Freedom Village Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Forest, California.
- Location
- 23442 El Toro Road, Lake Forest, California 92630
- CMS Provider Number
- 555391
- Inspections on file
- 17
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Freedom Village Healthcare Center during CMS and state inspections, most recent first.
A resident experienced significant weight loss and the RD recommended nutritional interventions, but there was a nine-day delay in communicating these recommendations to the physician, resulting in a delay in implementing necessary care. Facility staff acknowledged the failure to relay the RD's recommendations in a timely manner.
A resident's medical record inaccurately documented their fall history, indicating no falls in the last six months despite evidence of a fall prior to admission. This discrepancy was confirmed by an LVN and the ADON, who noted that such inaccuracies could lead to misinterpretation and delay in services, posing a risk to the resident's care.
A resident reported an allegation of physical abuse against two CNAs. Despite the facility's policy requiring suspension of staff accused of abuse, the CNAs continued to work during the investigation period, although they were not assigned to the resident. The DON acknowledged that the CNAs should have been suspended to ensure resident safety.
A facility failed to monitor a resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation involving two CNAs. The resident alleged rough handling and inappropriate behavior by the CNAs. The facility did not conduct the required 72-hour monitoring or establish a care plan to address the resident's needs, as confirmed by interviews with the RN and DON.
The facility failed to ensure food safety and sanitation in the kitchen, risking food-borne illnesses for 42 residents. Observations included unsanitary kitchen utensils, improper glove use by a dietary aide, and a juice machine lacking an air gap for backflow prevention. These issues were acknowledged by facility leadership.
A resident with impaired mobility and requiring maximal assistance for transfers was injured when a CNA transferred them alone, contrary to the care plan. The resident's leg was caught during the transfer, resulting in a right ankle fracture. The CNA was unaware of the two-person assist requirement, and it was noted that other staff had also been assisting the resident without additional help.
A resident was found with Voltaren gel at their bedside without a physician's order or care plan for self-administration, contrary to facility policy. The resident was applying the gel independently, despite not being assessed as a candidate for safe self-administration. An RN confirmed the lack of necessary documentation and orders.
The facility failed to document and update advance directives for three residents, risking treatment against their wishes. A resident's advance directive was not placed in the medical record, another's was not followed up on, and a third's POLST was not updated to reflect a formulated directive.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two residents. One resident's representative was notified about the last covered Medicare day but was given the wrong notification form. Similarly, another resident's representative was informed of the last covered day but also received the incorrect form. The SSD confirmed that the representatives were informed but not given the correct Advance Beneficiary Notification (ABN).
A resident experienced a 5.32% weight loss in one month, but the facility failed to conduct a nutritional assessment, involve a dietitian, update the care plan, or notify the physician and family. Staff confirmed that no change of condition was initiated, and the weight loss was not documented as required by facility policy.
The facility failed to ensure accurate reconciliation of controlled medications in the Omnicell, as required by their P&P. Controlled substances were not counted daily, leading to discrepancies in the Cycle Count Non-Compliant Report. Interviews with pharmacy staff and the DON confirmed that only 'touched' medications were counted, contrary to policy, posing a risk for medication diversion.
A resident was administered Colace without verifying stool patterns, contrary to the facility's policy. The LVN did not check the point click care dashboard or consult with the CNA, and a list of residents with loose stools was not provided. The DON confirmed these findings.
A resident with Parkinson's disease and dementia was prescribed Nuplazid for psychosis without documented evidence of behavioral monitoring or non-pharmacological interventions. The care plan lacked details on the use of the medication for paranoid ideation, and the DON confirmed the absence of necessary documentation and monitoring.
The facility failed to properly store and label medications, with issues including unrefrigerated eye drops, mixed storage of internal and external medications, and unlabeled inhalation medication. Additionally, expired medication was found, and a nurse left medications unattended during administration. These deficiencies were confirmed by staff during observations.
The facility failed to ensure the DSS overseeing the satellite kitchen was qualified, as required by California Code. During a survey, issues were found in both the main and satellite kitchens, including unclean equipment and lack of an air gap for a juice machine, potentially affecting 42 residents. The administrator acknowledged these findings.
A resident with a documented allergy to cucumber was served cucumber during lunch, despite the facility's records indicating the allergy. The Dietary Service Supervisor confirmed the oversight and acknowledged the need to replace the allergenic item. The resident stated that consuming cucumber would lead to vomiting and illness.
The facility failed to educate staff and visitors on safe food handling for outside food, risking foodborne illnesses for residents. The DSS did not provide specific guidance on cooking and cooling temperatures, and the DSD/IP only reminded staff to label food properly. Education was limited to CNAs, and licensed staff were not informed about safe food handling practices.
A facility failed to provide necessary hospice care for a resident, including missing weekly CHHA visits and lacking documentation in the hospice log. The hospice RN was also absent from a care conference. The DON confirmed these deficiencies.
The facility's QAA committee failed to document action plans for previously identified deficiencies in respiratory care and medication storage. The DON could not provide evidence of procedures for labeling and changing respiratory equipment or logs for medication storage checks. An LVN reported only checking medications weekly, not daily as required.
The facility failed to maintain accurate infection surveillance, with discrepancies in reported infections for residents. Infection control practices in the laundry room were inadequate, with clean linens in contact with personal items. Additionally, a nurse did not follow proper hand hygiene during medication administration, and improper Foley catheter care was observed, with the catheter tip not cleaned after use.
The facility failed to document the offer and discussion of influenza and pneumococcal vaccines for two residents who lacked decision-making capacity. Consent forms were incomplete, and there was no evidence of discussions about the risks and benefits of the vaccines, posing a risk of disease acquisition.
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, as required by their policies. Despite placing a work order to replace a faulty thermometer, night shift nurses left the temperature log incomplete, potentially affecting residents' medications. Interviews with the DON and an RN confirmed the importance of daily temperature recording.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for a resident and two others. A resident was prescribed ciprofloxacin for a UTI despite meeting criteria for gastroenteritis, without informing the physician. Another resident received azithromycin for a cough without confirming infection criteria. A third resident was given Augmentin for pneumonia, meeting criteria for gastroenteritis, without physician notification. The facility's IP failed to review antibiotic use effectively, and the DSD/IP and RN confirmed these findings.
The facility failed to provide adequate respiratory care for two residents. A resident's nasal cannula was not stored properly, and another resident's nasal cannula and storage bag were not dated as required by facility policy. These deficiencies were confirmed by LVNs during observations and interviews.
The facility did not follow the main menu for 42 residents, serving an alternate menu without notifying them. The Director of Food and Nutrition Services confirmed the deviation from the planned menu and the lack of resident notification.
Delay in Physician Notification of RD Recommendations Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate services to maintain optimal nutritional status. Specifically, the resident experienced a weight loss of 6 pounds (4.3%) over six days, as documented in the medical record. The registered dietitian (RD) conducted a nutrition assessment and recommended daily multivitamin with minerals, snacks three times daily, and Glucerna shakes with meals due to inadequate oral intake. These recommendations were documented on 9/9/25. However, the RD's recommendations were not communicated to the physician until nine days later, resulting in a delay in obtaining the necessary physician orders for the interventions. Facility policy required timely monitoring and intervention for undesirable weight changes, but the charge nurses did not relay the RD recommendations to the physician as required. This delay was acknowledged by both the LVN and the DON during interviews, confirming that the resident did not receive the recommended nutritional interventions in a timely manner.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one of the sampled residents, identified as Resident 1. The deficiency was identified during a review of the facility's policies and procedures, which require that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition be documented accurately in the medical record. Resident 1, who was admitted to the facility with moderately impaired cognition, had a documented fall prior to admission. However, the fall risk assessment inaccurately indicated that Resident 1 had no history of falls within the last six months. The inaccuracy in the fall risk assessment was confirmed during interviews with LVN 1 and the ADON. LVN 1 acknowledged that the assessment should have reflected a history of one to two falls, rather than none, and noted that such inaccuracies could lead to misinterpretation. The ADON also confirmed the error and expressed concern that inaccurate documentation could delay necessary services. This failure to maintain an accurate medical record posed a risk to Resident 1's care, as it could lead to inadequate fall prevention measures being implemented.
Failure to Suspend CNAs During Abuse Investigation
Penalty
Summary
The facility failed to adhere to its abuse protocol during an investigation of an alleged physical abuse incident involving a resident. The resident, who was capable of making her own medical decisions, reported an allegation of physical abuse against two CNAs. According to the facility's policy, staff members accused or suspected of abuse should be suspended pending the completion of the investigation. However, the facility did not suspend the two CNAs involved in the allegation during the investigation period. The investigation file showed that the CNAs continued to work, although they were not assigned to the resident who made the allegation. The facility's staffing sheets confirmed that the CNAs worked during the investigation period but were given different assignments. The Director of Nursing acknowledged that the CNAs should have been suspended to ensure the safety of the resident and other residents in the facility.
Failure to Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and/or maintained her highest practicable physical well-being. Specifically, the facility did not monitor the resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation. The resident alleged that two CNAs were rough while changing her diaper and laughed at her during the incident. Despite this report, the facility did not conduct the required 72-hour monitoring of the resident following the abuse allegation. The medical record review revealed that there was no care plan established to address the resident's safety and psychosocial well-being after the abuse allegation. Interviews with the RN and the DON confirmed these findings, acknowledging that the resident's medical record should have included a care plan and 72-hour monitoring by nursing and social services. This oversight had the potential to impact the resident's receipt of necessary care and services.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, posing a risk of food-borne illnesses to 42 residents. Observations revealed unsanitary conditions, including multiple metal sheet trays and baking pans with solid black residue, a whisk with a burnt handle, a melted spatula, a cracked spatula, and heavily marred cutting boards. Additionally, a gray plastic bin holding clean kitchen tools was found with water and black particles on the inner bottom surface. These conditions violate the USDA Food Code 2022, which mandates that utensils and food contact surfaces must be clean, durable, and easily cleanable. Further observations showed that a dietary aide handled clean plates with the same gloves used for dirty dishes without changing gloves or washing hands, increasing the risk of cross-contamination. Additionally, a juice machine lacked an air gap for backflow prevention, as required by the USDA Food Code 2022, which could lead to contamination of the juice provided to residents. These deficiencies were verified by the Maintenance Technician and acknowledged by the facility's Administrator, DON, and DSS.
Failure to Implement Two-Person Assist Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff implemented a two-person assist for transfers as required by the care plan for a resident, resulting in an injury. The resident, who had impaired mobility and required substantial or maximal assistance for transfers, was transferred by a single CNA from a shower chair to a bed. During this transfer, the resident's leg was caught between the nightstand, leading to a right ankle fracture. The CNA was unaware of the requirement for a two-person assist, and it was noted that other staff had also been assisting the resident without additional help. The resident's medical records indicated a history of generalized weakness and deconditioning, necessitating extensive assistance for transfers. The care plan, developed by the Case Manager and verified by the Director of Rehabilitation, clearly stated the need for a two-person assist due to the resident's right knee osteoarthritis and decreased activity tolerance. Despite these documented needs, the staff failed to adhere to the care plan, resulting in the resident's injury.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of self-administration of medications for one resident, identified as Resident 24. During an observation, two tubes of Voltaren gel, a topical pain medication, were found at the resident's bedside without a physician's order or care plan addressing self-administration. The facility's policy requires an assessment by the interdisciplinary care team to determine if self-administration is safe and appropriate, and to document this in the resident's care plan. However, Resident 24's medical records did not contain evidence of such an assessment or documentation. Interviews with the resident and a registered nurse (RN 1) revealed that the resident was applying the Voltaren gel independently for knee pain, despite not being deemed a candidate for safe self-administration according to a prior assessment. RN 1 confirmed the absence of a physician's order or care plan for self-administration, indicating a lapse in following the facility's policy and procedures for medication management.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directive information was documented and offered to three residents, leading to potential treatment against their wishes. For Resident 22, the facility did not obtain and place a copy of the advance directive in the medical record, despite the POLST indicating its existence. The Social Services Director (SSD) confirmed the absence of the document and acknowledged not contacting the family for a copy. Similarly, Resident 24's advance directive was not available in the medical record, even though assessments indicated its existence and a family member's intention to provide it. The SSD admitted the oversight. For Resident 25, the POLST was not updated to reflect the formulation of an advance healthcare directive, despite documentation of its existence. The SSD verified this discrepancy during a review.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two nonsampled residents, identified as Resident 45 and Resident 47. For Resident 45, the admission record indicated that the last covered day of Medicare Part A services was on August 3, 2024. Although the resident's representative was notified about the last covered Medicare day on May 17, 2024, they were incorrectly given a copy of the CMS 20052 SNF Beneficiary Protection Notification Review instead of the Advance Beneficiary Notification (ABN). Similarly, for Resident 47, the admission record showed that the last covered day of Medicare Part A services was on May 15, 2024. The resident's representative was informed of the last covered Medicare day on May 13, 2024, but was also provided with the CMS 20052 SNF Beneficiary Protection Notification Review instead of the ABN. During an interview and concurrent medical record review on October 22, 2024, the SSD confirmed that the representatives of both residents were informed of the last covered day for Medicare but were not given a copy of the ABN.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely intervention for a resident who experienced significant weight loss. Resident 22, who was part of a sample reviewed for weight loss, lost 5.32% of their body weight in one month. Despite this significant weight change, there was no assessment from nutritional services, no intervention from a registered dietitian, no care plan developed, and no notification to the resident's physician or family. This lack of action was contrary to the facility's policy and procedures, which require a Nutrition at Risk Review, physician and family notification, and care planning with nutritional goals when significant weight loss is identified. During an interview and medical record review, it was confirmed that the facility's staff, including RN 2 and LVN 1, did not initiate a change of condition for Resident 22. The staff acknowledged that the resident's weight loss was not documented in a care plan, nor was there a progress note indicating that the physician or family had been notified. The facility's process involves using a communication board on the electronic health record system to document changes, but this was not done for Resident 22. The failure to follow these procedures had the potential to result in continued nutritional decline and negative outcomes for the resident.
Failure in Controlled Medication Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate reconciliation and disposal of medications, specifically controlled substances. The facility's policy and procedure (P&P) required that controlled medications in the Omnicell, an automatic drug delivery system, be counted and verified daily by authorized staff. However, it was found that the facility did not comply with this requirement, as evidenced by discrepancies in the Cycle Count Non-Compliant Report. The report listed several controlled medications, such as acetaminophen-cod #3, alprazolam, hydrocodone-acetaminophen, hydromorphone, lorazepam, morphine sulfate, oxycodone, pregabalin, temazepam, tramadol, and zolpidem tartrate, which had not been counted for extended periods, some dating back several months. Interviews with the pharmacy staff and the Director of Nursing (DON) revealed that the night shift nurses were only counting controlled medications that were categorized as 'touched' during their shift, contrary to the facility's P&P that required all controlled substances to be counted daily. The DON confirmed that the facility was not compliant with the daily counting requirement, leading to the risk of medication diversion. The findings were verified through document reviews and interviews, highlighting a significant lapse in the facility's medication management practices.
Failure to Monitor Stool Softener Administration
Penalty
Summary
The facility failed to ensure proper monitoring of a nonsampled resident's medication regimen, specifically concerning the administration of a stool softener, Colace. The facility's policy requires that medication administration be in accordance with applicable laws and that licensed nurses confirm the Medication Administration Record (MAR) reflects the most recent medication order. However, during an observation, a Licensed Vocational Nurse (LVN) administered Colace to a resident without verifying if the resident was experiencing loose stools, as required by the medication order. The LVN admitted to not checking the resident's stool pattern through the facility's point click care dashboard or consulting with the Certified Nursing Assistant (CNA) on duty. The LVN also mentioned that a list of residents with loose stools, which is typically provided, was not available to her that day. This oversight was confirmed during an interview and concurrent medical record review with the Director of Nursing (DON), who verified the findings.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 25, was free from unnecessary psychotropic medications. Resident 25, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was prescribed Nuplazid, an antipsychotic medication, for psychosis related to Parkinson's disease manifested by paranoid ideation. However, there was no documented evidence of behavioral monitoring for episodes of paranoid ideation or any non-pharmacological interventions provided for Resident 25. Additionally, the care plan did not address the use of Nuplazid for the manifestation of paranoid ideation or include documentation of non-pharmacological interventions. During an interview and medical record review with the Director of Nursing (DON), it was confirmed that there was no documentation of Resident 25's episodes of paranoid ideation, nor was there any monitoring of these episodes or documentation of non-pharmacological interventions. The DON also verified the absence of a care plan for the use of Nuplazid medication for psychosis related to Parkinson's disease manifested by paranoid ideation. This lack of documentation and care planning indicates a failure to adhere to the facility's policy on antipsychotic medication use and informed consent, which requires that non-pharmacological interventions be attempted and documented before considering antipsychotic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. Resident 7's eye drop medication was not refrigerated as required, and Resident 22's cough medication was stored alongside a topical ointment, contrary to the facility's policy of separating internal and external medications. Additionally, Resident 686's inhalation medication lacked an opened date label, violating the facility's policy. The bottom drawer of Medication Cart 1 was found unclean, with spill residue and dried medication debris. Furthermore, expired medication was found in the medication storage room, specifically a bottle of aspirin with an expiration date of January 2024. During a medication administration observation, a licensed nurse left medications for Resident 27 unattended on two occasions. The nurse left two eye drop medications on the resident's overhead table while performing other tasks, such as washing hands and calling for assistance. This action was against the facility's policy, which states that medications should not be left unattended. These deficiencies were verified by the staff present during the observations, including a licensed vocational nurse, the director of nursing, and a registered nurse.
Unqualified DSS and Kitchen Deficiencies
Penalty
Summary
The facility failed to ensure that the Dietetic Services Supervisor (DSS) responsible for overseeing the satellite kitchen was qualified to manage the day-to-day functions of the food services department. This deficiency was identified during a recertification survey conducted from October 21 to October 24, 2024. The DSS was responsible for managing the skilled nursing facility's (SNF) satellite kitchen, where food was prepared in the main kitchen and then transported to the SNF. The main kitchen was managed by an executive chef, and a registered dietitian (RD) was employed part-time, working two days a week. However, the facility's documents did not provide evidence that the DSS met the qualifications required under the California Code, Health and Safety Code - HSC S 1265.4. During the survey, multiple issues were found in both the main and satellite kitchens, including unclean and improperly maintained kitchen utensils and equipment, as well as a failure to ensure an air gap for a juice machine. These deficiencies had the potential to negatively affect the health and well-being of 42 residents who consumed food prepared in the kitchen. The facility's administrator acknowledged these findings during an interview conducted on October 23, 2024.
Resident Served Allergenic Food Despite Known Allergy
Penalty
Summary
The facility failed to ensure that a resident with a known food allergy was not served an allergenic item, leading to a deficiency. Resident 27, who has an allergy to cucumber as documented in their dietary communication dated 4/12/24, was observed eating lunch independently on 10/21/24 and was served cucumber on their main plate. During an interview and diet card review with the Dietary Service Supervisor (DSS), it was confirmed that the resident had an allergy to cucumber. The DSS acknowledged the error and stated they would replace the cucumber. Resident 27 later confirmed in an interview that consuming cucumber would cause them to vomit and become ill.
Deficiency in Safe Food Handling Education
Penalty
Summary
The facility failed to ensure that education was provided to staff and family/visitors on safe food handling of outside food, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy allowed food to be brought in by visitors and family, but there was a lack of comprehensive education on safe food handling practices. The DSS stated that she informed residents and visitors about how long food could be kept in the refrigerator but did not provide specific guidance on proper cooking and cooling temperatures or distribute literature on safe food handling. The DSD/IP admitted to only reminding staff to label food properly and ensure it was appropriate for the resident's diet, without providing in-depth education on safe food handling practices. The in-services were limited to CNAs and did not include licensed staff, who were responsible for reheating food. LVN 2 confirmed that she did not educate visitors on safe food handling, and reheating was done by kitchen staff, not licensed staff or aides. The facility's leadership, including the Administrator and DON, acknowledged these findings.
Failure to Provide Required Hospice Services
Penalty
Summary
The facility failed to provide necessary hospice care and services for a resident, identified as Resident 22, who was part of a sample reviewed for hospice services. The deficiencies included the failure to ensure that the resident received a hospice aide visit once per week as ordered by the physician. Additionally, the hospice log lacked documentation regarding the Certified Home Health Aide (CHHA) visit. Furthermore, the hospice Registered Nurse (RN) was not included in the resident's Care Conference/Care Plan Meeting. The facility's policy and procedure for hospice services, revised in November 2024, outlined the responsibilities of hospice providers and the facility in managing the resident's care. However, a review of the medical records and facility documents revealed that the CHHA visits were not conducted as required, with no visits documented from March to October 2024, except for a few in May. The Director of Nursing (DON) confirmed these findings. Additionally, the hospice case manager was unable to attend a care conference meeting, and there was no documentation of hospice involvement in the resident's care conference.
Deficiencies in Respiratory Care and Medication Storage
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee identified and developed action plans to address deficiencies noted in the previous recertification survey. Specifically, the facility did not have documented evidence of action plans to correct issues related to respiratory care and medication storage. These deficiencies were cited again during the current recertification survey, indicating a lack of effective corrective measures. The absence of documentation for the respiratory care process, such as labeling and dating respiratory equipment, and the lack of a documented medication storage improvement process were highlighted during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). During the survey, the DON was unable to provide documentation to support the training and procedures claimed to be in place for respiratory care, such as labeling and changing respiratory tubing. Similarly, the DON could not provide logs or documentation for the medication storage checks that were supposed to be conducted daily by the charge nurse. An LVN interviewed stated that he only checked his medication chart once a week and only reviewed the morning medications he would administer, rather than the entire cart. This inconsistency in practice and lack of documentation contributed to the repeated citation of deficiencies in respiratory care and medication storage.
Infection Control Deficiencies in Surveillance, Laundry, and Hygiene Practices
Penalty
Summary
The facility failed to maintain an accurate infection surveillance program for September and October 2024. Several discrepancies were noted in the Infection Surveillance Reports, where residents were documented with incorrect infections. For instance, Resident 20 was reported to have a urinary tract infection but met the criteria for gastroenteritis. Similarly, Resident 25 was documented with pneumonia but met the criteria for gastroenteritis. These inaccuracies were confirmed by the Director of Staff Development/Infection Preventionist (DSD/IP) and Registered Nurse 1/Infection Preventionist (RN 1/IP), who acknowledged that the Infection Control Surveillance should be accurate for effective reporting and intervention. In the facility's laundry room, infection control practices were not properly implemented. Observations revealed that clean linens were in contact with personal items such as a radio, charger, sweater, and hat, which were placed on the folding area. This was verified by the Director of Housekeeping, indicating a breach in maintaining a sanitary environment for handling clean laundry. Additionally, there were lapses in hand hygiene practices by a licensed nurse (LVN 1) during medication administration for a resident. LVN 1 failed to perform hand hygiene after removing gloves and before donning new ones, as well as after touching potentially contaminated items like a TV remote and call light. Furthermore, improper Foley catheter care was observed for another resident, where the catheter tubing tip was not cleaned after draining urine, and the urinal was inadequately rinsed and stored. These practices were confirmed by the involved staff and the DSD, highlighting a failure to adhere to infection control protocols.
Failure to Document Vaccine Offer and Discussion
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza and pneumococcal vaccines in accordance with CDC guidelines. Resident 4, who lacked the capacity to make medical decisions, had a blank consent form for the pneumococcal vaccine, and there was no documentation of refusal or discussion of risks and benefits with the resident or their representative. Although the facility claimed that Resident 4 was offered the PPV 23 vaccine, they could not provide evidence of this offer or any related discussions. Similarly, Resident 25, also lacking decision-making capacity, had declined both the influenza and pneumococcal vaccines, as indicated by marks on their consent forms. However, there was no documentation to support that the risks, benefits, and potential side effects of the vaccines were discussed with the resident or their representative. The facility's staff confirmed these findings during interviews, and the lack of documentation posed a risk of the residents acquiring influenza and pneumonia.
Failure to Maintain Temperature Logs for Drug Dispensing System
Penalty
Summary
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, which is crucial for ensuring the safe operating conditions of the equipment. According to the facility's policies and procedures, medications and biologicals should be stored at appropriate temperatures as per the United States Pharmacopeia guidelines and manufacturer guidance. The facility's policy also requires daily monitoring of the temperature in medication storage areas. However, a review of the Automated Drug Delivery System (ADDS) Daily Temperature and Cycle Count Log revealed multiple instances where the temperature gauge was either blank or not working during the night shift across several months. Interviews with the Director of Nursing (DON) and a registered nurse (RN) confirmed that the temperature should be recorded daily. Despite placing a work order to replace the faulty thermometer, the night shift nurses continued to leave the temperature log incomplete. The DON and RN acknowledged that failing to accurately record temperature monitoring could potentially affect the residents' medications. The facility's Pharmacy ADDS Checklist also indicated that any concerns, such as temperature excursions, should be reported to the DON and pharmacy, with documentation of who was notified and the actions taken to resolve the issues.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate use of antibiotics for one sampled resident and two nonsampled residents. Resident 20 was prescribed ciprofloxacin for a urinary tract infection despite meeting the McGeer's Criteria for gastroenteritis, with no documented evidence that the physician was informed of the discrepancy. Similarly, Resident 9 was given azithromycin for a cough without documentation indicating whether the infection met the criteria for a true infection. Resident 25 was prescribed Augmentin for pneumonia, although the resident met the criteria for gastroenteritis, and there was no evidence that the physician was informed of this inconsistency. The facility's Infection Preventionist (IP) or designee was responsible for reviewing antibiotic utilization as part of the antibiotic stewardship program, but failed to identify and address these inconsistencies. During interviews, the Director of Staff Development/Infection Preventionist (DSD/IP) and a registered nurse (RN 1/IP) confirmed the findings and acknowledged that the facility should have notified the physician or obtained clarification for the use of antibiotics when residents did not meet the criteria. The Administrator and Director of Nursing (DON) also acknowledged these findings, indicating a lapse in the facility's adherence to its own policies and procedures regarding antibiotic use.
Inadequate Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 17 and Resident 22, as observed during a survey. For Resident 17, the nasal cannula tubing was not stored in a sanitary manner when not in use. It was observed hanging on the concentrator instead of being stored in a bag, as required by the facility's policy. This observation was confirmed by LVN 3 during an interview, and the Director of Nursing (DON) was informed of the findings. For Resident 22, the facility did not date the nasal cannula tubing and respiratory storage bag, which is a requirement according to the facility's policy on oxygen administration. The policy mandates that oxygen equipment should be changed and dated every Sunday by the night shift staff. During an observation, it was noted that Resident 22's nasal cannula and storage bag were undated and unlabeled. This was verified by LVN 2 during a concurrent interview. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents receiving such care.
Failure to Follow Main Menu and Notify Residents
Penalty
Summary
The facility failed to ensure that the main menus were followed for all 42 residents who consumed food prepared in the kitchen. According to the facility's policy and procedure titled 'Menu Alternatives' dated 2018, the Director of Food and Nutrition Services is responsible for supervising meal preparation and ensuring the menu is followed and served as planned. However, on the specified date, the lunch main menu, which included Burgundy Beef Tenderloin Tips, Parslied Noodles, and Seasoned Spinach, was not served. Instead, the alternate menu, which included Turkey Pot Pie and Seasoned Spinach, was prepared and served without notifying the residents of the menu change. This was confirmed through observation and interviews with the Director of Food and Nutrition Services, who acknowledged the deviation from the planned menu and the lack of resident notification.
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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