Foothill Regional Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Tustin, California.
- Location
- 14662 Newport Avenue, Tustin, California 92780
- CMS Provider Number
- 555730
- Inspections on file
- 31
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Foothill Regional Medical Center D/p Snf during CMS and state inspections, most recent first.
A long-term care facility failed to implement proper infection control practices, as evidenced by incomplete infection surveillance, unsanitary conditions, and improper use of PPE. The facility's infection surveillance tool did not record all residents with infections, and staff failed to disinfect stethoscopes and maintain cleanliness. Additionally, staff were not aware of Enhanced Barrier Precautions, leading to improper PPE use during high-contact activities.
The facility failed to develop comprehensive care plans for two residents, one requiring Jejunostomy tube feeding and an abdominal binder, and another dependent on GT feeding. Despite physician's orders, there was no documented care plan for their specific needs, confirmed by staff interviews. The CNO and Director of Quality and Risk acknowledged these deficiencies.
The facility failed to conduct required skin assessments every two hours for two residents with splint devices, as ordered by their physicians. Observations and interviews revealed that the assessments were not documented, and the care plans did not include necessary interventions. Staff cited time constraints as a reason for the oversight.
The facility failed to maintain the required head of bed (HOB) elevation for residents with gastrostomy tubes (GT), as observed in four residents. The facility's policy required the HOB to be elevated at a 30-degree angle or more during enteral feeding and medication administration to prevent aspiration. However, observations revealed that the HOB for these residents was not elevated to the required angle, posing a risk for complications. Staff members acknowledged the errors and the facility's CNO and Director of Quality and Risk were informed of these findings.
A facility failed to obtain informed consent for the use of side rails for a resident with encephalopathy. Despite a physician's order for padded side rails, the necessary informed consent from the resident's representative was not documented. Facility staff confirmed the oversight, acknowledging that the informed consent process had not been completed prior to the use of the side rails.
A facility failed to provide adequate pharmaceutical services, resulting in a 3.85% medication error rate. An LVN did not administer a complete dose of a multivitamin via GT, leaving residue in the cup, contrary to facility policy. Additionally, the LVN signed the electronic MAR for a saliva substitute oral gel before administering it, violating documentation protocols. These actions were confirmed by the CNO and Director of Quality and Risk.
A facility failed to document monitoring of seizure activities and side effects for a resident on multiple anticonvulsant medications, potentially leading to unnecessary medication use and adverse effects. The absence of a physician's order for monitoring was confirmed by both an RN and the CNO.
A facility failed to monitor a resident's behavior for the effectiveness of clonidine, a psychotropic medication used for irritability, and did not obtain informed consent when the medication's administration route, dose, and targeted behavior were changed. The resident had memory problems and impaired cognitive skills, and the facility lacked documentation of behavior monitoring. The Director of Quality and Risk acknowledged the absence of policies for psychotropic medication use.
A facility failed to properly store and label medications, as observed during a survey. An LVN left medications unattended on a cart, and a resident's simethicone bottle lacked an opened date label. The CNO and Director of Quality and Risk acknowledged these issues, highlighting the importance of locking medication carts and labeling opened medications to prevent risks.
The facility failed to maintain kitchen equipment in a sanitary condition and did not properly store food items, leading to potential contamination risks. Observations revealed stained cups, dusty lids, and marred cutting boards, along with expired and unlabeled food items in storage. The CDM verified these deficiencies.
The facility failed to offer and administer the COVID-19 vaccine to three residents, placing them at risk of infection. A resident's immunization record lacked evidence of vaccination, and the DSD/MDS Coordinator admitted the vaccine was not offered. Another resident's record showed consent for vaccination, but the vaccine was not administered due to oversight. The Director of Infection Prevention and CNO acknowledged these findings.
The facility failed to repair the dish machine in a timely manner, resulting in the final rinse temperature not reaching the required 180°F. Despite the CDM's efforts to address the issue through work orders and emails to the Plant Operations Director, the problem persisted, leading to the use of manual dishwashing for sanitization. The deficiency was confirmed through observations, interviews, and document reviews, with no corrective actions documented.
A facility failed to provide a resident or their representative with written notification of the bed hold policy during a transfer to an acute care hospital. Despite the facility's policy requiring such notification, staff interviews revealed that the necessary documentation was not provided, and the Chief Nursing Officer acknowledged the oversight.
The facility failed to complete quarterly MDS assessments for two residents, with the last assessments documented in early September. The MDS Coordinator confirmed the oversight was due to a calendar discrepancy, and the CNO acknowledged the expectation for timely submissions.
A facility failed to accurately code the MDS for a resident who was prescribed aspirin for anticoagulation. The MDS was incorrectly coded to reflect the use of an anticoagulant, despite aspirin not being classified as such. This error was confirmed by the DSD/MDS Coordinator and acknowledged by the CNO.
The facility failed to ensure proper storage of garbage and refuse, as observed in the area around the dumpster and compactor, which was littered with disposable items and a dark liquid with odor. The Plant Operations Director confirmed the need for cleaning, and the findings were acknowledged by the CNO and Director of Quality and Risk.
A resident with chronic respiratory failure fell when a CNA was lowering the siderail to take vital signs. The facility failed to conduct required neurological, skin, and body assessments post-fall, as per their P&P. Interviews with staff revealed inconsistencies in documentation and adherence to fall prevention protocols.
A facility failed to maintain complete and accurate fall risk documentation for a resident with a history of falls and high fall risk. The resident's Morse Fall Scale scores were either left blank or inaccurately recorded, despite staff acknowledging the resident's active nature and tendency to manipulate crib rails. The CNO confirmed the inaccuracies, which were not in line with the facility's policy.
The facility failed to ensure that two residents were free from physical restraints unless needed for medical treatment. The facility did not conduct assessments, obtain informed consent, or secure physician's orders before applying seat belt and chest strap restraints. Additionally, the facility did not implement the least restrictive interventions or monitor and document the use of these restraints.
The facility failed to ensure padded side rails for two residents with seizure disorders, despite physician's orders. Both residents were observed with elevated side rails without padding, which was confirmed by staff during observations and medical record reviews.
The facility failed to assess three residents for the risk of entrapment from elevated side rails, potentially placing them at risk for serious injury. Observations and medical record reviews confirmed that the residents' records lacked necessary assessments, a deficiency verified by facility staff.
A resident was prescribed quetiapine for neuro irritability without proper behavior indication, monitoring of behavior and side effects, or a formulated care plan. The deficiencies were confirmed through medical record reviews and interviews with the RN and DON.
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. An LVN did not administer medications to a resident within the prescribed two-hour window, potentially affecting the resident's health.
The facility failed to ensure proper storage and disposal of medications, as evidenced by an expired nasal spray found on a resident's bedside table and a vitamin D bottle with an unknown substance on it. Both incidents were acknowledged by staff and posed potential risks to resident well-being.
The facility failed to maintain sanitary conditions in the kitchen, with issues including dirty and worn-out utensils, a dirty kitchen hood, improper plumbing for the ice machine, and expired test strips for sanitizing solutions. These deficiencies were verified by the Dietary Services Supervisor and acknowledged by the Director of Food Services.
The facility failed to record all residents with infections on the Infection Surveillance Tool, maintain cleanliness in the laundry room, and remove isolation signage after a precaution order was discontinued. These deficiencies were confirmed through observations, record reviews, and staff interviews.
The facility failed to implement their Antibiotic Stewardship Program by not conducting necessary assessments using McGeer's criteria for three residents prescribed antibiotics and not notifying physicians when criteria were not met for three other residents. This oversight was confirmed by the Director of Infection Control and the Infection Control Coordinator.
A resident did not receive the COVID-19 vaccine despite consent being obtained from their responsible party. The consent form was misplaced, and the physician was not notified, resulting in the vaccination not being administered.
The facility failed to ensure that a resident's POLST was obtained and maintained in the medical record. Despite a physician's order for a Full Code and to obtain a POLST, the document was not present in the resident's medical record. Interviews with RNs confirmed the absence and acknowledged that the POLST should have been included to know the resident's code status and wishes.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge to another SNF. A review of the resident's medical record and interviews with the Ombudsman and RN confirmed the lack of notification.
The facility failed to develop and update comprehensive care plans for four residents, omitting necessary safety measures such as padded side rails and wheelchair restraints, despite physician orders and observed use. This was confirmed by interviews and record reviews with the facility's RNs.
The facility failed to ensure the medical record for a resident was complete and accurate. Physician's orders for a Posey Bed Enclosure and bilateral No-No Posey Sleeves were signed and dated but lacked the required time documentation. The RN Charge Nurse and DON confirmed that orders should be signed, dated, and timed, indicating a failure to adhere to the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection control practices, as evidenced by several deficiencies observed during the survey. The infection surveillance tool used by the facility did not record all residents with infections, only those with positive culture results. This oversight was confirmed by the Director of Infection Prevention, who admitted that the surveillance forms did not include all residents identified with infections according to McGeer's criteria. This failure to comprehensively track infections posed a risk for the transmission of disease-causing microorganisms. Additionally, the facility did not maintain a sanitary environment for its residents. During an initial tour, a resident's water pitcher was found to be dirty, with yellowish powder and stains, which was verified by an LVN. The LVN acknowledged that the water from the pitcher was used during medication administration, indicating a lapse in maintaining cleanliness and infection control. Furthermore, multiple LVNs failed to disinfect their stethoscopes after use on residents and before exiting their rooms, which was acknowledged by the staff and the CNO, highlighting a breach in infection control protocols. The facility also failed to ensure proper use of personal protective equipment (PPE) during resident care. Several staff members, including LVNs and RCPs, did not wear gowns while performing high-contact activities such as medication administration through gastrostomy tubes and suctioning through tracheostomy tubes. The staff's lack of awareness and training on Enhanced Barrier Precautions (EBP) was evident, as they were not familiar with the guidelines requiring gown and glove use during such procedures. This lack of adherence to PPE protocols further increased the risk of infection transmission within the facility.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific care needs. Resident 18, who was on a Jejunostomy tube feeding, had physician's orders for a pureed diet for oral gratification and the use of an abdominal binder to prevent GT dislodgement. However, the facility did not document a care plan to address these nutritional needs or the use of the abdominal binder. Interviews with CNA 3 and RN 2 confirmed the absence of a care plan for Resident 18's oral feeding, tube feeding, and abdominal binder use, despite the presence of physician's orders. Similarly, Resident 7, who was dependent on GT feeding, did not have a documented care plan addressing their enteral feeding needs. The medical record review and interview with RN 1 confirmed that the facility did not initiate a person-centered care plan for Resident 7's tube feeding, relying instead on standard professional practice. The CNO and Director of Quality and Risk acknowledged these findings, indicating a lack of individualized care planning for these residents.
Failure to Conduct Required Skin Assessments for Residents with Splints
Penalty
Summary
The facility failed to provide appropriate care for two residents, Residents 4 and 12, by not conducting required skin assessments every two hours when splint devices were applied, as ordered by their physicians. The facility's policy and procedure for splint application required visual checks of the skin before and after the application of splints, with documentation of these checks. However, observations and interviews revealed that these assessments were not documented, and the care plans for both residents did not include interventions for skin assessments every two hours. Resident 4, who had contractures on both upper and lower extremities, was observed without the prescribed splint devices in place. The medical record review showed physician orders for the application of bilateral splints with skin checks every two hours, but there was no evidence of these checks being documented. Interviews with the RNA and LVN confirmed the lack of documentation and the absence of specific times for skin assessments, citing time constraints as a reason for the oversight. Similarly, Resident 12, also with contractures, was observed without the splint devices. The resident's physician had ordered the application of splints with skin checks every two hours, but the care plan did not include these interventions. Interviews with the RNA and LVN confirmed the absence of documentation for the skin assessments. The CNO was informed of these findings and verified the lack of documentation and care plan interventions for both residents.
Failure to Maintain Proper HOB Elevation for Residents with GT
Penalty
Summary
The facility failed to ensure proper care and services for residents with gastrostomy tubes (GT), as observed in four residents. The facility's policy required the head of the bed (HOB) to be elevated at a 30-degree angle or more during enteral feeding and medication administration to prevent aspiration. However, during observations, it was noted that the HOB for Residents 1, 7, 9, and 12 was not elevated to the required angle, posing a risk for complications related to GT use. Resident 9, who was GT dependent, had their medication administered by LVN 1 with the HOB at a 20-degree angle, contrary to the facility's policy. LVN 1 acknowledged the error upon checking the bed's leveler. Similarly, Resident 12, also GT dependent, had their medication administered by LVN 3 with the HOB between 15 and 30 degrees. LVN 3 admitted to using visual judgment rather than the bed's indicator, which showed the angle was less than 30 degrees. Resident 1, receiving enteral feeding, was observed with the HOB at a 20-degree angle, confirmed by LVN 1, who acknowledged the requirement for a 30-degree angle to prevent aspiration pneumonia. Resident 7, dependent on a tracheostomy and GT, was observed with the HOB at a 15-degree angle during tube feeding. RN 4 confirmed the need for a 30-degree angle to prevent complications and adjusted the HOB accordingly. The facility's CNO and Director of Quality and Risk were informed of these findings and acknowledged the deficiencies.
Failure to Obtain Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails for one of the residents reviewed, identified as Resident 11. The facility's policy requires informed consent when side rails are used for patient safety. However, during a review of Resident 11's medical records, it was found that there was no documented evidence of informed consent for the use of padded bilateral upper and lower side rails. This oversight was confirmed during interviews with facility staff, including a CNA and an RN, who acknowledged that the informed consent had not been obtained prior to the use of the side rails. Resident 11, who was admitted to the facility with a history of encephalopathy, was observed with elevated padded bilateral upper and lower side rails. A physician's order for these side rails was present in the medical records, but the necessary informed consent from the resident's representative was missing. The RN confirmed that the bed was changed to one with side rails recently, and the informed consent process had not been completed. The CNO and Director of Quality and Risk were informed of these findings and acknowledged the deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in a medication error rate of 3.85%. During a medication administration observation, a licensed nurse (LVN 4) did not administer the complete dose of a multivitamin to a resident via a gastrostomy tube (GT), as significant residue was left in the medication cup. The facility's policy requires that any noticeable medication residue should be mixed with water and administered to ensure the complete dose is given. This oversight was confirmed by both LVN 4 and the Chief Nursing Officer (CNO), who acknowledged that medications should be administered as ordered by the physician. Additionally, the facility failed to ensure that the electronic Medication Administration Record (MAR) was signed only after the medication was administered. LVN 4 signed the electronic MAR for a saliva substitute oral gel before actually administering it to the resident. The CNO and Director of Quality and Risk confirmed that the electronic MAR should be signed during or immediately after medication administration, not before. These failures in medication administration and documentation could potentially affect the resident's health conditions and pose risks for complications or delays in interventions.
Failure to Monitor Seizure Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not document the monitoring of seizure activities and side effects for a resident who was prescribed multiple anticonvulsant medications, including clobazam, clonazepam, diazepam, lacosamide, lamotrigine, and levetiracetam. This lack of documentation and monitoring could lead to the resident receiving unnecessary medications and experiencing significant adverse effects. During an interview and medical record review, it was confirmed that there was no physician's order for monitoring the seizure activity and side effects of the anticonvulsant medications for the resident. The last recorded seizure activity was noted on 11/8/24, as reported by the resident's mother. Both the RN and the CNO verified the absence of a physician's order for monitoring, highlighting a deficiency in the facility's medication management practices.
Failure to Monitor Psychotropic Medication and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically clonidine, which was used to manage irritability. The facility did not monitor the resident's behavior to assess the effectiveness of the medication. Despite the resident having a history of memory problems and severely impaired cognitive skills, there was no documented evidence that the resident's behavior of irritability was monitored. Interviews with the Director of Pharmacy and a registered nurse confirmed that the behavior should have been monitored, but the medical record lacked documentation of such monitoring. Additionally, the facility did not obtain informed consent from the resident's representative when changes were made to the clonidine medication's route of administration, dose, and targeted behavior. The initial consent was for a clonidine patch for agitation, but the medication was later administered via a gastrostomy tube for irritability without updated consent. The Director of Quality and Risk acknowledged that the facility lacked policies and procedures for the use of psychotropic medications, as they did not have residents with psychiatric issues.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen leaving medications unattended on top of a medication cart. The medications included a green bottle of refresh eye lubricant, packets of polyethylene glycol, and doses of calcium carbonate tablets. The LVN acknowledged that the medications should have been stored inside the locked medication cart when unattended to prevent unauthorized access or administration errors. Additionally, a bottle of simethicone for a resident was found without an opened date label, contrary to the facility's policy requiring multi-dose vials to be labeled with an expiration date once opened. The LVN confirmed the absence of the label and stated that the nurse who first opened the medication should have labeled it. The Chief Nursing Officer (CNO) and Director of Quality and Risk acknowledged these findings, emphasizing the importance of locking medication carts and labeling opened medications to prevent risks such as medication theft and cross-administration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations in the kitchen and storage areas. During an inspection, it was noted that kitchen equipment was not maintained in a sanitary condition. Specifically, seven black cups had white stains, a plastic container lid was dusty, and a white tray with ceramic cups had brown stains and dust. Additionally, cutting boards were heavily marred and discolored, indicating they were not properly cleaned or replaced as needed. These conditions were verified by the Certified Dietary Manager (CDM), who acknowledged the need for re-cleaning and replacement of the items. Furthermore, the facility did not ensure proper storage of food items, which could lead to contamination. Observations in the walk-in refrigerator revealed meat and other food items past their 'good through' dates, such as black beans and pineapples, which were not discarded in a timely manner. There were also unlabeled items, including a piece of cake in multiple containers and a bin of flour, which should have been labeled and dated according to the facility's policy. The CDM confirmed these findings, acknowledging the failure to follow proper labeling and storage procedures.
Failure to Administer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was offered and administered to three residents, which placed them at risk of acquiring COVID-19. Resident 1's immunization record did not show evidence of COVID-19 vaccination, and the Director of Staff Development (DSD)/MDS Coordinator admitted that the vaccine was not offered to Resident 1's responsible party. Similarly, Resident 17's immunization record lacked documentation of COVID-19 vaccination from 2023 to 2025, and the DSD/MDS Coordinator confirmed that the vaccine was not offered to Resident 17's responsible party. Resident 6's responsible party had consented to the COVID-19 vaccination, but the immunization record did not show evidence of administration. The DSD/MDS Coordinator acknowledged that the vaccine was not administered due to an oversight. The Director of Infection Prevention and the Chief Nursing Officer (CNO) were informed of these findings and acknowledged the oversight in offering and administering the COVID-19 vaccine to the residents.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure the dish machine was repaired in a timely manner, resulting in the dish machine's final rinse temperature not reaching the required minimum of 180 degrees Fahrenheit as per manufacturer instructions. This deficiency was identified through observations, interviews, and document reviews. The Certified Dietary Manager (CDM) confirmed that the dish machine had not been showing the correct final rinse temperature and had submitted work orders to the engineering department, but the issue remained unresolved. As a result, the facility resorted to using a manual dishwashing method for sanitization. The facility's Dish Machine Temp Log revealed consistent failures in reaching the required final rinse temperature from August 2024 to January 2025, with no corrective actions or managerial reviews documented. Despite the CDM's efforts to address the issue by submitting work orders and following up with the engineering department, the problem persisted. The CDM also sent an email to the Plant Operations Director, highlighting the need for an external company to fix the broken water system, but no response or action was taken. Interviews with the Plant Operations Director confirmed that only two work orders were received, and the issue was temporarily fixed. However, the persistent problem with the dish machine's temperature was not adequately addressed, as evidenced by the lack of follow-up on the CDM's email. The Chief Nursing Officer and Director of Quality and Risk were informed of these findings, acknowledging the deficiency in maintaining the dish machine's proper functioning.
Failure to Notify Resident of Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy, revised in September 2024, mandates that residents be informed of their right to a bed hold upon admission and at the time of transfer or leave. However, during the review of Resident 8's medical records, it was found that the resident was transferred to an acute care hospital without receiving a written notification of the bed hold policy. Interviews with facility staff, including RN 1 and the Pediatric Social Worker, revealed that the bed hold notification was not provided to Resident 8's representative. The Pediatric Social Worker confirmed that although the Notice of Transfer or Discharge form included a seven-day hold notification, it was not given to the resident's representative because the form lacked instructions to do so. The Chief Nursing Officer (CNO) and Director of Quality and Risk acknowledged these findings, indicating a lapse in the facility's adherence to its own policies regarding resident rights during transfers.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed for two residents, Resident 6 and Resident 13. Resident 6 was admitted to the facility, and the last quarterly MDS assessment was completed on September 6, 2024, with no subsequent assessment documented. Similarly, Resident 13's last annual MDS assessment was completed on the same date, with no quarterly assessment following it. During an interview and medical record review, the MDS Coordinator/Director of Staff Development (DSD) confirmed that the assessments were missed due to a discrepancy in the submission date on her calendar. The Chief Nursing Officer (CNO) acknowledged the findings and stated that the expectation was for the MDS Coordinator to complete and submit each MDS assessment on time.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. The deficiency involved Resident 6, who was admitted to the facility and had a physician's order to receive aspirin 40.5 mg chewable tablet via gastrostomy tube (GT) daily, with the indication for use being anticoagulation. However, the MDS was incorrectly coded to reflect the use of an anticoagulant, despite aspirin not being classified as such. This error was confirmed during an interview and medical record review with the Director of Staff Development (DSD)/MDS Coordinator, who acknowledged the mistake. The Chief Nursing Officer (CNO) was also informed and acknowledged the findings, stating the expectation for MDS assessments to be completed and submitted accurately.
Improper Storage of Garbage and Refuse
Penalty
Summary
The facility failed to properly store garbage and refuse in the area of the garbage dumpster and compactor. During an observation and interview with the Plant Operations Director, it was noted that the area around the dumpster and compactor was littered with disposable cups, papers, cardboard boxes, pieces of wood, and a dark liquid with an odor. The Plant Operations Director confirmed these observations and acknowledged that the area should be free of litter and required cleaning. This situation was later communicated to the Chief Nursing Officer (CNO) and the Director of Quality and Risk, who acknowledged the findings.
Failure to Implement Fall Prevention Protocols and Conduct Assessments
Penalty
Summary
The facility failed to provide necessary care and services for a resident who sustained a fall. The facility did not implement its policy and procedure (P&P) for conducting hourly rounding, neurological, skin, and body assessments after the resident's fall. The resident, who had chronic respiratory failure and was ventilator-dependent, fell when a certified nursing assistant (CNA) was lowering the siderail to take vital signs. The resident hit the floor and was later transferred to an acute care hospital emergency department. The facility's P&P required a change of condition report to be filled out and documented in the resident's medical record, including any injuries. However, the medical record review showed that neurological assessments were not conducted to assess the resident's level of consciousness, mentation, behavior, and other critical factors. Additionally, there was no documentation of skin and body assessments for over three hours after the fall. Interviews with facility staff, including a licensed vocational nurse (LVN), a registered nurse (RN), and the chief nursing officer (CNO), revealed inconsistencies in the documentation and lack of adherence to the fall prevention protocol. The CNO confirmed that hourly rounding and assessments were not documented, and there was no documented witness statement from the CNA involved in the incident. The director of quality assurance acknowledged these findings.
Incomplete and Inaccurate Fall Risk Documentation
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding the documentation of the resident's Fall Risk Assessment. The resident, who had a history of falls and was considered high risk due to a Morse Fall Scale score of 55, had incomplete and inaccurate documentation on subsequent assessments. On three occasions, the resident's fall risk score was either left blank or inaccurately recorded as a lower risk than previously assessed. Interviews with facility staff revealed that the resident was known to be active and had a tendency to manipulate crib rails, increasing the risk of falls. Despite this, the fall risk assessments on certain dates were not properly documented, potentially impacting the resident's care. The Chief Nursing Officer confirmed the inaccuracies and omissions in the fall risk assessments, acknowledging that the resident's fall risk score was not consistently recorded according to the facility's policy and the resident's condition.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, Resident 8 and Resident 24, were free from the use of physical restraints unless needed for medical treatment. The facility did not conduct an assessment, obtain informed consent, or secure a physician's order before applying seat belt and chest strap restraints to these residents while they were in their wheelchairs. Additionally, the facility did not implement the least restrictive interventions prior to using these restraints and failed to monitor and document their use. These actions compromised the residents' independence and psychosocial well-being. For Resident 8, the medical record review showed no assessment, informed consent, or physician's order for the use of seat belt and chest strap restraints in the wheelchair. Observations and interviews with staff confirmed that Resident 8 was using these restraints without proper documentation or monitoring. Similarly, for Resident 24, the medical record review also lacked an assessment, informed consent, and physician's order for the restraints. Staff interviews verified that Resident 24 was using the restraints without the necessary documentation and monitoring. The Director of Nursing confirmed these findings during an interview and medical record review.
Failure to Ensure Padded Side Rails for Residents with Seizure Disorders
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for two residents, both of whom had a history of seizure disorders and physician's orders for padded side rails. Resident 3 was observed on two separate occasions with bilateral upper and lower side rails elevated without padding, despite a physician's order dated 9/8/23 to apply seizure pads to all four side rails for safety. This was verified by LVN 3 during an observation, interview, and concurrent medical record review on 2/28/24. Similarly, Resident 16 was observed with bilateral upper side rails and one lower side rail elevated without padding, despite a physician's order dated 3/2/23 to use padded side rails while in bed for safety. This was confirmed by RN 4 during an observation, interview, and concurrent medical record review on 2/29/24. Both residents' medical records indicated a history of seizure disorders, necessitating the use of padded side rails to prevent injury.
Failure to Assess Risk of Entrapment from Elevated Side Rails
Penalty
Summary
The facility failed to ensure that three residents (Residents 13, 14, and 24) were assessed for the risk of entrapment from elevated side rails, which could potentially place them at risk for serious injury. Resident 13, who had impaired mobility and cognitive impairment, was observed on multiple occasions with bilateral side rails elevated at the head of the bed. A review of Resident 13's medical record showed no assessment for the risk of entrapment from the elevated side rails, a fact verified by RN 3 during an observation and medical record review. Similarly, Resident 14, who had diagnoses including seizure disorder and spasticity, was observed with bilateral side rails elevated at the head of the bed and one side rail elevated at the foot of the bed. RN 3 confirmed that Resident 14's medical record also lacked an assessment for the risk of entrapment from the elevated side rails. Resident 24, who was severely cognitively impaired and dependent on staff for all ADL care, was observed with all four side rails elevated and padded. A review of Resident 24's medical record and plan of care showed no documented evidence of an assessment for the risk of entrapment or a care plan problem addressing the use of the side rails. This lack of assessment was confirmed by both CNA 5 and RN 2 during interviews and concurrent medical record reviews. The facility's failure to assess these residents for the risk of entrapment from elevated side rails represents a significant deficiency in ensuring resident safety and preventing potential accidents.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the physician's order for quetiapine, a medication used to treat symptoms of schizophrenia or bipolar disorder, did not include a behavior indication for its use, and there was no monitoring of behavior and side effects related to the medication. Additionally, the resident's medical record did not show monthly psychotropic summaries or a formulated plan of care for the use of quetiapine. These failures were observed in the medical record review and confirmed through interviews with the RN and DON. The resident in question was admitted to the facility with severe cognitive impairment and issues with neurostorming and agitation requiring sedation. The resident was prescribed quetiapine 25 mg at bedtime for neuro irritability. However, the physician's order lacked specific behavior manifestations, behavior monitoring, and side effects monitoring. Furthermore, there was no documented evidence of an IDT Care Conference for Behavior and Psychotropic Management, nor was there a care plan addressing the use of quetiapine. These deficiencies were verified by the RN and DON during interviews and medical record reviews.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below 5%, with an observed error rate of 8%. During a medication administration observation, a licensed nurse (LVN 3) did not administer medications to Resident 3 as scheduled. Specifically, Resident 3 had a physician's order for ocular lubricant ophthalmic solution and chlorhexidine mouthwash to be administered at 0800 hours. However, these medications were not given within the prescribed two-hour window, as they were administered at 1119 and 1121 hours, respectively. The facility's policy and procedure (P&P) titled Medication Orders and Management, revised in September 2021, stipulates that medications should be administered within one hour before or after the prescribed time. LVN 3 verified that the medications were not administered within this timeframe. This failure to adhere to the scheduled medication times had the potential to negatively affect Resident 3's health.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and disposal of medications, as evidenced by two specific incidents. In the first incident, Resident 16's expired medication, Flonase nasal spray, was found on the resident's bedside table. The medication had an open date of 1/14 and an expiration date of 2/14. During an initial tour, a CNA acknowledged the presence of the expired medication but admitted to not informing the licensed nurses. An RN later confirmed that the medication should not have been left on the bedside table and should have been stored in the medication cart and disposed of after expiration. In the second incident, Resident 1's vitamin D liquid bottle was found with an unknown substance accumulated on the outside. The bottle was stored inside Medication Cart A. An LVN verified the findings and acknowledged that the build-up of the unknown substance on the bottle posed a potential infection control concern. Both incidents highlight the facility's failure to adhere to its own policies and procedures regarding medication storage and labeling, potentially impacting resident well-being.
Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure the sanitary requirements were met in the kitchen, leading to multiple deficiencies. Observations revealed that the cutting boards were heavily marred, discolored, and had deep grooves, making them difficult to clean and sanitize. Additionally, several kitchen utensils, including rubber spatulas, butter brushes, ladles, and strainers, were found to be cracked, chipped, discolored, and worn out, posing a safety hazard and potential for cross-contamination. The utensils were also observed to be dirty, with food particles and residue, indicating improper cleaning practices. The kitchen hood over the stove was found to be covered in brownish, yellowish dirt residue, which could potentially drip onto food, causing contamination. The microwave used to warm up residents' food was also observed to be dirty with dry, crusted debris inside and on the door. Furthermore, the plumbing for the ice machine lacked an air gap, creating a risk of backflow and cross-contamination. The test strips used to measure the pH of the chemical sanitizing solution for washing raw fruits and vegetables were expired, and the pH value of the solution was found to be above the acceptable range, compromising the effectiveness of the sanitization process. These deficiencies were identified during an initial kitchen tour and verified by the Dietary Services Supervisor (DSS). The DSS acknowledged the findings and stated that the issues should have been addressed to prevent potential foodborne illnesses in the medically vulnerable resident population. The Director of Food Services also confirmed the findings and emphasized the importance of maintaining proper pH levels for the chemical sanitizing solution to ensure the safe consumption of fruits and vegetables.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices were implemented, leading to several deficiencies. Firstly, the facility did not record all residents with infections on the Infection Surveillance Tool. Only residents with positive culture results were listed, while those with symptoms or on antibiotics without positive cultures were excluded. This was confirmed through interviews with the Administrator, DON, and Director of Infection Control, who acknowledged that the surveillance forms did not include all residents with identified infections, contrary to the facility's policy and procedures (P&P). This oversight was verified during a record review and interviews conducted on multiple occasions with the facility's staff. Additionally, the facility failed to maintain cleanliness in the laundry room. During an observation, the laundry soap bucket was found directly on the floor, covered in dirt and dust, with a rust-colored sludge film on the lid. The Director of Plant Operations (DPO) confirmed the findings and acknowledged the need for cleaning and proper storage of the soap bucket. This failure to maintain a sanitary environment in the laundry room was observed and verified during a tour of the facility. Lastly, the facility did not remove isolation signage after the neutropenic precaution order for a resident was discontinued. An RN was observed entering the resident's room without the required gown and gloves, despite a contact isolation sign on the door. The RN confirmed that the resident was no longer on contact isolation, and the DON later verified that the isolation signage should have been removed. This discrepancy was confirmed through a review of the resident's medical records and interviews with the facility's staff.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship Program as required by their policies and procedures. Specifically, the facility did not conduct assessments using the McGeer's criteria for three residents who were prescribed antibiotics. These residents were prescribed various antibiotics, but there was no documented evidence that the necessary assessments were conducted to determine if the antibiotics were truly needed. This failure was confirmed by the Director of Infection Control during an interview and medical record review. Additionally, the facility did not notify physicians when the McGeer's criteria were not met for three other residents who were prescribed antibiotics. The McGeer's Criteria for Surveillance Checklists for these residents showed that the criteria for true infection were not met, yet the residents were still prescribed antibiotics. The Infection Control Coordinator confirmed that the physicians were not notified about the residents' symptoms not meeting the criteria, which could have led to the discontinuation of unnecessary antibiotics. The report highlights that the facility's failure to adhere to their Antibiotic Stewardship Program and McGeer's criteria potentially led to the inappropriate use of antibiotics. This oversight could have significant implications for the residents' health, including increased risk of adverse drug events and antibiotic resistance. The facility's policies clearly state that all antimicrobial use should be monitored, and the necessary assessments and notifications were not carried out as required.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure the COVID-19 vaccination was administered to Resident 9 after receiving consent from the resident's responsible party. Medical record review showed that the consent form was signed on 1/6/23, but the vaccination was never administered. The Infection Control Coordinator confirmed that the charge nurse who obtained the signature placed the consent form in the medical records basket instead of giving it to the charge nurse responsible for notifying the physician. As a result, the physician was not informed, and the vaccination was not given to Resident 9.
Failure to Maintain POLST in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that Resident 22's Physician Orders for Life-Sustaining Treatment (POLST) was obtained and maintained in the medical record. The facility's policy, revised in August 2023, mandates that all departments honor the POLST to communicate an individual's wishes about life-sustaining and resuscitative measures. Resident 22 was admitted to the facility and had a physician's order dated October 19, 2022, for a Full Code and to obtain a POLST. However, a review of Resident 22's medical record on February 26, 2024, revealed that the POLST was not present. Interviews with RN 1 and RN 2 confirmed the absence of the POLST in the medical record, with RN 2 acknowledging that the POLST should have been included to know the resident's code status and wishes in case of an emergency. Without the POLST, the resident was considered full code by default.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of Resident 25's discharge to another skilled nursing facility (SNF). This deficiency was identified during a closed medical record review initiated on 2/29/24, which revealed that Resident 25 was discharged on 12/19/23 without documented evidence of notification to the Ombudsman. Interviews with the facility's assigned Ombudsman and RN 3 confirmed that no discharge notifications had been provided to the Ombudsman office for this year or the previous year. The Ombudsman verified that she had not received any discharge notifications for Resident 25 or any other residents during this period.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive care plans for four residents, leading to deficiencies in individualized care. For Residents 3 and 16, the care plans did not include the use of padded side rails for safety and injury protection, despite physician orders and the residents' history of seizure disorders. This omission was confirmed during interviews and record reviews with the facility's registered nurses, who acknowledged that the care plans should have included these safety measures. Similarly, the care plans for Residents 8 and 24 were not revised to reflect the use of seat belt and chest strap restraints in their wheelchairs, even though these restraints were observed in use. The registered nurses responsible for updating the care plans verified that the interventions for the use of these restraints were missing from the residents' plans of care. These failures indicate a lack of adherence to the facility's policy and procedures for developing and updating comprehensive care plans based on individual resident needs.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the medical record for one of twelve sampled residents (Resident 19) was complete and accurate. This deficiency was identified through an interview, medical record review, and facility policy and procedure (P&P) review. Specifically, the medical record for Resident 19, who was admitted to the facility on an unspecified date, contained physician's orders for a Posey Bed Enclosure and bilateral No-No Posey Sleeves that were signed and dated but lacked the required time documentation. These orders were dated 1/30/24 and 2/5/24. During an interview on 2/28/24, the RN Charge Nurse and Director of Nursing (DON) confirmed that physician's orders should be signed, dated, and timed, indicating a failure to adhere to the facility's P&P titled Physician Order - End of Month Recaps, revised 9/23, which aims to ensure the accuracy of renewal orders for medications and treatments.
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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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