications. Resident 6, who was admitted with atrial fibrillation, received apixaban without being monitored for signs and symptoms of bleeding from June 25, 2024, to July 15, 2024. The Director of Nursing (DON) acknowledged this oversight during an interview and record review. Similarly, Resident 40, also diagnosed with atrial fibrillation, was not monitored for bleeding while on apixaban from April 13, 2024, to July 17, 2024, as confirmed by the DON. Resident 52, with a history of diabetes, hypertension, and falls, received enoxaparin without monitoring for bleeding or other adverse effects. The DON verified the lack of monitoring during an interview and record review. Additionally, the facility's Administrator confirmed that there was no specific policy and procedure for anticoagulant medications, and the existing Medication Monitoring and Management policy, dated October 2012, did not address apixaban or Lovenox. This lack of monitoring had the potential for side effects to go undetected, as indicated by the drug information from DailyMed.
Failure to Follow Prescribed Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu during a tray line observation, impacting three residents who consumed food in the facility. On July 17, 2024, the facility's Summer Menu for Week 3, Wednesday, was reviewed, which included Taco Casserole, Seasoned Fresh Zucchini, Fiesta Salad, and Tangy Glazed Fresh Fruit. However, during the tray line observation, discrepancies were noted in the portion sizes and food items served to Residents 9, 45, and 35, which did not align with the menu or dietary requirements. Resident 9, who was on a renal diet with an 80-gram protein restriction, was served only one taco with one ounce of ground meat instead of the prescribed two tacos with one and a half ounces of meat each. This was due to the use of an incorrect measuring scoop. Resident 45, also on a renal diet with a large portion requirement, received a regular portion instead of a large portion, as the dietary staff was unsure of the correct portion size for a large renal diet. Resident 35, on a regular large portion diet with pureed texture, was served a smaller portion of pureed taco casserole than required, again due to the use of an incorrect scoop. The Registered Dietitian (RD) confirmed that serving less than the required portions could lead to weight loss and emphasized the importance of following the menu. The facility's policy, dated April 14, 2014, mandates adherence to the written menu to meet nutritional requirements. The failure to follow the menu as prescribed had the potential to negatively impact the residents' nutritional status, especially given their medical conditions, which included end-stage renal disease, diabetes mellitus, protein-calorie malnutrition, dementia, and dysphagia.
Inadequate Implementation of Infection Control Practices
Penalty
Summary
The facility failed to properly implement Infection Prevention and Control practices, as evidenced by several observations and interviews. Direct care staff were not aware of which residents were on Enhanced Barrier Precautions (EBP), a measure requiring the use of gowns and gloves during high-contact resident care. For instance, CNA 1 was observed practicing EBP while feeding Resident 40, who was not on the EBP list. Additionally, there was confusion among staff regarding the reasons for EBP for Residents 6 and 117, with inconsistent explanations provided by different staff members. The facility also failed to adhere to cohorting guidelines for EBP. Residents 6 and 117 were placed in the same room despite Resident 6 being colonized with C. diff, a highly contagious bacteria. The Director of Nursing (DON) and Infection Preventionist (IP) were unable to provide a rationale for this decision. The IP acknowledged that Resident 117, who was at high risk due to end-stage renal disease and the presence of a dialysis catheter, should not have been roomed with Resident 6. The facility's policy on Enhanced Barrier Precautions, revised in June 2024, was not followed. The policy requires a risk assessment to determine the need for EBP and advises against cohorting residents with multidrug-resistant organisms (MDRO) with those at high risk of acquiring infections. The IP admitted to not reviewing hospital documentation thoroughly, which led to the inappropriate room assignment for Resident 117.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during meal times, as observed by surveyors. Certified Nursing Assistants (CNAs) were seen feeding Residents 40 and 43 while standing, rather than sitting at eye level, which is necessary for promoting social interaction and communication. CNA 1 was observed feeding Resident 40 while standing, and acknowledged in an interview that he should have been sitting. Similarly, the Restorative Nurse Assistant (RNA) was seen feeding Resident 43 while standing and admitted that sitting would have facilitated better eye contact and communication. Resident 40, who was admitted with a fracture, abnormal gait, and metabolic encephalopathy, was assessed as severely impaired and requiring extensive assistance with feeding. Resident 43, admitted with hemiplegia, hemiparesis, cerebral infarction, and dysphagia, had a BIMS score indicating severe cognitive impairment and needed limited assistance during meals. The facility's policy on Resident Rights emphasizes care that promotes dignity and respect, and their competency validation document specifies that staff should be seated at eye level when assisting with meals. These observations and interviews highlight a failure to adhere to these standards, impacting the residents' quality of life.
Failure to Assist Residents with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to two residents during mealtime, leading to deficiencies in their care. Resident 30 was observed with an incomplete lunch meal tray setup, with plastic coverings on food items and an unopened milk carton. The resident, who has severe cognitive impairment, chronic obstructive pulmonary disease, dysphagia, muscle weakness, and dementia, was unable to remove the plastic coverings or open the milk carton. The Director of Staff Development confirmed that it was the responsibility of the CNA to open the food and set it up for the residents. Similarly, Resident 29 was observed with a meal tray that was not properly set up, with plastic coverings on plated food items and a drink placed out of reach. The resident, who has end-stage heart failure, dysphagia, dementia, muscular dystrophy, and severe arthritis of the wrist, stated she needed help to access her drink. Interviews with CNAs revealed that the facility's process was to prepare the food and remove the plastic seal for the residents, which was not done in this case. The facility's policies indicated that residents should be properly prepared to eat before a meal and receive adequate supervision and assistance during mealtime.
Delay in Addressing Abnormal Chest X-Ray Results
Penalty
Summary
The facility failed to ensure timely medical intervention for a resident, identified as Resident 22, who had abnormal chest x-ray results indicating bilateral infiltrates, suggestive of a lung infection. The resident was admitted with diagnoses including aftercare for a right femur fracture and malnutrition. On May 10, 2024, the resident exhibited altered levels of consciousness and other concerning symptoms, prompting the ordering of a chest x-ray and laboratory tests. The chest x-ray, conducted on May 13, 2024, revealed bilateral infiltrates, but the results were not addressed by the physician until May 15, 2024. The physician's notes from May 13, 2024, indicated a plan to discontinue Macrobid, an antibiotic for a urinary tract infection, and start Avelox for the lung infection. However, this order was not communicated to the licensed nurse or the Director of Nursing (DON) at the time. The physician uploaded his notes on May 15, 2024, and the order for Avelox was not placed until that morning. The medication was not administered until May 17, 2024, due to a lack of communication and follow-up, resulting in a delay in treatment. Interviews with the DON and the Infection Preventionist revealed that the facility's process for notifying physicians of abnormal results was not followed. The physician typically communicated orders to the DON, who was not informed of the Avelox order on May 13, 2024. The physician admitted to uploading his notes late and not ensuring the order was communicated. The facility's policy required immediate notification of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with a history of impulsive behavior and falls. The resident, who was blind and had severely impaired cognitive status, was observed with bumps on her forehead, indicating recent falls. Despite being at high risk for falls due to confusion, gait problems, and Alzheimer's dementia, the resident was not provided with a 1:1 sitter or frequent monitoring, as noted in her care plan. The resident's medical history included a fracture of the left radius, abnormal gait, and metabolic encephalopathy. Observations revealed that the resident was often left alone, attempting to get up from her wheelchair, which posed a significant fall risk. The care plan had identified the need for a 1:1 sitter due to the resident's impulsive behavior, but this intervention was not implemented, leading to multiple falls and injuries. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not on frequent checks and did not have a bed alarm, despite being visually impaired and having a history of falls. The DON acknowledged that the resident's care plan was ineffective and should have been re-evaluated to meet her needs. The facility's policy on fall management was not adequately followed, as the resident's environment was not free from fall hazards, and necessary interventions were not in place.
Inaccurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for a resident when a random controlled medication audit did not reconcile. Specifically, the Individual Narcotic Record for a resident indicated that Norco, a potent controlled medication for pain, was signed out on two occasions but was not documented on the Medication Administration Records (MAR) to indicate it was administered. This discrepancy was identified during a survey when the records for four random residents receiving controlled medications were reviewed. The resident in question had a physician's order for Norco to be administered as needed for pain. During interviews, the Licensed Vocational Nurse (LVN) acknowledged that the Norco tablets were unaccounted for in the MAR for the specified dates. The Director of Nursing (DON) confirmed the facility's process for controlled medication administration, which includes logging the medication, assessing the resident's pain, administering the medication, and documenting it in the MAR immediately. The facility's policy and procedure for medication administration and storage were reviewed, highlighting the requirement for accurate documentation of controlled substances. The failure to document the administration of Norco resulted in inaccurate accountability of controlled medications, with potential for misuse or diversion.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications. Specifically, a resident diagnosed with schizoaffective disorder was administered aripiprazole, an antipsychotic medication, without adequate behavioral monitoring. The resident's medical records showed a physician's order for aripiprazole to manage hallucinations, but there was no documented monitoring of the target behavior of visual hallucinations during the medication's use from July 2023 to July 2024. During interviews and record reviews, the Director of Nursing acknowledged the lack of monitoring for the resident's target behavior while on aripiprazole. The facility's policy on Behavior/Psychoactive Drug Management, dated November 2018, was reviewed and found not to include guidelines for behavioral monitoring. This oversight had the potential to result in unnecessary medication use, increasing the risk of medication interactions and adverse reactions.
Inappropriate Antibiotic Use Due to Non-compliance with Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were prescribed and administered under the guidance of their antibiotic stewardship program for a resident. The resident's condition did not meet the McGeer's criteria for the use of antibiotics for a urinary tract infection (UTI). Despite this, the resident was prescribed and administered Macrobid, an antibiotic for UTI, from May 11 to May 17, 2024. The resident's urinalysis and urine culture results indicated the presence of Escherichia coli, but the resident did not exhibit symptoms of a UTI, as confirmed by the facility's Surveillance Data Collection Form. Additionally, the physician's order to discontinue Macrobid and switch to Avelox, an antibiotic for lung infection, was not carried out as ordered. The Infection Preventionist (IP) acknowledged that the resident's condition did not meet the criteria for a UTI and that the physician should have been notified to reevaluate the use of Macrobid. The facility's policy on antibiotic stewardship, which includes the use of McGeer's criteria and antibiotic time-outs, was not followed, leading to inappropriate antibiotic use.
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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