Driftwood Healthcare Center - Santa Cruz
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Cruz, California.
- Location
- 675 24th Avenue, Santa Cruz, California 95062
- CMS Provider Number
- 055109
- Inspections on file
- 27
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Driftwood Healthcare Center - Santa Cruz during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident left the facility unsupervised through an unsecured wooden door, which was neither locked nor alarmed, leading to a deficiency in supervision. The RN confirmed the lack of security measures, and the DON acknowledged the risk posed by unlocked doors. Maintenance staff admitted the door was not regularly monitored, and there were no logs of door checks before the incident.
The facility failed to implement proper infection control practices, including staff not sanitizing hands when handling meal trays, entering COVID-19 isolation rooms without appropriate PPE, and improper handling of sterile dressings. Additionally, oxygen equipment was not maintained, and hand hygiene was neglected between resident interactions, increasing the risk of infection spread.
Three residents in an LTC facility were administered psychotropic medications without documented informed consent. Despite the facility's policy requiring verification and documentation of informed consent by the Licensed Nurse, the Director of Nursing was unable to locate the necessary consents for the medications prescribed to these residents.
The facility failed to update care plans for three residents following allegations of abuse. One resident reported missing money, another alleged verbal abuse by a roommate, and a third reported multiple incidents, including physical and verbal abuse by a CNA and financial abuse. The care plans did not reflect the interdisciplinary team's recommendations or include interventions to minimize emotional distress.
The facility failed to properly assess and document the use of bed rails for several residents, leading to potential safety risks. Bed rails were installed for residents who did not require them, without obtaining necessary physician orders, informed consent, or developing care plans. The DON confirmed these deficiencies, which violated the facility's policy and procedure for bed rail use.
The facility failed to manage a resident's behavioral health needs, as evidenced by the resident's frequent screaming episodes that disturbed other residents. Despite the resident's severe cognitive impairment and medical conditions, no care plan was developed to address the behavior, and staff did not intervene during the episodes. The facility's policy on behavior assessment and monitoring was not followed, leading to a deficiency in care.
The facility failed to provide adequate social services support for several residents, leading to unaddressed psychosocial needs. A resident reported missing money, but there was no timely follow-up. Another resident alleged verbal abuse by a roommate, yet the recommended psychological evaluation and monitoring were not implemented. A third resident reported physical and financial abuse, with no documented follow-up. Additionally, a resident's disruptive behavior was not managed, despite complaints from others. The facility did not fulfill its responsibility to address these residents' psychosocial needs.
The facility failed to provide appropriate pharmaceutical services, including the unavailability of a prescribed medication for a resident with bipolar disorder, discrepancies between controlled drug records and medication administration records for several residents, and improper handling of controlled substances. These issues were confirmed by the DON and involved missing documentation and signatures, contrary to facility policy.
A facility failed to ensure residents were free from unnecessary psychotropic medications. One resident received multiple psychotropic drugs without a gradual dose reduction (GDR) or documented rationale for contraindication, despite no exhibited behaviors. Another resident was prescribed Seroquel without specific indication or initial AIMS assessment. A third resident's GDR assessment lacked a documented rationale for contraindication. The facility's policies require specific diagnoses and documentation for antipsychotic use, which were not followed.
The facility failed to provide palatable and attractive food, as evidenced by resident complaints and a test tray evaluation. Surveyors found a breaded chicken fillet to be hard, dry, and overcooked, contrary to the facility's standards for meal preparation. The consultant dietary manager disagreed with the surveyors' assessment.
The facility failed to follow food safety standards, as wet pans and bowls were improperly stored, a cup was left in a sugar container, and unpasteurized eggs were used during breakfast service. The CDM and RD confirmed these practices were against facility policies, posing a risk of foodborne illness to residents.
The facility failed to keep the dumpster lid closed, potentially attracting pests. Observations revealed that a staff member left the lid open after disposing of garbage, and the dumpster was overflowing with boxes, preventing closure. The dietary supervisor confirmed the lids should be closed, aligning with the facility's policy on food waste disposal.
The facility failed to ensure call buttons were accessible for seven residents, potentially delaying assistance. Observations revealed call buttons were often placed out of reach, such as on the floor or covered by items, despite staff acknowledging they should be within reach. This issue was confirmed by multiple staff members and contradicted the facility's policy.
The facility failed to maintain a safe and sanitary environment, with a resident's room having bent window screens, a large hole in the wall, and a leaking toilet pipe. Two other residents had peeling walls exposing drywall. These issues were not addressed despite being reported, posing potential health and safety risks.
The facility failed to ensure that two residents were informed about having an advance directive and that their POLST forms were completed. One resident, with diagnoses including cerebral infarction and dementia, had an incomplete POLST, and the absence of an advance directive was confirmed. Another resident, with conditions such as sepsis and diabetes, had neither a POLST nor an advance directive documented. The facility's policy required social services to facilitate the advance directive process, which was not followed in these cases.
A breach of resident confidentiality occurred when a nurse left computer screens open and unattended, displaying sensitive health information for two residents. This happened while the nurse was providing care, leaving the information exposed in a busy hallway, contrary to the facility's confidentiality policy.
A facility failed to create a comprehensive care plan for a resident prescribed Eliquis for DVT prevention. Despite the resident's history of mood disorder and traumatic brain injury, no care plan was developed to include goals, interventions, and monitoring for bleeding symptoms. The DON confirmed the absence of a care plan, which violated the facility's policy.
The facility failed to provide necessary care for two residents. One resident had open skin areas on her face without a treatment order, and another resident, at high risk for falls, lacked a physician-ordered floor mat at his bedside. These deficiencies were confirmed by an LVN.
A resident's indwelling catheter was not properly secured, and the urinary tube was filled with thick yellow sediments. Observations revealed inadequate securing of the catheter stabilization device and dried blood on the resident's thigh. Interviews with staff highlighted inconsistencies in catheter care practices, and the resident's records lacked documentation of catheter and device changes, contrary to facility policies.
The facility failed to ensure the Consultant Pharmacist identified and reported drug irregularities during monthly medication regimen reviews for two residents. One resident received two loop diuretics simultaneously for over a year without a documented rationale, while another was on five psychotropic medications without attempts at gradual dose reduction, despite no exhibited behaviors. The physician disagreed with the CP's recommendations without providing a clinical rationale, contrary to facility policy.
A resident was prescribed both furosemide and torsemide, two loop diuretics, for over a year without clear justification, leading to unnecessary medication use. The consulting pharmacist was unsure of the rationale, and the facility's policy emphasized safe medication administration, highlighting a deficiency in medication management.
A medication error rate of 7.41% was identified in an LTC facility due to two errors involving a resident. An LVN administered an incorrect dosage of Lamictal due to a stock issue, and improperly administered olopatadine eye drops by not following the correct procedure. The errors were observed during a medication pass, and the facility's policies were not adhered to.
The facility failed to properly store medications and biologicals, as an emergency kit contained expired lorazepam, and a treatment cart was left unlocked in the hallway. An LVN confirmed the expired medication should have been replaced, and a policy requires outdated medications to be removed. Additionally, an RN left a treatment cart unsecured while attending to a resident's wound care, contrary to the facility's policy requiring medication supplies to be locked when unattended.
A resident on a pureed diet, who disliked fish, was served pureed fish for lunch despite their documented preference. The RD confirmed the oversight, noting that an alternative should have been provided according to facility policy.
A resident on antibiotics experienced stomach upset and was unable to receive crackers at night, leading to refusal of medication. The facility lacked proper snack storage and did not assess the resident's food preferences upon admission, as confirmed by the DON and RD.
A resident's bed had a loose and wobbly headboard and footboard, compromising safety. The DON and the resident confirmed the issue during an observation. LVN A mentioned that faulty equipment should be logged and followed up, while the DO stated that maintenance should check the binder daily. However, no work order was found for the resident's bed in the maintenance log for June.
A resident with multiple diagnoses and severe cognitive impairment fell and fractured her cervical vertebra due to the facility's failure to provide adequate supervision and develop a proper care plan. The resident was not checked frequently, and her fall care plan was not tailored to her needs, leading to the incident.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Resident Elopement Due to Unsecured Exit
Penalty
Summary
The facility failed to provide adequate supervision for a resident who managed to leave the facility without supervision, putting the resident at risk for accidents. On the day of the incident, the resident, who uses a walker, was able to exit the facility through a wooden door that led to the street. This door was accessible from the resident's room via a sliding door that opened to a patio. The wooden door was neither locked nor equipped with an alarm, allowing the resident to leave unnoticed. Further investigation revealed that the facility's Registered Nurse confirmed the absence of a lock and alarm on the wooden door. Additionally, a glass door near another room was found ajar, and its alarm system was not functioning. The Director of Nursing acknowledged that unlocked doors posed a risk to residents. The facility's maintenance staff admitted that the wooden door was not included in their regular monitoring prior to the incident, and there were no logs of door checks before the date of the incident. The facility's policy required daily testing of door alarms, but policies on accident hazards were not provided.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, leading to potential infection spread. The registered dietician was observed walking in the hallway with gloves on after leaving the kitchen, acknowledging the oversight. Additionally, multiple staff members, including the rehab director, CNAs, and the infection preventionist, handled lunch trays and checked meal tickets without sanitizing their hands, despite acknowledging the need for hand hygiene. In COVID-19 isolation rooms, staff members, including the activity director and CNAs, entered without appropriate personal protective equipment. Some wore surgical masks instead of N95 respirators, and one CNA entered without a gown. These actions were contrary to the facility's policy requiring enhanced transmission-based precautions, including the use of N95 masks, gowns, gloves, and eye protection. Other deficiencies included undated oxygen tubing and dusty concentrator filters for residents on supplemental oxygen, improper handling of sterile dressings by a registered nurse, and failure to perform hand hygiene between assisting different residents with meals. Additionally, a CNA was observed not wearing a face mask during a COVID-19 outbreak, and another CNA used dirty gloves to handle clean items during incontinent care, further risking cross-contamination.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents received informed consent before the administration of psychotropic medications. Resident 39, diagnosed with psychosis and depression, was prescribed olanzapine and trazodone without documented informed consent. Similarly, Resident 48, with diagnoses of psychosis and mood disorder, was given Depakote and olanzapine without informed consent documentation. Resident 64, diagnosed with a psychotic disorder, was administered valproic acid without the necessary informed consent. The Director of Nursing (DON) was unable to locate the informed consents for these medications in the clinical records of the three residents. Despite reviewing the records and checking with medical records, the informed consents were not found. The facility's policy requires that the Licensed Nurse verify with the Physician that informed consent has been obtained and documented, which was not adhered to in these cases.
Failure to Update Care Plans for Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that care plans related to alleged abuse were reviewed and updated by the interdisciplinary team (IDT) for three residents. Resident 61, who was admitted with chronic obstructive pulmonary disease, asthma, and shoulder pain, reported missing money from his wallet. Although the IDT discussed the issue, the care plan was not updated to include interventions to prevent complications related to the missing money. The Director of Nursing confirmed that the care plan should have been updated following the IDT meeting. Resident 63, admitted with sepsis, candidiasis, major depressive disorder, and multiple sclerosis, alleged verbal abuse by a roommate. The IDT recommended several actions, including alert charting and a psychological evaluation, but the care plan was not updated to reflect these interventions. The nursing supervisor confirmed that the care plan should have been revised to include the IDT's recommendations. Resident 75, with a history of a femur fracture, traumatic amputation, and brain hemorrhages, reported multiple incidents, including physical and verbal abuse by a CNA, financial abuse, and being accused of verbal abuse. The care plans for these incidents lacked interventions to minimize emotional distress and did not reflect the IDT's recommendations. The nursing supervisor acknowledged that the care plans were not updated as required. The facility's policy mandates that care plans be re-evaluated and modified to reflect changes in care, service, and treatment.
Improper Use of Bed Rails in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of bed rails for five residents, leading to potential safety risks. Residents 81 and 285 had bed rails installed despite their evaluations indicating they did not require them. The Director of Nursing (DON) confirmed that there were no documented alternatives offered, no physician orders or informed consent obtained, and no care plans developed for the use of bed rails for these residents. Additionally, the facility's policy requires a side rail evaluation, informed consent, and a physician's order, none of which were followed in these cases. Similarly, Residents 22, 26, and 28 had bed rails installed without the necessary physician orders or completed side rail evaluations. The DON confirmed that Resident 22's evaluation indicated she did not require bed rails, and the evaluation process was not completed for Residents 22 and 28. Resident 26 also lacked a physician's order for bed rails. These oversights in following the facility's policy and procedure for bed rail use placed the residents at risk of entrapment and serious injury.
Failure to Manage Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately monitor, evaluate, and manage the behavior of Resident 285, who exhibited episodes of screaming that resembled a baby crying. This behavior was observed on multiple occasions, causing discomfort to other residents in the same hallway. Despite the noticeable distress caused by Resident 285's screaming, no nursing staff or certified nursing assistants intervened to check on the resident during these episodes. Resident 285's medical history includes diagnoses such as sepsis, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, unspecified dementia, dysphagia, and gastrostomy status. The resident's admission minimum data set indicated severe cognitive impairment. The Director of Nursing confirmed that Resident 285 did not have an admission care conference, and the behavior was not addressed in a care plan. Additionally, the interdisciplinary team conducted a risk meeting but failed to address the behavior. The facility's policy on behavior assessment, intervention, and monitoring requires that behavioral symptoms be identified and evaluated, with a care plan developed accordingly. However, this protocol was not followed, as the behavior was neither documented nor communicated to the physician, and no safety strategies were implemented to protect the resident and others from harm.
Failure to Provide Adequate Social Services Support
Penalty
Summary
The facility failed to provide appropriate social services support for four residents, leading to deficiencies in addressing their psychosocial needs. Resident 61, who was admitted with chronic obstructive pulmonary disease, asthma, and shoulder pain, reported missing money from his wallet. Despite the report being made to the social services director (SSD), there was no timely follow-up or documentation to address the potential psychosocial effects of the incident. The director of nursing confirmed that the SSD's documentation was delayed and only completed after the surveyor began the investigation. Resident 63, diagnosed with sepsis, candidiasis, major depressive disorder, and multiple sclerosis, alleged verbal abuse by a roommate. Although the interdisciplinary team (IDT) recommended a psychological evaluation and monitoring for emotional distress, the SSD did not implement these plans. Similarly, Resident 75, who had a history of traumatic injuries and cognitive impairment, reported physical and verbal abuse by a certified nursing assistant and financial abuse. The SSD failed to document any follow-up actions to address these allegations or the resident's emotional distress. Resident 285, with diagnoses including sepsis, anemia, diabetes, dementia, and dysphagia, exhibited screaming behavior that disturbed other residents. Despite observations and complaints from other residents, the facility did not conduct an admission care conference or develop a care plan to manage the behavior. The SSD acknowledged that the behavior should have been addressed, but no actions were taken to assess or manage the resident's psychosocial needs. The facility's job description for social services emphasized the responsibility for addressing residents' psychosocial needs, which was not fulfilled in these cases.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services, as evidenced by several deficiencies in medication management. A medication, Lamictal, prescribed for a resident with bipolar disorder, was not available in the required dosage, leading to missed doses on consecutive days. The Licensed Vocational Nurse (LVN) responsible for administering the medication confirmed the absence of the 200 mg dosage and had reordered it from the pharmacy, but it was still unavailable the following day. This failure to provide the prescribed medication in a timely manner was contrary to the facility's policy on pharmaceutical services. Additionally, discrepancies were found between the controlled drug records (CDR) and the medication administration records (MAR) for four residents. Instances were noted where medications were recorded in the CDR but not documented as administered in the MAR. The Director of Nursing (DON) verified these discrepancies and emphasized the importance of accurate documentation in both records to avoid mismatches. Interviews with LVNs revealed that some signatures were missing due to oversight or being in a hurry, which is against the facility's policy requiring immediate documentation of controlled medication administration. Further issues included the improper handling of controlled substances, such as the destruction of medications without the required witness signatures. For one resident, a controlled substance was wasted with only one nurse's signature instead of the required two. Moreover, the destruction records for three residents lacked a registered nurse's signature, only having the consulting pharmacist's signature. Another resident's controlled medications did not have a CDR initiated, which is necessary for accountability. These lapses in procedure had the potential for misuse or diversion of medications, as noted in the report.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 2 was administered five psychotropic medications without a gradual dose reduction (GDR) and without documented clinical rationale for why the GDR was contraindicated. Despite the resident not exhibiting any behaviors for which the medications were indicated over a six-month period, there were no attempts to reduce the dosage or discontinue the medications. Interviews with staff confirmed the absence of mood changes or anxiety in the resident, yet the physician's notes repeatedly stated that GDR was contraindicated without providing a clinically pertinent explanation. Resident 41 was prescribed Seroquel without a specific and documented indication, and there was no initial AIMS assessment conducted. The diagnosis of psychotic disorder was deemed non-specific, and the facility's policy required a comprehensive assessment and specific diagnosis for antipsychotic medication use. The Director of Nursing (DON) confirmed the absence of an AIMS assessment in the resident's medical record, which is required upon initiation of antipsychotic medication and every six months thereafter. For Resident 59, the GDR assessment for the use of Seroquel lacked a physician-documented clinical rationale for why the GDR was contraindicated. The DON expressed concerns about the lack of explanation for the contraindication, which is necessary to communicate with the resident's family. The facility's policy mandates that the physician must document why the benefits of the medication outweigh the risks if a GDR is contraindicated, but this documentation was not provided.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and attractive, as evidenced by multiple resident complaints about the quality of the meats served, specifically noting that they were hard and dry. A test tray evaluation was conducted during a lunch service, where four surveyors, along with the consultant dietary manager (CDM), sampled a breaded chicken fillet. The fillet was found to be very hard, difficult to cut, and overcooked, with a dark brown breading and dry meat inside. All four surveyors agreed on these observations, while the CDM stated that the chicken tasted fine. The facility's job descriptions for the cook and registered dietician indicate responsibilities for preparing palatable, nourishing, and well-balanced meals that meet residents' nutritional and dietary needs. However, the observations during the test tray evaluation suggest a failure to meet these standards, potentially affecting residents' food intake and nutritional health.
Food Safety Violations in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. Pans and bowls used for food preparation and service were found stacked and stored while still wet, which was confirmed by the consultant dietary manager (CDM) as a violation of the facility's policy that requires air drying before stacking. Additionally, a Styrofoam cup was found inside a sugar container, which the dietary supervisor (DS) acknowledged should not have been there, as scoops or cups should not be stored inside food bins. Furthermore, the facility used unpasteurized eggs during a breakfast meal service. Observations in the walk-in refrigerator revealed eggs with no markings to indicate pasteurization, and the CDM confirmed that the facility should be using pasteurized eggs. The cook was unaware of the pasteurization status of the eggs and had served fried and over easy eggs to residents. The registered dietician (RD) later confirmed that the eggs were not pasteurized, which is against the facility's policy that recommends using pasteurized egg products for the elderly due to their increased susceptibility to foodborne illnesses.
Improper Dumpster Lid Management
Penalty
Summary
The facility failed to ensure that the dumpster lid was kept closed, which had the potential to attract pests. During an observation from the director of nursing's (DON's) office, it was noted that a staff member opened the dumpster lid to dispose of garbage and left it open. A follow-up observation confirmed that the lid remained open. Additionally, during a concurrent observation and interview with the dietary supervisor (DS), it was observed that the dumpster was overflowing with cartons of boxes, preventing the lid from closing. The DS confirmed that all dumpster lids should be kept closed to prevent attracting pests. The facility's undated policy and procedure titled 'Food Handling Practices' indicated that proper food waste disposal practices should be followed, including keeping lids/doors to dumpsters closed when not dumping garbage.
Inaccessible Call Buttons for Residents
Penalty
Summary
The facility failed to ensure that call buttons were easily accessible for seven residents, potentially causing delays in attending to their needs. Resident 285, who had severe cognitive impairment and multiple health issues, was observed struggling to reach her call button, which was caught between the mattress and bed rail. Certified Nursing Assistant O confirmed that the call button should be within the resident's reach. Resident 286, with severe cognitive impairment, had her call button covered by towels and socks on a bedside drawer, making it inaccessible. Similarly, Resident 6, who had severe cognitive impairment and was seated in a wheelchair, had her call button clipped to a pillow at the head of the bed, far from her reach. Both situations were confirmed by CNA O and Resident 6's caregiver, who acknowledged the call buttons were not within reach. Other residents, including Resident 80, Resident 40, Resident 13, and Resident 49, also had inaccessible call buttons due to their placement on the floor or at the head of the bed, out of reach. These observations were confirmed by staff members, including CNA O, RN R, and CNA I, who all stated that call buttons should be within residents' reach. The facility's policy also indicated that call lights should be placed within residents' reach, highlighting a systemic issue in ensuring accessibility.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents. Specifically, Resident 59's room had bent window screens, a large hole in the wall, and a leaking toilet pipe that wet the floor every time it was flushed. Despite informing the staff, these issues were not addressed, leading to potential health and safety risks. Additionally, the walls at the heads of the beds of two other residents were peeling, exposing the drywall beneath. These deficiencies were observed during a survey, and the regional maintenance director acknowledged that these issues should have been fixed.
Failure to Ensure Advance Directives and POLST Completion for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 6 and 284, were informed about having an advance directive (AD) and that their Physician Orders for Life-Sustaining Treatment (POLST) forms were completed and readily available. For Resident 6, who was admitted with diagnoses including cerebral infarction, developmental delay, dementia, and parkinsonism, the POLST was found incomplete during a review by the Director of Nursing (DON) and the Social Service Director (SSD). The sections regarding medical interventions, artificially administered nutrition, and information and signatures were not marked completely. The SSD confirmed that Resident 6 did not have an advance directive, and the issue was not addressed during the initial care conference with the resident's responsible party. Similarly, for Resident 284, who was admitted with diagnoses including sepsis, open wounds, depression, and type 2 diabetes mellitus, the POLST was not present in the chart or the electronic health record. The DON and SSD confirmed the absence of both the POLST and an advance directive for Resident 284. The facility's policy and job descriptions indicated that the social services department was responsible for facilitating the advance directive decision-making process and ensuring that residents or their representatives were informed and assisted in formulating an advance directive if needed.
Breach of Resident Confidentiality Due to Unattended Computer Screens
Penalty
Summary
The facility failed to protect the confidentiality of residents' protected health information (PHI) when a licensed nurse left computer screens open and unattended on the treatment cart. This occurred for two residents, Resident 31 and Resident 64. During an observation, it was noted that a registered nurse (RN K) left the computer screen open displaying Resident 31's physician's treatment orders, which included wound treatments, while attending to the resident's care. The computer was left unattended in a busy hallway, potentially exposing sensitive information to unauthorized individuals. The Director of Nursing (DON) confirmed that nurses are expected to sign out from the computer before entering a resident's room, especially in high-traffic areas. Similarly, for Resident 64, RN K left the computer screen open with the resident's wound treatment information while providing care. The facility's policy on confidentiality, which was undated, emphasized the importance of protecting residents' privacy and ensuring that medical information is not accessible to unauthorized persons. The failure to adhere to these policies resulted in a breach of confidentiality for the residents involved.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was prescribed Eliquis, an anticoagulant medication, for the prevention of deep vein thrombosis (DVT). The resident, who had a history of unspecified mood disorder and traumatic brain injury, was admitted with a physician's order for Eliquis to be administered twice daily. However, a review of the resident's medical record revealed that there was no care plan in place to address the use of Eliquis, including goals, approaches, interventions, and monitoring for signs and symptoms of bleeding. During an interview, the Director of Nursing acknowledged the absence of a care plan for the medication, which was contrary to the facility's policy requiring a comprehensive care plan to be completed within seven days after the comprehensive assessment.
Failure to Provide Necessary Care and Services for Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. Resident 10, who was admitted to the facility with open skin areas on her face, did not have a treatment order for these areas. Observations over several days confirmed the presence of these open skin areas without any treatment orders being initiated. This lack of action was acknowledged by a licensed vocational nurse, who confirmed the absence of a treatment order for Resident 10's condition. Similarly, Resident 184, who was at high risk for falls due to a dementia diagnosis, did not have a floor mat at his bedside as ordered by his physician and recommended by the interdisciplinary team. Despite being identified as a necessary intervention in his fall care plan, observations revealed the absence of the floor mat on multiple occasions. This oversight was also confirmed by a licensed vocational nurse, who acknowledged the missing floor mat despite its documented necessity in the resident's care plan.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter. The resident's catheter was not properly secured, and the urinary tube connected to the drainage bag was filled with thick yellow sediments. This was observed during a wound treatment session, where it was noted that the catheter stabilization device was inadequately secured with surgical tape, and there was a small amount of dried blood on the resident's left thigh. The facility's policy indicated that routine catheter care should be performed daily, and the catheter should be inspected for any problems, with enough slack provided before securing to prevent tension on the tubing. Interviews with the RN and the DON revealed discrepancies in the catheter care practices. The RN stated that the urine bag should be changed at least monthly or as needed, while the DON indicated it should be changed weekly and as needed for blockage, leakage, or sediment buildup. The catheter stabilization device was also supposed to be changed weekly and as needed. However, the resident's clinical records lacked documentation of when the catheter, urine bag, and stabilization device were last changed, indicating a failure to adhere to the facility's policies and procedures for catheter care.
Failure to Identify and Report Drug Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported drug irregularities during the monthly medication regimen review (MRR) for two residents. Resident 29 was receiving two loop diuretics, Furosemide and Torsemide, simultaneously for over a year without a documented risk/benefit assessment or clinical rationale. The CP admitted to not identifying this duplicate therapy as an irregularity during the monthly MRR, which was confirmed during an interview with the Director of Nursing (DON). Resident 2 was prescribed five psychotropic medications for conditions such as bipolar disorder and brief psychotic disorder. Despite the resident not exhibiting any behaviors for which these medications were indicated over a six-month period, there was no documented evidence of attempts to gradually reduce the doses (GDR) of these medications. The physician repeatedly marked GDR as contraindicated without providing a clinical rationale for this decision, even after the CP recommended a dose reduction. The facility's policy requires that medication regimen review recommendations and findings be documented and acted upon, with the physician providing a rationale if they reject the CP's recommendations. However, in the case of Resident 2, the physician disagreed with the CP's recommendations without offering a clinical rationale, which was confirmed by the DON and nursing supervisor during the survey.
Duplicate Loop Diuretics Prescribed to a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, as evidenced by the administration of two medications from the same therapeutic class for over a year. The resident, who was admitted with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, and chronic congestive heart failure, was prescribed both furosemide and torsemide, which are loop diuretics. The physician orders indicated that furosemide was prescribed on one date, and torsemide on another, leading to duplicate therapy. During interviews, the consulting pharmacist expressed uncertainty about the rationale for the resident being on both medications and acknowledged that there are no current standards of practice supporting the use of double loop diuretics simultaneously for the same or different medical conditions. The facility's policy on pharmaceutical services emphasized that medications should be administered safely and only those necessary to treat existing conditions should be included in a resident's medication regimen. This oversight in medication management had the potential to expose the resident to unnecessary medication and increased risk of adverse effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.41% during a medication administration observation, exceeding the acceptable threshold of 5%. This was due to two medication errors involving one resident. The first error occurred when a Licensed Vocational Nurse (LVN) administered an incorrect dosage of Lamictal to a resident. The resident was supposed to receive a total of 250 mg of Lamictal, but only received 50 mg because the 200 mg dosage was not in stock. The LVN had reordered the medication from the pharmacy the previous day, but it was still unavailable the following day, resulting in the resident missing a dose. The second error involved the improper administration of olopatadine eye drops. The LVN did not apply the drops into the conjunctival sac as required and failed to instruct the resident to close their eyes slowly or compress the tear ducts after administration. The LVN was unaware of the correct procedure, which was confirmed by the Director of Nursing, who stated that eye drops should be applied to the conjunctiva sac and pressure applied to the lacrimal gland post-administration. The facility's policy on eye drop administration, which outlines these steps, was not followed, leading to the medication error.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, as evidenced by two specific incidents. First, during a medication storage inspection, an emergency medication kit was found to contain expired lorazepam tablets, with an expiration date of 04/2024. This was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the expired medication should have been replaced. The facility's policy on medication storage, dated 1/2024, mandates that outdated medications be immediately removed from stock and reordered from the pharmacy. In a separate incident, a treatment cart containing wound care supplies was left unlocked and with a drawer open in the hallway. This occurred while a registered nurse (RN) was treating a resident with wounds on the gluteal folds. The RN had left the cart unattended to retrieve a skin protectant packet, leaving the cart unsecured. The facility's policy from 2007 requires that medication supplies remain locked when not in use or attended by authorized personnel. Both incidents highlight lapses in adherence to the facility's medication storage policies.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which led to a deficiency in dietary services. Resident 46, who was on a pureed diet, had a documented dislike for fish. Despite this, during a tray line observation, it was noted that a kitchen staff member plated pureed fish on Resident 46's lunch tray. The registered dietician confirmed that the tray card indicated the resident's dislike for fish and acknowledged that an alternative entree should have been provided. The facility's policy requires that residents be offered substitute food items of similar nutrient value when they dislike a menu item, but this was not adhered to in this instance.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to provide snacks in accordance with a resident's needs, preferences, and requests, specifically for a resident who was on antibiotics that caused stomach upset. The resident reported that the night staff did not have crackers available when requested, leading to the resident stopping the antibiotic treatment. The resident's medical history included acute on chronic systolic heart failure, hypertension, and gastro-esophageal reflux disease. The resident's medication administration record showed refusals of the antibiotic doses due to the lack of snacks to alleviate stomach upset. Observations and interviews revealed that the facility did not store snacks at nurse stations or medication rooms, and the kitchen staff discarded evening snacks in the morning. The director of nursing confirmed the lack of snack storage and reliance on kitchen staff for snack provision. Additionally, there was no documentation of a dietary assessment for the resident's food preferences upon admission, as required by the facility's policy. The registered dietitian confirmed the absence of a nutrition assessment for the resident, highlighting a failure to meet the resident's dietary needs and preferences.
Unsafe Bed Conditions for a Resident
Penalty
Summary
The facility failed to provide a safe and comfortable environment for Resident 81 due to loose and wobbly headboard and footboard on the resident's bed. During an observation and interview with the Director of Nursing (DON) and Resident 81, it was noted that the wooden headboard was tilted to the left with a screw on the right side about to come off, and the footboard was leaning forward and wobbly when touched. Both the DON and Resident 81 confirmed these observations. Licensed Vocational Nurse A (LVN A) stated that staff should report faulty equipment, such as a malfunctioning bed, to the maintenance log at the nurse station and follow up if the work order is not completed. The Director of Operations (DO) indicated that faulty equipment should be recorded in the maintenance binder, which should be checked daily by maintenance staff. However, a review of the maintenance log at nurse station AA revealed no work order regarding Resident 81's bed, and no work orders were entered for the entire month of June 2024.
Failure to Prevent Resident Fall and Injury
Penalty
Summary
The facility failed to prevent accidents for a resident who had multiple diagnoses, including Leigh's disease, dementia, and osteoporosis, among others. The resident was assessed to have a severe cognitive impairment and required limited assistance with transfers and walking. Despite being identified as high risk for falls, the facility did not develop a care plan for Activities of Daily Living (ADL) functional/rehabilitation potential and did not implement resident-centered interventions for falls. This lack of proper planning and supervision led to the resident experiencing a fall that resulted in a fracture of the second cervical vertebra and a facial laceration. The resident's clinical records indicated that she was not steady and required staff assistance for walking and turning around. However, on the night of the incident, the resident was found on the ground in another resident's room with a laceration on her eyebrow. Interviews with staff revealed that the resident was not checked frequently and did not receive the required assistance. The resident's fall care plan was not tailored to her specific needs, and there was no ADL care plan in place, which was confirmed by the Registered Nurse and other staff members. Further review of the facility's policies indicated that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility's fall management policy also emphasized the need for resident-centered approaches to managing falls, which were not implemented in this case. The lack of supervision and appropriate care planning directly contributed to the resident's fall and subsequent injuries.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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.
