Golden Empire
Inspection history, citations, penalties and survey trends for this long-term care facility in Grass Valley, California.
- Location
- 121 Dorsey Drive, Grass Valley, California 95945
- CMS Provider Number
- 056391
- Inspections on file
- 33
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Golden Empire during CMS and state inspections, most recent first.
A resident with cerebral palsy and severe cognitive impairment was found in bed crying and curled in a fetal position while another resident with dementia and intact cognition sat at the edge of the bed with his pants or briefs down. CNAs observed the second resident with one hand under the first resident's gown and the other on his own genital area, and the first resident's penis was exposed. The distressed resident verbally requested that the other be removed. The ADON characterized the incident as sexual abuse, and the facility's abuse policy states that residents must not be subjected to abuse by anyone, including other residents.
Two residents sharing a room were involved in an alleged sexual abuse incident when CNAs twice found one cognitively intact resident with his pants or briefs down, touching his own genitals and physically contacting a severely cognitively impaired resident whose genitalia were exposed and who became tearful and asked for the other resident to be removed. Although the CNA reported the incident to the Nurse Supervisor, the ADM later confirmed that the allegation was not reported to the state survey agency until the following day, exceeding the facility’s abuse policy requirement that mandated reporters notify the Department of Public Health within two hours of an abuse allegation.
The facility did not complete required annual performance reviews for a CNA, as the CNA’s personnel file showed the last documented review occurred several years after hire with no subsequent evaluations. The DSD confirmed that annual performance reviews are required for all CNAs to ensure they are performing their job, and acknowledged that no more recent review was on file. Facility policy on competency evaluation requires ongoing assessment of employee competencies and skills, including subsequent and/or annual evaluations based on the facility assessment, training program evaluation, and job performance evaluations.
A resident with a history of THC substance abuse was admitted with multiple diagnoses, and THC products were found in their room on two occasions. Despite this, staff did not develop a substance abuse care plan or notify the physician, as confirmed by interviews and record review. Facility policy required care planning and physician notification for such changes in condition, but these actions were not taken.
Meal tickets containing residents' personal and medical information, including names, photos, and room numbers, were left unattended and visible in the dining area and then discarded in regular trash, making the information accessible to other residents and visitors. Staff confirmed that these practices did not protect the confidentiality of residents' information, contrary to facility policy.
The facility did not ensure accurate MDS assessments for four residents, including those on hospice care and one using a C-PAP machine. Errors included incorrectly marking a resident as receiving invasive mechanical ventilation, failing to document terminal prognosis and hospice care for two residents, and inconsistent coding of hospice status and prognosis for another. These inaccuracies were confirmed by the MDS Coordinator and contradicted by medical records and staff interviews.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards.
Trash dumpsters and containers near the kitchen were found with open lids or no lids, containing items such as used gloves and a cigarette butt. Facility staff confirmed the issue, and policy review showed that daily inspections and closed lids are required to maintain sanitation.
Surveyors identified multiple infection control deficiencies, including incorrect assignment of enhanced barrier precautions signage, failure of staff to use required PPE during high-contact care, open doors for rooms on COVID-19 isolation, improper disinfection of BP equipment, and improper labeling and storage of respiratory equipment. These lapses were confirmed by staff interviews and record reviews, with staff acknowledging that facility policies were not followed.
Flies were observed in the kitchen, landing on food and surfaces, despite recent pest control services. The Dietary Supervisor, Maintenance Supervisor, Registered Dietitian, and DON all confirmed the ongoing fly problem and the risk of food contamination, indicating the facility's pest control measures were not effective.
Surveyors found expired medications and medical supplies in multiple medication carts, incomplete and unchecked crash carts with expired equipment, and a medication bottle stored in a refrigerator meant for resident food. LNs and the DON confirmed these deficiencies, which were not in accordance with facility policies requiring removal of expired items, daily crash cart checks, and separate storage of medications and food.
A resident with severe cognitive impairment slapped another resident, also with severe cognitive impairment, across the face while both were near a door to the courtyard. The incident was witnessed by a CNA and confirmed by staff interviews. Facility policy prohibits abuse of any kind, but the event occurred, resulting in a failure to protect a resident from physical abuse.
A resident with end-stage Alzheimer's disease and other diagnoses was enrolled in hospice care, but the required significant change in status assessment (SCSA) was not completed as mandated by facility policy. Both the MDSC and DON confirmed that the assessment should have been done following hospice enrollment.
Two residents did not receive care according to professional standards when a nurse failed to document a required PICC line arm measurement for one resident, and another resident's insulin administration record was altered without proper late entry documentation. These actions resulted in incomplete and inaccurate medical records, contrary to facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Surveyors found that after emergency insulin vials were removed from the E-Kit, staff did not ensure the kit was replaced within the facility's required 72-hour timeframe. The E-Kit remained unreplaced for six days, as confirmed by a nurse and the DON, despite facility policy and documentation logs.
A resident with terminal dementia receiving hospice services did not have required hospice documentation, such as the plan of care, visit schedules, or visit notes, in their clinical records. Nursing staff and the DON confirmed the absence of these documents and were unclear about the hospice staff's schedule and care coordination process, despite facility policy and agreements mandating such documentation and communication.
The facility did not ensure the Medical Director attended any QAPI committee meetings over several months, as required by policy. Despite being invited, the MD declined participation and did not send a designee, and did not acknowledge written reports provided by the facility. This resulted in the QAPI committee lacking required medical oversight for a census of 137 residents.
A resident with severe cognitive impairment and a high risk for wandering was able to leave the facility in a wheelchair without staff awareness and was found near a busy street by a staff member arriving for work. Staff interviews and record reviews confirmed that the resident required supervision and had a history of exit-seeking behaviors, but staff did not notice the resident's absence until after the incident.
The IP did not report two infectious disease outbreaks—one gastrointestinal and one respiratory—to CDPH within the required 24-hour period, despite facility policy mandating prompt notification. The gastrointestinal outbreak involved five residents with symptoms such as nausea and vomiting, while the respiratory outbreak affected three residents with fever and cough. The IP confirmed awareness of the reporting requirement and acknowledged the delays.
The infection preventionist did not report a flu and RSV outbreak to the Department of Health Services within the required 8-24 hour window, as mandated by facility policy. The delay occurred because the outbreak happened over a weekend when the IP was not present, and she was unaware of the reporting requirement.
A resident with cognitive impairments was found with a bruise on her hip, but the facility failed to investigate the injury as required by their Abuse policy. The DON confirmed no documentation or investigation was conducted to determine the cause of the bruise.
A resident with neurocognitive disorder and dementia experienced two incidents: a bruise of unknown origin on the hip and lacerations on fingers caused by a CNA during nail trimming. The facility failed to develop care plans for these injuries, contrary to their policy, potentially impacting the resident's care and well-being.
A resident with cognitive impairments suffered lacerations on her fingers due to improper nail trimming by a CNA, and the facility failed to reeducate the CNA or investigate the incident. Additionally, an LVN did not follow the physician's wound care orders, leaving the resident's fingers without the required dressings. The facility's wound care policy was not followed, and staff interviews confirmed the lack of corrective actions.
The facility failed to report an outbreak of scabies to the California Department of Public Health when three residents and one staff member tested positive. Despite policies requiring such reporting, the infection preventionist confirmed that the outbreak was not reported. One resident had a rash that led to all 20 residents in the dementia unit being treated preventatively, and the first case was identified in another resident.
A facility failed to monitor the effectiveness of Haloperidol (Haldol) prescribed to a resident with dementia and severe major depressive disorder with psychotic features. Despite the care plan requiring staff to monitor and document behaviors, no monitoring was in place, which was confirmed by the DON.
Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident was found inappropriately touching another resident. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was discovered in bed in a fetal position, curled up and crying, with his penis exposed. Resident 2, who had a diagnosis of unspecified dementia and intact cognition per his MDS, was found sitting at the edge of Resident 1's bed with his pants or briefs pulled down, one hand under Resident 1's gown and the other on his own genital area. After the incident, Resident 1 was tearful and stated, "Get him away from me." According to IDT notes and staff interviews, CNA 1 and CNA 2 entered Resident 1's room for a recheck and observed Resident 2 at the end of Resident 1's bed with his pants or briefs down, his back to the door, and his hand extended toward Resident 1. CNA 1 reported seeing Resident 2 with his right hand on his own genitals and his left hand on Resident 1's hip, and when Resident 1's covers were pulled back, Resident 1's penis was exposed out of his brief. CNA 2 corroborated that Resident 2 had no brief or underwear on, his brief was on the floor, his right hand was under Resident 1's gown, and Resident 1's penis was exposed. The Assistant Director of Nursing stated she would consider this incident sexual abuse and affirmed that every resident has the right to be free from abuse, consistent with the facility's abuse policy stating that residents must not be subjected to abuse by anyone, including other residents.
Failure to Timely Report Alleged Sexual Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the appropriate authorities within the required time frame. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was allegedly subjected to sexual abuse by a cognitively intact roommate, Resident 2, who had a diagnosis of unspecified dementia. According to IDT notes, two CNAs entered the shared room for a recheck and found Resident 2 sitting at the end of Resident 1’s bed with his pants down, his back to the door, one hand under Resident 1’s gown, and his other hand on his own genital area. In a separate interview, CNA 1 reported that on the evening prior, he had entered the room after providing evening care and found Resident 2 sitting on Resident 1’s bed with his briefs pulled down, his right hand on his own genitals, and his left hand on Resident 1’s hip; when CNA 1 pulled back the covers, Resident 1’s penis was exposed, and Resident 1 became tearful and stated, “Get him away from me.” CNA 1 stated he reported this to the Nurse Supervisor on duty that evening. The Administrator confirmed in interview that the abuse allegation occurred on 2/8/26 and that the report to the California Department of Public Health (CDPH) was not made until 2/9/26 at 4:12 p.m. The facility’s policy and procedure on Abuse, Neglect, Exploitation, and Misappropriation, revised 10/12/23, requires all mandated reporters to report incidents or alleged violations of abuse not later than two hours after the allegation is made, including a written report to the local Department of Public Health Licensing and Certification office. The Administrator also stated that her expectation was that the initial incident report of the abuse allegation be sent to CDPH and other enforcement agencies within two hours of the allegation. The delay between the time the allegation was made and the time it was reported to CDPH constituted a failure to follow the facility’s abuse reporting policy and the federal requirement for immediate reporting of alleged abuse.
Missed Annual Performance Review for CNA
Penalty
Summary
The facility failed to complete annual performance reviews for a CNA, resulting in a missed evaluation for one of three sampled CNAs (CNA 1). Review of CNA 1’s employee file showed that the CNA was hired on 5/1/2018 and the most recent performance review on file was dated 5/17/2021, with no subsequent annual reviews documented. In an interview on 2/6/26 at 9:22 a.m., the Director of Staff Development (DSD) confirmed that the most recent documented performance review for CNA 1 was from 2021 and stated that performance reviews are supposed to be done annually for all CNAs, with the purpose of ensuring the staff member is doing their job. Review of the facility’s 2024 policy and procedure titled “Competency Evaluation” indicated that it is the facility’s policy to evaluate each employee to assure they meet appropriate competencies and skills for performing their job, and that subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of training programs, and/or job performance evaluations. This failure had the potential for the facility to be unaware of staffing performance concerns for CNA 1, with the potential for all resident care to be negatively affected.
Failure to Develop and Implement Substance Abuse Care Plan and Notify Physician
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional nursing standards for a resident with a known history of THC (tetrahydrocannabinol) substance abuse. The resident was admitted with multiple diagnoses, including a right knee fracture, major depressive disorder, anxiety, and difficulty walking. Documentation showed that the resident had a social history of THC use, and on two separate occasions, THC products were found in the resident's room. Despite these findings, there was no evidence that a care plan addressing substance use was developed, nor was there documentation of physician notification regarding the resident's substance abuse. Interviews with facility staff, including licensed nurses, a CNA, the Social Service Director, and the Social Services Assistant, confirmed that no substance abuse care plan was created and the physician was not notified after THC was found. Staff members stated that they would have expected a care plan to be implemented and the physician to be notified to ensure the resident's safety and appropriate care. The resident herself confirmed that she was not provided with an individualized substance abuse care plan upon admission or after the discovery of THC in her room, and expressed that such a plan would have been helpful. A review of facility policies indicated that comprehensive care planning and physician notification are required following resident assessments and any change in condition, including incidents involving substance abuse. The facility's failure to follow these policies resulted in the lack of monitoring, care planning, and physician involvement for the resident's substance abuse, as documented in the resident's records and confirmed by staff interviews.
Failure to Protect Resident Confidentiality in Meal Ticket Handling
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information for all 137 residents, as evidenced by meal tickets containing identifiable information being left unattended and easily accessible in the main dining room. Observations showed that returned breakfast trays had meal tickets displaying residents' names, facility identification numbers, colored photographs, room numbers, bed numbers, and dining locations in plain view, while other residents and visitors were present. Additionally, a dietary assistant was seen discarding these meal tickets into a regular trash can during tray cleanup, with the trash later compacted and disposed of in an outside dumpster. The registered dietician confirmed that this practice made residents' personal information easily accessible to others and acknowledged that disposing of the tickets in regular trash did not protect confidentiality. Review of the facility's HIPAA policy indicated a requirement to protect resident information and comply with federal guidelines.
Inaccurate MDS Assessments for Residents on Hospice and Special Treatments
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for four residents. For one resident with sleep apnea, the MDS was incorrectly marked as receiving an invasive mechanical ventilator, despite documentation and staff interviews confirming the resident only used a C-PAP machine at bedtime and had never been on a ventilator. The MDS Coordinator acknowledged the error, and the Director of Nursing confirmed that such inaccuracies could impact the quality of care provided. Another resident, admitted with severe cognitive impairment and a terminal prognosis, had a Certification of Terminal Illness and physician orders indicating hospice care for end-stage dementia. However, the MDS did not reflect the resident's terminal status or hospice care, as confirmed by the MDS Coordinator, who admitted to miscoding the assessment. Similarly, a third resident with a terminal diagnosis and on hospice care was not identified as such in two separate MDS assessments, and the MDS also failed to indicate a life expectancy of less than six months, contrary to medical documentation. A fourth resident, admitted under hospice services for dementia with severe agitation, had multiple MDS assessments that did not consistently reflect the terminal prognosis or hospice care status. The MDS Coordinator acknowledged that these assessments contained conflicting and inaccurate information, which could affect care planning. Facility policy requires that qualified staff conduct accurate assessments reflective of each resident's status, but this was not followed in these cases.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Improper Storage of Trash and Open Dumpsters
Penalty
Summary
Trash dumpsters outside the kitchen backdoor were observed with open lids, and an additional trash container containing used gloves, a hairnet, and a cigarette butt was found without a lid. These observations were made during a concurrent observation and interview with the Head of the department, who confirmed the lids were open. The Registered Dietitian also confirmed that open dumpsters and trash cans near the kitchen could attract flies, which could enter the kitchen when the back door was opened. A review of the facility's policy indicated that garbage and trashcans must be inspected daily to ensure lids are closed and no debris is present on the ground or surrounding area.
Infection Control Lapses in PPE Use, Equipment Disinfection, and Respiratory Care
Penalty
Summary
The facility failed to maintain effective infection prevention and control measures in several instances, as observed and documented by surveyors. In one case, enhanced barrier precautions (EBP) signage was incorrectly assigned to the wrong resident's bed, leading to confusion among staff about which resident required EBP. A certified nursing assistant (CNA) entered a room with an EBP sign without wearing the required personal protective equipment (PPE) and assisted a resident with incontinence care, only using gloves instead of both gown and gloves. The infection preventionist (IP) later clarified that the EBP sign was misplaced and should have been for a different resident, but this error was not corrected in a timely manner, resulting in improper infection control practices. In another instance, nursing staff did not implement EBP for a resident who had colonized bacteria and a skin tear requiring dressing. Despite the EBP sign being posted and the care plan indicating the need for gown and glove use during high-contact care, two CNAs performed an incontinence brief change without wearing gowns. One CNA was unaware of the EBP sign, and both confirmed that proper PPE should have been used. Additionally, the facility failed to enforce isolation precautions for COVID-19 positive residents, as doors to rooms with special droplet/contact precautions were left open, contrary to facility policy and posted signage instructing that doors remain closed. Further deficiencies included improper disinfection of blood pressure (BP) cuffs and machines, with staff using hand sanitizer wipes or alcohol prep pads instead of EPA-registered disinfectants as required by facility policy. There were also lapses in the handling of respiratory equipment: a resident's nebulizer mask was found unlabeled and not stored in a bag, and another resident's oxygen humidifier was left open and not replaced as ordered. These failures were confirmed through staff interviews and record reviews, with staff acknowledging the lapses and referencing facility policies that were not followed.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of flies in the kitchen. During an observation with the Dietary Supervisor, flies were seen flying around and landing on kitchen counters, food processors, cooking utensils, dishes, and food. The Dietary Supervisor confirmed the presence of flies and acknowledged the risk of food contamination. The Maintenance Supervisor also confirmed the ongoing fly problem in the kitchen and stated that the last pest control service was conducted earlier in the month, but the issue persisted. Further interviews with the Registered Dietitian and the Director of Nursing confirmed the infestation of flies in the kitchen and the potential for food contamination. The facility's policy required maintenance to ensure insects were not present and to contact the outside vendor for additional treatments if insects were found. Despite monthly pest control services, the flies remained, indicating the measures taken were not effective in maintaining a pest-free environment in the kitchen.
Expired Medications, Incomplete Crash Carts, and Improper Medication Storage Identified
Penalty
Summary
Surveyors observed that medications and medical supplies stored in three medication carts were expired, including haloperidol, isopropyl alcohol, Microkill One wipes, Maxorb II wound dressing, antiseptic skin cleanser, extra protective cream, anti-itch cream, iodoform packing strip, hydrogen peroxide, phenazopyridine tablets, skintegrity wound cleanser, biofreeze gel, syringes, and catheter stabilization devices. Additionally, an unlabeled pill identified as methadone was found in a narcotic box, and opened petrolatum dressings were present in the cart. Licensed nurses confirmed the presence of these expired and improperly stored items, acknowledging the importance of removing expired medications and supplies to prevent their use. Crash carts, which are essential for emergency situations, were not checked daily as required by facility policy, with multiple days missed from May to August. Inspections revealed that the crash carts did not contain the required number of normal saline containers, instead containing sterile water, and included a suction connection tubing that had expired in 2011. The Director of Nursing confirmed these discrepancies and the lack of regular checks, which are necessary to ensure the readiness and completeness of emergency equipment and supplies. A medication bottle containing acidophilus probiotic was found stored in a refrigerator designated for resident food in the memory unit. Both a certified nursing assistant and a licensed nurse confirmed that medications were being stored with food, which posed a risk for cross contamination. The Director of Nursing stated that medications requiring refrigeration should be kept in a secured medication refrigerator, not with resident food. Facility policies reviewed indicated that outdated, contaminated, or deteriorated medications should be removed from stock and that refrigerated medications must be kept separate from foods.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident with severe cognitive impairment slapped another resident, also with severe cognitive impairment, across the right side of the face. The incident occurred when one resident was attempting to open a door to the courtyard and the other resident, standing nearby, spontaneously slapped her. This event was witnessed by a CNA, who reported that her back was initially turned and she did not see the events leading up to the slap, but turned around in time to see the physical contact occur. Both residents involved had diagnoses of dementia and were assessed as having severe cognitive impairment according to their MDS records. The facility's policy and procedure on abuse, dated April 2025, states that each resident has the right to be free from abuse, including physical abuse, and that residents must not be subjected to abuse by anyone. Interviews with staff, including a CNA, a licensed nurse, and the DON, confirmed the occurrence of the incident and acknowledged that such behavior constitutes abuse and is not tolerated according to facility policy.
Failure to Complete Significant Change Assessment After Hospice Enrollment
Penalty
Summary
A significant change in status assessment (SCSA) was not completed for one of the sampled residents after the resident was enrolled in a hospice program. The resident, who had diagnoses including frontotemporal neurocognitive disorder and major depressive disorder, was admitted with a terminal prognosis related to end-stage Alzheimer's disease. Physician orders and hospice documentation confirmed the resident's terminal status and enrollment in hospice care. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) acknowledged that a SCSA should have been completed following the resident's enrollment in hospice but was not done. The Director of Nursing (DON) also confirmed that a SCSA is required when a resident is admitted to hospice. Facility policy states that a SCSA must be completed within 14 days of identifying a significant change, including hospice enrollment, but this was not followed in this case.
Failure to Follow Professional Standards in PICC Line Monitoring and Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure professional standards of care were followed for two residents. For one resident with a PICC line in the right arm, the physician's order required weekly measurement and documentation of the mid-upper arm circumference to monitor for complications. On review, the MAR/TAR was missing a signature for the required measurement on a specified date, and both the DON and a licensed nurse confirmed that the absence of documentation indicated the task was not completed. The facility's policy also required weekly measurement and documentation, which was not followed in this instance. For another resident with type I diabetes and a history of diabetic ketoacidosis, the physician ordered daily administration of Tresiba insulin. The MAR for a specific month showed that the resident did not receive insulin on two dates, and there was no documentation explaining the missed doses. The DON confirmed the absence of documentation and the increased risk to the resident due to their medical history. Later, the MAR was found to have been altered to indicate that the insulin was administered on those dates, but there was no corresponding late entry or explanation in the nursing progress notes as required by facility policy. Interviews with nursing staff revealed that the nurse responsible for the insulin administration acknowledged correcting the MAR after being questioned about the missing documentation, but did not follow the facility's process for late charting. The facility's documentation policy required that late entries be clearly indicated and explained in the progress notes, which was not done in this case. These failures resulted in incomplete and inaccurate medical records for both residents.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Timely Replace Opened Emergency Medication Kit
Penalty
Summary
The facility failed to implement an efficient process to accurately document and secure emergency medications (E-Kit) for its residents. During an inspection of the medication storage room, it was observed that the E-Kit containing insulin was stored in the medication refrigerator with a red tag, indicating it had been opened. The E-Kit logs showed that vials of Humalog and Lantus insulin were removed on two separate dates, and the E-Kit had not been replaced for six days after the last removal. A licensed nurse confirmed the delay in replacement and stated that it takes longer for refrigerated E-Kits to be replaced. The Director of Nursing confirmed that the E-Kit had not been replaced in a timely manner and acknowledged that staff should have followed up to ensure prompt replacement. Review of the facility's policy indicated that open E-Kits should be replaced with sealed kits within 72 hours of opening. The failure to replace the E-Kit within the required timeframe was directly observed and confirmed by staff interviews and record review.
Failure to Maintain and Document Hospice Coordination for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the hospice team and facility staff for a resident with a terminal diagnosis of dementia who was admitted under hospice services. Despite an agreement and facility policy requiring communication and documentation of hospice care, the resident's clinical records and dedicated hospice binder lacked essential hospice documents, including the hospice plan of care (POC), visit schedules, and visit notes. The only hospice-related document present was the consent for hospice services, and the hospice sign-in and visit log were blank. Licensed nurses and the DON confirmed that there was no documentation of hospice visits or communication, and staff were unaware of the hospice staff's schedule or the disciplines assigned to the resident. Interviews with nursing staff and leadership revealed a lack of understanding and implementation of the process for coordinating care with the hospice agency. The DON acknowledged that the absence of hospice documentation in the resident's records meant that staff might not be aware of the resident's current care needs or any changes in their condition. The facility's own policy and the service agreement with the hospice agency required the maintenance of medical records, including progress and clinical notes describing all inpatient services, but these were not present for the resident receiving hospice care.
Medical Director Absence from QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director (MD), a required member of the Quality Assurance and Performance Improvement (QAPI) committee, attended any of the QAPI meetings from January to May 2025. Despite holding monthly QAPI meetings to review quality reports, identify care concerns, discuss safety issues, and implement corrective actions, the MD did not participate in these meetings. Attendance records confirmed the MD's absence, and the facility did not have a designee attend in the MD's place. Interviews with the Administrator (ADM) and Director of Nursing (DON) revealed that the MD was invited to each meeting but declined, citing being too busy. The ADM reported that the MD was verbally notified of issues and provided with written reports, but the MD did not acknowledge receipt of these reports. The facility's QAPI policy required the MD or a designee to be part of the committee, but this requirement was not met during the specified period, affecting oversight for a census of 137 residents.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents, specifically in the case of a resident with severe cognitive impairment and a high risk for wandering or elopement. The resident, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, COPD, and Diabetes Mellitus, was able to leave the facility in a wheelchair without staff awareness. The resident was found by a kitchen staff member on a driveway ramp near a busy street, and staff were unaware that the resident was missing until the kitchen staff returned the resident to the unit. The facility's policy required immediate action if a resident was found missing, but this was not followed as staff did not notice the resident's absence. Record reviews confirmed that the resident had a high score on the facility's Wandering Risk Scale and required supervision and permission to be outside. Interviews with staff and review of progress notes indicated that the resident regularly demonstrated exit-seeking behaviors and that the incident occurred without staff knowledge. The Director of Nursing and Administrator confirmed that the resident was confused, required supervision, and that staff were unaware of the resident's exit and location at the time of the incident.
Delayed Reporting of Infectious Disease Outbreaks to Public Health Authorities
Penalty
Summary
The infection preventionist (IP) failed to report two potential infectious disease outbreaks to the California Department of Public Health (CDPH) within the required 24-hour timeframe, as outlined in the facility's policies. Specifically, a gastrointestinal outbreak affecting five residents with symptoms of nausea, vomiting, and loose stool began on 4/8/2025 but was not reported to CDPH until 4/11/2025, resulting in a three-day delay. Similarly, a respiratory outbreak involving three residents with fever, cough, and congestion started on 5/3/2025 and was reported to CDPH on 5/5/2025, two days late. Facility policies reviewed indicated that unusual occurrences, including outbreaks and suspected outbreaks, must be reported to the appropriate health authorities within 24 hours. During an interview, the IP acknowledged awareness of the 24-hour reporting requirement and confirmed the delays in reporting both outbreaks. These actions were not in accordance with the facility's Unusual Occurrences, Infection Prevention and Control Program, and Outbreak of Communicable Diseases policies.
Failure to Timely Report Flu and RSV Outbreak
Penalty
Summary
The infection preventionist (IP) failed to report an outbreak of influenza and Respiratory Syncytial Virus (RSV) in the facility within the required 8-24 hour timeframe as outlined in the facility's policy on unusual occurrences. The policy specifies that epidemic outbreaks or prevalence of communicable diseases must be reported to the Department of Health Services within this period. During an interview, the IP acknowledged that the outbreak occurred over a weekend when she was not working and admitted she did not know she was required to report it within 24 hours, resulting in a delayed notification.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse policy and investigate an injury of unknown origin for a resident who was found with a bruise on her left hip. The facility's policy requires that any complaints, observations, suspicions, or reports of incidents, including bruises of unknown origin, be investigated to rule out abuse. However, in this case, there was no documentation or investigation conducted to determine the cause of the bruise, nor were there any witness accounts, resident representative accounts, or employee interviews documented as required by the policy. The resident involved was admitted with diagnoses including frontotemporal neurocognitive disorder, tremors, and dementia, which affected her memory, recall, and decision-making abilities. Despite the presence of a bruise on the resident's hip, the Director of Nursing (DON) confirmed that no investigative report or follow-up was conducted, and she could not recall which staff member discovered the bruise or when it was discovered. This lack of action and documentation was contrary to the facility's established procedures for handling such incidents.
Failure to Develop Care Plans for Resident Injuries
Penalty
Summary
The facility failed to develop care plans for a resident who experienced two separate incidents. The first incident involved a bruise of unknown origin found on the resident's left hip. Despite the facility's policy requiring a care plan to be implemented or updated when a skin condition is identified, no care plan was developed for this bruise. The resident was admitted with diagnoses including frontotemporal neurocognitive disorder, tremors, and dementia, which could complicate the identification and management of such conditions. The second incident involved lacerations on two fingers of the resident's right hand, caused by a CNA while trimming the resident's fingernails. The lacerations were treated with normal saline and wrapped with gauze, but again, no care plan was developed to address this injury. The Director of Nursing confirmed that care plans should have been developed for both the bruise and the lacerations, but they were not, which could have led to the resident's needs not being properly identified and managed.
Failure to Provide Proper Wound Care and Staff Reeducation
Penalty
Summary
The facility failed to provide quality care for a resident who was unable to make decisions on her own due to conditions such as frontotemporal neurocognitive disorder, tremors, and dementia. A Certified Nursing Assistant (CNA) trimmed the resident's fingernails and accidentally cut the skin, causing lacerations on two fingers of her right hand. The facility did not conduct corrective reeducation with the CNA to prevent recurrence of such incidents. Additionally, the Licensed Vocational Nurse (LN) did not follow the physician's wound care treatment directions for the resident's lacerated fingers, as the treatment was not administered on specified dates, and the fingers were observed without the required dressings. The facility's policy on wound care was not adhered to, as the licensed nurse did not track the effectiveness of treatments or contact the Medical Director for a change in treatment orders when the wound was not healing. Observations revealed that the resident's fingers were not wrapped in dressing as ordered by the physician, and the LN admitted to not following the treatment orders because the fingers were not bleeding or appearing infected. Interviews with facility staff confirmed the lack of reeducation for the CNA and the absence of an investigation into the incident, highlighting a failure in ensuring proper care and adherence to physician orders.
Failure to Report Scabies Outbreak
Penalty
Summary
The facility failed to report an outbreak of scabies to the California Department of Public Health (CDPH) when three residents and one staff member tested positive for the condition. The facility's infection preventionist (IP) confirmed that the outbreak was not reported, despite the facility's policies requiring such reporting. The review of the undated policy titled 'Outbreak Reporting' and the policy titled 'Reporting Communicable Diseases' dated 7/1/14 indicated that the IP was responsible for reporting outbreaks to CDPH and the local public health officer. However, this was not done in this case. During the investigation, it was found that Resident 1 had a rash that spread all over their body, leading to all 20 residents in the dementia unit being treated for scabies as a preventative measure. The IP's line listing indicated that Resident 3 was the first to be diagnosed with scabies, and in total, one staff member and three residents tested positive. Additionally, two residents were being treated empirically for scabies. The IP confirmed that the outbreak was not reported to CDPH, which was a failure to adhere to the facility's own policies and state requirements.
Failure to Monitor Antipsychotic Medication Effectiveness
Penalty
Summary
The facility failed to monitor a resident who was prescribed an antipsychotic medication, Haloperidol (Haldol), for effectiveness. The resident, who had a diagnosis of dementia and severe major depressive disorder with psychotic features, was admitted to the facility and prescribed Haldol due to extreme paranoia. Despite the facility's policy requiring close monitoring of antipsychotic medications, there was no monitoring in place to evaluate the response or effectiveness of the medication from the time it was prescribed until the time of the survey. The Director of Nursing confirmed that there should have been a monitor in place to track the resident's behaviors and symptoms. The resident's care plan indicated that staff would monitor and document behaviors and symptoms of extreme paranoia, but this was not done. The Medication Administration Record (MAR) from the relevant period showed no data collected from behavior monitoring, which was supposed to be used by the facility physician and pharmacist to determine the appropriate dose and effectiveness of the antipsychotic medication. This lack of monitoring could result in the unnecessary use of the medication and a potential decline in the resident's overall health status.
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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