Eden Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayward, California.
- Location
- 27350 Tampa Avenue, Hayward, California 94544
- CMS Provider Number
- 056052
- Inspections on file
- 38
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Eden Healthcare Center during CMS and state inspections, most recent first.
A resident using a Purewick external catheter system reported that the urine collection canister was only rinsed with soap and water and never disinfected. A CNA confirmed the canister was cleaned once or twice daily with soap and water only, with no documentation of cleaning. An undated posted procedure directed staff to scrub the canister with soap and water and dry it, but did not include the manufacturer-required steps of fully submerging the canister in a soapy solution and then in 70% IPA for at least ten minutes each. The IP and facility policies stated that the urine collection system should be cleaned and disinfected per manufacturer instructions and that alcohol is an appropriate disinfectant for non‑critical items, but actual practice did not meet these requirements.
A resident with intact cognition and significant comorbidities was left in a Hoyer sling for an extended period during a bed change, developed increasing and eventually excruciating L hip pain, and repeatedly requested to be returned to bed. Instead of honoring these requests, staff and an outside vendor proceeded in attempting a wheelchair/power chair fitting while the resident remained in pain and became increasingly agitated, screaming and using profanity. The resident was only returned to bed after the chair was removed, despite a facility policy requiring that residents be treated with dignity and respect and allowed to make choices about daily life.
Two moderately cognitively impaired roommates, both ambulatory and with significant medical conditions including metabolic encephalopathy, pneumonia due to COVID-19, spinal stenosis, and dementia, were involved in an altercation after one resident asked the other to take a cell phone call into the hallway so he could rest. A CNA alerted an LVN, who found a resident in the bathroom washing blood from his face and noted facial injuries, while the roommate sat on his bed talking to himself and was later observed with a small drop of blood on his hand. Progress notes and ED documentation described lacerations to the right eyebrow and lower eyelid, swelling and bloodshot appearance of the right eye, facial contusions, and resident reports of being struck in the face and chest by the roommate. This occurred despite a facility abuse prevention policy stating residents have the right to be free from all forms of abuse, including physical abuse.
Two residents with cognitive impairments were involved in a physical altercation, resulting in multiple skin tears and a bite injury. Staff responded after hearing a commotion and found one resident swinging her arms at the other, who was defending herself. The incident led to pain and injuries, demonstrating a failure to protect residents from abuse as required by facility policy.
A licensed nurse (ADON) increased a resident's Seroquel dose to 50 mg twice daily without a physician's order, as shown in the MAR and confirmed by record review and staff interviews. The DON verified that the nurse acted beyond her scope of practice by making this medication change without proper authorization.
A resident with schizoaffective disorder and severe cognitive impairment received an increased dose of Seroquel without a documented physician order, clinical indication, or timely informed consent. The medication change was implemented based on a verbal instruction, but records did not support the need for the increase, and the required written consent from the responsible party and physician was not obtained until months later.
A resident with quadriplegia was left unsupervised on a hoyer lift for 30 minutes and assisted by only one staff member during a transfer, contrary to the care plan requiring a two-person assist. This resulted in the resident's discomfort and potential risk of injury, as confirmed by the ADON and facility policy.
The facility failed to ensure appetizing and nutritious meals, affecting all residents, including those on pureed diets. Residents reported unpalatable food, confirmed by test trays showing flavorless and greasy meals. Staff did not follow recipes for pureed bread, using water instead of broth, milk, or juice, affecting nutritional value. The Dietary Supervisor and RD were responsible for food quality, but deficiencies in taste and nutrition were evident.
The facility failed to maintain sanitary conditions for resident food storage, as observed in a refrigerator with brown stains and undated food items. Staff interviews revealed inconsistencies in policy implementation, with some family members placing food in the refrigerator themselves. The Dietary Supervisor, IP LVN, DON, and Administrator all highlighted the need for food to be labeled and dated, but the refrigerator was found dirty and with undated items.
The facility failed to ensure proper disposal of garbage and refuse, as the dumpster lid was observed open on multiple occasions, contrary to facility policy. Interviews with staff confirmed the expectation for the dumpster to be closed, with janitorial staff responsible for its maintenance. This deficiency potentially affected all 116 residents.
The facility did not consistently complete infection surveillance checklists as part of its antibiotic stewardship program. The IP LVN admitted to performing McGeer criteria assessments mentally without documentation, citing a lack of guidance. The DON and Administrator expected the IP LVN to review antibiotic use against the McGeer criteria and consult with physicians if criteria were not met, potentially affecting all residents prescribed antibiotics.
The facility failed to conduct smoking assessments for a resident, provide supervision for another, and implement safety measures for a third, leading to unsafe smoking practices. Additionally, medications were left at the bedside for two residents without proper assessments, violating facility policy.
The facility failed to properly label and store medications on two units, with loose pills and improper storage of topical and oral medications on the South 2 Unit, and an illegible expiration date on a medication bottle on the North 1 Unit. Staff interviews revealed inconsistencies in responsibilities for maintaining medication cart cleanliness and checking for expired medications.
A facility failed to notify a physician when a resident's blood sugar levels exceeded 350 mg/dL, contrary to its policy. The resident, with a history of diabetes and on insulin therapy, had multiple instances of elevated blood sugar levels documented without physician notification. Staff interviews revealed inconsistent understanding of the notification policy, with some nurses indicating they would only notify if levels exceeded 400 mg/dL, while others suggested a lower threshold.
The facility failed to maintain a safe and homelike environment for two residents, one with a hole in their bathroom door and another with an exposed electrical box. Despite policies requiring prompt maintenance, no requests were documented, and staff interviews revealed a lack of communication and oversight, with the acting administrator unaware of these issues.
A facility failed to accurately code the MDS assessment for a resident with schizophrenia, despite a PASRR Level II determination indicating the need for specialized mental health services. The MDS was incorrectly marked as not having a serious mental illness, contrary to the resident's documented condition. Interviews with staff revealed a lapse in ensuring the accuracy of assessments, as required by facility policy.
A resident with a serious mental disorder was not referred for a Level II PASARR evaluation after a positive Level I screening, contrary to facility policy. The deficiency was discovered during a survey, revealing that the necessary referral was delayed until prompted by the surveyor. Interviews with staff indicated a lapse in following the established process for PASARR evaluations.
A resident's medication orders lacked specified dosages, leading to improper administration of supplements by an LVN. Despite the facility's policy requiring clarification of incomplete orders, the LVN did not contact the physician for the correct dosages. Interviews with staff confirmed the expectation to verify and clarify medication orders, highlighting a deficiency in following established procedures.
A facility failed to ensure a resident's physician order matched their POLST form, which indicated a DNR status. Despite the resident's advance directive and POLST form indicating DNR, the Order Summary Report listed a Full Code order. Interviews with staff, including LVNs and the DON, highlighted the expectation for matching documentation, which was not met, resulting in a failure to adhere to the resident's advance directive.
A facility failed to maintain accurate medical records for a resident with a history of dementia and other conditions, by incorrectly documenting skin assessments. Despite having a Stage 4 pressure ulcer, nursing staff mistakenly recorded the resident as having clear skin. The DON and Administrator acknowledged the records should have been accurate but were unsure why errors occurred.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure injury, as required by their policy. During an observation, an LVN performed wound care without using a gown or following EBP, and there was no signage or PPE available outside the resident's room. The resident's family had requested that EBP not be used, feeling it demeaned the resident, but this refusal was not documented. The IP LVN and DON acknowledged the necessity of EBP for residents with wounds to prevent infections.
A resident with severe cognitive impairment was offered a pneumococcal vaccine without the facility contacting the conservator for consent, as required by policy. The resident, unable to make healthcare decisions, declined the vaccine. Staff interviews revealed a misunderstanding of the protocol, with no documented evidence of conservator contact.
A resident with osteoporosis did not receive their prescribed Fosamax medication despite it being documented as administered in the MAR. The resident reported not receiving the medication, indicating a failure in the facility's medication management process. Interviews revealed that the facility did not follow its policy for handling unavailable medications, leading to a significant lapse in care.
The facility failed to provide a safe and clean environment for two residents when another resident with severe cognitive impairment repeatedly entered their rooms and urinated on their belongings and the floor, causing emotional distress. Staff interviews confirmed the behavior and the need for more supervision.
Failure to Clean and Disinfect Urine Collection Canister per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to clean and disinfect a urine collection canister according to the manufacturer’s instructions and the facility’s own policies. A cognitively intact resident, admitted with chronic systolic heart failure, acute myocardial infarction, and type 2 diabetes mellitus, used a Purewick external female catheter urine collection system every shift for urinary incontinence management. During an observation and interview in the resident’s room, the resident reported that the urine canister had never been disinfected and had only been rinsed with soap and water. A CNA stated that the resident’s urine canister was cleaned with soap and water once or twice a day and that there was no documentation of canister cleaning. An undated procedure titled “Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter” posted in the resident’s bathroom directed staff to empty urine into the toilet, scrub the canister with soap and water using a brush, and dry it with a paper towel, with no disinfection step or required contact time. The Infection Preventionist confirmed that staff were educated to clean and disinfect the canister with soap and water and to wipe off sediments with a brush, and also confirmed there was no documentation for canister cleaning. Review of the facility’s policy “External Catheter for Female Urinary Incontinence Management” stated that the urine collection system and accessories should be cleaned and disinfected at each use or at least daily per manufacturer’s instructions. The manufacturer’s instructions for “Cleaning the Collection Canister” required an initial rinse, then full submersion of the canister and lid in a dish soap solution for a minimum of ten minutes with brushing while submerged, followed by rinsing, visual inspection, and then full submersion in 70% isopropyl alcohol for a minimum of ten minutes, with a final rinse and drying. The Infection Preventionist acknowledged that following these instructions could prevent growth of bacteria and fungus and that the canister is a non‑critical care item. The facility’s policy on cleaning and disinfection of resident-care items identified alcohol as an appropriate disinfectant for non‑critical items, but the implemented procedure and staff practice did not follow the required cleaning and disinfection steps or contact times for the resident’s urine collection canister.
Failure to Honor Resident’s Choice and Dignity During Painful Hoyer Transfer
Penalty
Summary
The deficiency involves a failure to honor a cognitively intact resident’s right to dignity, respect, and choice during a transfer and equipment change. The resident, who had chronic systolic CHF and morbid obesity, was admitted on an earlier date and had a BIMS score of 15, indicating intact cognition. During an episode in which his malfunctioning bariatric bed was being changed, he was lifted from bed in a Hoyer sling operated by a restorative nursing assistant, with rehab staff and outside Kaiser staff present. The process took longer than the resident anticipated, and while he remained suspended in the sling, he began experiencing increasing left hip pain. Staff adjusted the existing bariatric bed so it could be removed from the room, leaving the resident in the sling for an extended period. Once the old bed was removed, instead of immediately returning the resident to bed as he requested due to escalating, “excruciating” left hip pain, Kaiser staff brought in a wheelchair/power chair and attempted to proceed with a wheelchair fitting. The resident repeatedly requested to be returned to bed and expressed that he did not want to continue with the fitting because of his pain. Staff attempted to support his left hip but continued with efforts to fit him to the chair while he remained in the sling and became increasingly agitated, screaming, cussing, and demanding to go back to bed. Only after the wheelchair/power chair was removed from the room was the new bariatric bed brought in and the resident returned to bed, at which point he verbalized displeasure with vulgar comments about the pain he experienced while in the sling. The facility’s own resident rights policy states that residents are to be treated with dignity and respect and allowed to make choices about daily life, which was not followed in this incident.
Failure to Protect Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. One resident with metabolic encephalopathy and pneumonia due to COVID-19, who had a BIMS score of 12 indicating moderate cognitive impairment, shared a room with another resident diagnosed with spinal stenosis and unspecified dementia, also with a BIMS score of 12. On the evening of the incident, a CNA alerted an LVN that the first resident was in the bathroom with visible facial bleeding. The resident reported that his roommate had hit him in the face after he asked the roommate, who was pacing and talking on a cell phone, to take the call into the hallway so he could rest. When the LVN entered the room, the injured resident had an injury on his forehead and was washing blood from his face, while the roommate was sitting on his bed talking to himself; during the subsequent police investigation, a small drop of blood was noted on the roommate’s hand. Progress notes documented that the resident had lacerations to the right eyebrow and right lower eyelid, with the right eye swollen, red, and bloodshot. The lacerations measured approximately 4 cm by 0.5 cm on the right eyebrow and 2 cm by 0.5 cm on the right lower eyelid. The resident stated that when he tried to talk to his roommate about pacing and phone use, the roommate suddenly raised his arms and made contact with his right eye, causing the injury. An emergency department note recorded that the resident complained of pain in his head, face, and chest, and that he reported being hit in both the face and chest by his roommate. The ED documented contusions to the right maxillary soft tissues and the soft tissue surrounding the right eye and supraorbital ridge, with a discharge diagnosis of injury due to physical assault, contusion of face, and safeguarding concerning adult. These events occurred despite the facility’s written Abuse Prevention Policy, which states that residents have the right to be free from all forms of abuse, including physical abuse, and that the facility prohibits and prevents such abuse.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect two residents from abuse when a physical altercation occurred between them. Resident 2, who had dementia with behavioral disturbances and severe cognitive impairment (BIMS score of 5), and Resident 4, who had moderate cognitive impairment (BIMS score of 10) and a diagnosis of osteomyelitis, were involved in the incident. Resident 2 sustained multiple skin tears with bleeding, while Resident 4 suffered a skin tear on her right index finger after being bitten. The altercation began when Resident 4 became upset that Resident 2 was using her wheelchair, leading Resident 4 to scratch Resident 2, and Resident 2 to bite Resident 4's finger. A registered nurse responded to a commotion in the shared room and observed Resident 4 swinging her arms at Resident 2, who was attempting to defend herself. Staff intervened and separated the residents, but not before Resident 2 had sustained significant injuries. The facility's abuse prevention policy prohibits all forms of abuse and neglect, but the incident resulted in pain and injuries to both residents, indicating a failure to ensure their safety from abuse.
Nurse Increased Medication Dose Without Physician Order
Penalty
Summary
A licensed nurse, specifically the Assistant Director of Nursing (ADON), increased the dose of Seroquel (Quetiapine) for a resident without obtaining a physician's order. The resident's medication was changed to 50 mg twice daily, as reflected in the Medication Administration Record (MAR) from December 2024 through April 2025. Review of the resident's electronic health record and order summary did not show any physician authorization for this dosage increase. During interviews and record reviews, the ADON acknowledged entering a verbal order for the increased dose but could not provide evidence of a physician's directive for this change. The Director of Nursing (DON) confirmed that the ADON acted beyond the scope of her license by increasing the medication dose without a physician's order. This action was not supported by any documented indication or authorization from a physician.
Unnecessary Psychotropic Drug Increase Without Proper Orders or Consent
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and severe cognitive impairment had their Seroquel (Quetiapine) dosage increased from 25 mg twice daily to 50 mg twice daily without a documented physician order, clinical indication, or timely informed consent. The resident's records showed no increase in hallucination episodes to justify the dosage change, and the new order for Seroquel did not match the previously documented indication or monitoring for schizoaffective disorder. The Assistant Director of Nursing (ADON) stated she entered the new order based on a verbal instruction during an interdisciplinary team meeting, but could not find documentation of a physician's order or indication for the increase in the resident's electronic health record. Additionally, the required written informed consent for the psychotropic medication increase was not obtained from the resident's responsible party (RP) until over two months after the medication change was implemented. The consent form remained unsigned by both the RP and the physician during this period, and facility records indicated the RP was available for part of the time when the consent could have been obtained. Facility policy requires that psychotropic medications be clinically indicated, necessary, and supported by documented evaluation and consent, which was not followed in this case.
Resident Left Unsupervised on Hoyer Lift
Penalty
Summary
The facility failed to ensure safe patient handling for a resident who was left unsupervised on a hoyer lift for 30 minutes and was assisted by only one staff member during a transfer. The resident, who was admitted with diagnoses of polymyositis and quadriplegia, required assistance for personal care and was totally dependent on staff for transfers. The resident's care plan specified the need for a two-person assist during transfers and emphasized the importance of staff supervision while the resident was on the hoyer lift. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident suspended on the hoyer lift without supervision, assuming the next CNA would lower the resident. However, the resident remained unsupervised for an extended period, and when another CNA eventually attended to the resident, they attempted to transfer the resident alone, causing discomfort. The Assistant Director of Nursing confirmed that two staff members should be present during hoyer lift transfers to prevent falls and ensure resident comfort, as per the facility's policy on safe resident handling and transfers.
Deficiencies in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was appetizing and prepared according to the facility's guidelines, affecting all 116 residents receiving meals, including 18 on pureed diets. During a Resident Council Meeting, several residents with intact cognition reported that the food lacked variety, flavor, and was unpalatable. Observations during meal service confirmed these complaints, with test trays revealing flavorless, overcooked vegetables, greasy chicken, and dessert with an artificial taste. The Dietary Supervisor acknowledged the issues, describing the meals as bland and the chicken as tough. Additionally, the facility did not adhere to its own recipe for pureed bread, which called for broth, milk, or juice, and instead used water and margarine, potentially affecting the nutritive value. Staff were observed preparing pureed bread incorrectly, and interviews revealed a lack of awareness about the recipe requirements. The Dietary Supervisor and Registered Dietitian confirmed that the use of water instead of the specified ingredients could dilute the nutritional content, as water lacks calories and protein. Interviews with the Director of Nursing and the Administrator indicated a reliance on the Dietary Supervisor and Registered Dietitian to ensure food quality and adherence to recipes. However, the failure to follow recipes and ensure palatable meals was evident, as staff did not review or follow the recipes correctly, leading to deficiencies in both taste and nutritional value of the meals served to residents.
Failure to Maintain Sanitary Conditions for Resident Food Storage
Penalty
Summary
The facility failed to ensure that foods brought in by visitors were stored in a sanitary manner, specifically in the resident refrigerator. During an observation, the refrigerator was found to have brown stains and liquid at the bottom, along with undated food items such as half a cake, a bag of Chinese takeaway, and a fast-food bag. Licensed Vocational Nurse (LVN) #6 confirmed that the food items were not dated and mentioned that some residents' family members placed food into the refrigerator themselves, contrary to the facility's policy. Interviews with various staff members, including the Dietary Supervisor (DS), Infection Prevention Licensed Vocational Nurse (IP LVN), Director of Nursing (DON), and the Administrator, revealed inconsistencies in the implementation of the facility's policy. The DS stated that only staff were permitted to place food in the refrigerator, and it was supposed to be cleaned every three days. However, the IP LVN admitted that the refrigerator was not routinely checked or cleaned, and the DON and Administrator both emphasized that food should be labeled and dated by whoever received it. Despite these expectations, the refrigerator was observed to be dirty with undated food items, indicating a lapse in adherence to the facility's procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the proper disposal of garbage and refuse, as observed during a survey. The facility's policy required that refuse containers and dumpsters outside the facility have tightly fitting lids and be kept covered when not being loaded to minimize debris accumulation and prevent insect or rodent attraction. However, during observations on two separate occasions, the dumpster lid was found open, with trash visible. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator confirmed that the dumpster was supposed to be closed, with the janitorial staff responsible for maintaining it. This deficiency had the potential to affect all 116 residents residing in the facility at the time of the survey.
Failure to Complete Infection Surveillance Checklists
Penalty
Summary
The facility failed to consistently complete infection surveillance checklists as part of its antibiotic stewardship program for residents who received prescribed antibiotic therapy. The facility's policy, implemented in July 2023, required an infection prevention and control program that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. However, the facility's Infection Control Data Logs from January 2024 through September 2024 did not indicate if infections met the McGeer criteria, except for one instance in February 2024. The Infection Prevention (IP) Licensed Vocational Nurse (LVN) admitted to performing the McGeer criteria assessments mentally without documenting them, citing a lack of guidance as a new IP. Interviews with the IP LVN, Director of Nursing (DON), and the Administrator revealed a lack of adherence to the expected procedures. The IP LVN acknowledged her inexperience and the absence of proper guidance, while the DON and Administrator expressed their expectations for the IP LVN to review antibiotic use against the McGeer criteria and consult with physicians if the criteria were not met. This deficiency had the potential to affect all residents in the facility who were prescribed antibiotics.
Deficiencies in Smoking Safety and Medication Administration
Penalty
Summary
The facility failed to complete a smoking assessment for Resident #79, who was admitted with a medical history including schizophrenia and cognitive impairment. Despite the facility's policy requiring smoking assessments, there was no evidence that Resident #79 was assessed for their ability to smoke safely. Observations revealed burn holes in the resident's pants, indicating unsafe smoking practices. Interviews with staff, including the Director of Nursing and a Certified Nurse Assistant, confirmed a lack of awareness and assessment regarding the resident's smoking habits. Resident #91, who was assessed to require supervision while smoking, was observed smoking without supervision in the facility's courtyard. The resident had a history of schizoaffective disorder and intact cognition, as indicated by their BIMS score. Despite the assessment indicating the need for supervision, staff interviews revealed that the resident was provided with a nicotine patch but was not consistently supervised while smoking. The facility also failed to implement a safety intervention for Resident #10, who required a smoking apron due to safety concerns such as dropping ashes and impaired motor skills. Observations showed the resident smoking without the apron, and staff interviews indicated a lack of communication and awareness about the need for this safety measure. Additionally, the facility did not adhere to its medication policies, as medications were left at the bedside for Residents #58 and #82 without proper assessments for self-administration, contrary to facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in the medication carts on two units, South 2 and North 1. On the South 2 Unit, loose pills were found in the medication cart, and a topical medication and nebulizer solution were not stored separately from oral medications, contrary to the facility's policy. On the North 1 Unit, a bottle of guaifenesin oral solution had an illegible expiration date, which was confirmed by the LVN responsible for the cart. Interviews with various staff members, including RNs, LVNs, the Infection Prevention LVN, the Director of Nursing, and the Administrator, revealed inconsistencies in the understanding and execution of responsibilities regarding medication cart cleanliness, organization, and checking for expired medications. While charge nurses were generally held responsible for maintaining the carts, there was uncertainty about the frequency of checks for expired medications and the protocol for handling medications with illegible expiration dates. The facility's policies clearly outlined the need for separate storage of different types of medications and the importance of identifying expiration dates, but these were not consistently followed.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar levels reached 350 mg/dL or higher, as required by the facility's Hypoglycemia/Hyperglycemia Management policy. This deficiency was identified for one resident who had a history of type two diabetes mellitus and was on long-term insulin therapy. The resident's blood sugar levels were documented to be 350 mg/dL or higher on multiple occasions in July 2024, yet there was no documentation in the resident's progress notes indicating that the physician was notified of these elevated levels. Interviews with facility staff revealed a lack of consistent understanding and adherence to the policy regarding when to notify a physician about high blood sugar levels. Licensed Vocational Nurse #3 and Registered Nurse #17 indicated they would contact a physician only if blood sugar levels exceeded 400 mg/dL, while Registered Nurse #18 stated that most physicians wanted to be notified if levels were above 300 mg/dL. The Director of Nursing was unsure of the specific threshold for notification, and the Administrator acknowledged the need for an established level for physician notification.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment for its residents, as evidenced by the presence of a tennis ball-sized hole in the bathroom door of a resident's room. The resident, who had a history of depression and moderate cognitive impairment, reported that the hole had been there since their admission. Despite the facility's policy requiring maintenance issues to be documented and addressed promptly, no maintenance request was made for this issue. Interviews with staff revealed a lack of communication and documentation regarding the damage, with the CNA admitting to noticing the hole months prior but failing to report it. Another deficiency was identified in a different resident's room, where the cover for the call light electrical box was not fully attached, exposing wires. This resident also had moderate cognitive impairment and reported that while the call light issue had been resolved, the electrical box remained unrepaired. The facility's maintenance records showed no documented requests for this repair, and interviews with staff indicated that the maintenance director position was vacant, leading to a lack of oversight and follow-up on maintenance issues. The facility's policies on maintaining a safe and homelike environment and electrical safety were not adhered to, resulting in unresolved maintenance issues that compromised the residents' living conditions. The acting administrator, who had taken on the role of maintenance director, was unaware of these specific issues, highlighting a gap in the facility's maintenance request and repair process.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the Preadmission Screening and Resident Review (PASRR) requirements for a resident with a serious mental illness. Specifically, the MDS assessment for a resident with a diagnosis of schizophrenia was incorrectly coded as not having a serious mental illness, despite a PASRR Level II determination report indicating the need for specialized services to address mental health needs. This discrepancy was identified during a review of the resident's annual MDS, which was not aligned with the PASRR Level II determination. Interviews with facility staff, including an MDS Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the MDS assessments were expected to be accurate and reflective of the resident's condition. The LVN acknowledged the error in coding and was unsure why it was missed, while the DON emphasized the responsibility of MDS staff to ensure accuracy. The facility's policy on conducting accurate resident assessments requires that each assessor certifies the accuracy of their portion of the assessment, highlighting a lapse in adherence to this policy.
Failure to Conduct Timely Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with a serious mental disorder, was referred for a Level II PASARR evaluation following a positive Level I PASARR screening. The facility's policy requires that all applicants be screened for serious mental disorders or intellectual disabilities, and if a Level I screening is positive, a Level II evaluation must be conducted by the state-designated authority. However, the facility did not adhere to this policy for one resident who was admitted with a diagnosis of bipolar type schizoaffective disorder and schizophrenia, as indicated by their medical records and admission MDS. The deficiency was identified during a survey when it was discovered that the resident's Level I PASARR screening, which was positive for a suspected mental illness, did not lead to a timely Level II evaluation. Interviews with facility staff, including the MDS LVN and the Director of Nursing, revealed that the necessary referral to the PASARR office was not made until prompted by the surveyor. The facility's policy assigns the responsibility of tracking PASARR screening status and making referrals to the Social Services Director and/or MDS Coordinator, but this process was not followed in this instance.
Failure to Specify Medication Dosages
Penalty
Summary
The facility failed to ensure medication orders specified the intended dosages for a resident, leading to a deficiency in medication administration. The resident, who was admitted with a medical history of essential hypertension, chronic systolic heart failure, and alcohol-induced acute pancreatitis, had active orders for supplements such as folic acid, vitamin A, vitamin B6, and vitamin D3. However, these orders did not specify the dosages to be administered. During a medication pass, an LVN administered these supplements using the facility's stock bottles without confirming the correct dosages, as the orders were incomplete. Interviews with various staff members, including the LVN involved, the Infection Prevention LVN, another LVN, the DON, and the Administrator, revealed a consistent understanding that medication orders should include specific dosages and that nurses should contact the physician for clarification if orders are incomplete. Despite this understanding, the LVN did not seek clarification from the physician before administering the medications, resulting in a failure to adhere to the facility's medication administration policy, which requires correcting discrepancies and reporting them to the nurse manager, MD, or DON.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's physician order was consistent with their Physician Orders for Life-Sustaining Treatment (POLST) form, which indicated a Do Not Resuscitate (DNR) status. The resident, who had a history of neuropathy, type 2 diabetes, epilepsy, bipolar type schizoaffective disorder, dysphagia, and cognitive communication deficit, was admitted with an advance directive indicating DNR. However, the resident's Order Summary Report contained an order for Full Code, which was inconsistent with the POLST form signed by both the resident and the physician. Interviews with facility staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that there was an expectation for the POLST form and physician orders to match. Staff were responsible for ensuring the correct code status was documented and communicated. The discrepancy between the POLST form and the physician's order was not identified or corrected, leading to a failure in adhering to the resident's advance directive and the facility's policy on communication of code status.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #22, by not documenting accurate skin assessment information. The facility's policy on documentation required that each resident's medical record accurately represent their experiences and include sufficient details about their care. However, the records for Resident #22, who had a medical history of unspecified dementia, major depressive disorder, muscle wasting and atrophy, dysphagia, protein-calorie malnutrition, and adult failure to thrive, were found to be inaccurate. Specifically, the resident's care plan indicated a focus on impaired skin integrity related to peripheral vascular disease, with interventions requiring weekly skin assessments. Despite this, a surgical and wound care progress note reported a Stage 4 pressure ulcer on the resident's right lateral foot, which was not accurately reflected in the nursing weekly summaries. Both a Registered Nurse and a Licensed Vocational Nurse documented that the resident had clear skin, which was incorrect. Interviews with the nursing staff revealed that these entries were mistakes, and the Director of Nursing and the Administrator acknowledged that the medical records should have been complete and accurate, but they did not know why the assessments were filled out incorrectly.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure injury, as required by their policy. The policy specified that EBP should be considered for residents with wounds or indwelling medical devices, and included making gowns and gloves available near the resident's room. However, during an observation, a Licensed Vocational Nurse (LVN) performed wound care for the resident without using a gown or following EBP, and there was no signage or personal protective equipment (PPE) available outside the resident's room. Interviews revealed that the resident's family had requested that EBP not be used, feeling it demeaned the resident. The Infection Preventionist (IP) LVN and the Director of Nursing (DON) both stated that EBP was necessary for residents with wounds to prevent infections, and the IP LVN was surprised that the precautions were not in place. The IP LVN also noted that the refusal by the resident's family was not documented, and the LVN should have communicated this refusal when it occurred. The facility staff acknowledged the mistake in not implementing EBP during the resident's wound treatment.
Failure to Obtain Conservator Consent for Vaccination
Penalty
Summary
The facility failed to ensure that the responsible party for a resident with severe cognitive impairment was educated and provided the opportunity to consent for a pneumococcal vaccination. The facility's policy required that residents or their representatives receive education about the benefits and potential side effects of the vaccine, and that a consent form be signed prior to administration. However, in the case of the resident in question, who had a conservator due to severe cognitive impairment, the facility did not contact the conservator for consent. Instead, the resident, who was unable to make healthcare decisions, was approached directly and refused the vaccine. The resident's medical records indicated a history of schizophrenia and severe cognitive impairment, with a BIMS score of 6. Despite the resident's inability to consent, the facility's staff offered the vaccine directly to the resident, who declined and refused to sign the declination form. Interviews with facility staff, including the Infection Prevention LVN and the Director of Nursing, revealed a misunderstanding of the protocol, as the staff believed they had contacted the conservator but had no documented evidence of such contact. The Director of Nursing and the Administrator both acknowledged that the conservator should have been contacted for consent before approaching the resident.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident diagnosed with quadriplegia and osteoporosis, as they did not ensure the availability and administration of Fosamax, a medication prescribed to treat osteoporosis. Despite the medication being ordered and documented in the Medication Administration Record (MAR) as administered on specific dates in May and June 2024, the resident reported not receiving the medication. The discrepancy between the MAR entries and the resident's account suggests a failure in the medication administration process. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the facility did not follow its policy for handling unavailable medications. The policy requires notifying the pharmacy, physician, and resident if a medication is unavailable, which was not adhered to in this case. The facility's failure to ensure the medication was available and administered as ordered by the physician highlights a significant lapse in the medication management process, potentially affecting the resident's treatment and well-being.
Failure to Provide a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe and clean environment for two residents when another resident, who had severe cognitive impairment and a history of psychotic disorder, repeatedly entered their rooms and urinated on their belongings and the floor. Resident 4, who had a BIMS score of 2 out of 15 indicating severely impaired cognition, was reported to have gone into Resident 1's room and urinated on the curtain next to the bed, causing Resident 1 emotional distress. Resident 1, who had a BIMS score of 13 out of 15 indicating intact cognition, expressed feeling mad and upset about the incident. Staff interviews confirmed that Resident 4 had a behavior of entering other residents' rooms and urinating in undesignated areas, which was a known issue documented in Resident 4's progress notes. Additionally, Resident 4 was observed entering Resident 6's room without permission and had previously urinated on the floor in Resident 6's room. Resident 6, who had a BIMS score of 10 out of 15 indicating moderately impaired cognition, also expressed feeling mad about the incident. Staff interviews corroborated that Resident 4's behavior was a concern and that more supervision was needed for Resident 4 to ensure the safety of other residents. The facility's policy on residents' rights to a safe and clean environment was not upheld, as confirmed by the administrator during an interview.
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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