Golden Modesto Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 1900 Coffee Road, Modesto, California 95355
- CMS Provider Number
- 056301
- Inspections on file
- 44
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Golden Modesto Care Center during CMS and state inspections, most recent first.
A resident with dysphagia and dementia had an active diet order for a regular diet with minced and moist texture and mildly thick liquids, while a speech therapy evaluation recommended puree solids and nectar thick liquids. Nursing staff, the DON, and the speech therapist all described a facility process requiring nurses to notify the physician of new speech therapy diet recommendations, update the diet order in the medical record, and inform dietary, but this process was not followed. The diet order was not changed to match the speech therapy recommendations, and the physician and dietary department were not properly notified, contrary to the facility’s Diet Changes policy and professional documentation standards.
A contracted RN failed to administer any scheduled morning medications to nine residents during a single morning medication pass, despite physician orders and facility policy requiring medications to be given within a defined time window. Staff interviews confirmed that the RN left all scheduled morning medications in the cart and did not provide an explanation. The affected residents had multiple chronic conditions, including HTN, DM, HF, COPD, atrial fibrillation, kidney failure, and lupus, and their MARs showed numerous missed doses of antihypertensives, anticoagulants, insulin and other DM agents, diuretics, cardiac drugs, psychiatric medications, and supplements. SBAR documentation for each resident recorded that morning medications were not administered and that residents were later assessed with no adverse effects noted at that time, while facility policies and the RN job description required timely administration of medications as ordered by practitioners.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident admitted with multiple complex medical conditions did not have a baseline care plan developed within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that the necessary plan, which should have included physician orders, dietary and therapy services, and initial goals, was not completed, resulting in a lack of formal guidance for the resident's care.
A resident's representative requested medical records, but due to the absence of a medical records director and lack of communication among staff, the facility did not provide the records within the required timeframe. Facility policy required records to be provided within 30-60 days, but the request was not fulfilled, resulting in the resident's right to access their health information not being honored.
A resident with severe cognitive impairment was served a meal tray with regular consistency instead of the ordered full liquid diet with nectar thick consistency, leading to coughing and emesis. The facility's protocol for checking meal trays was not followed, as CNAs served the trays without waiting for nurses to verify them. The resident was sent to the emergency room as a precaution to rule out aspiration.
A resident with severe cognitive impairment was served a regular meal instead of a physician-ordered full liquid diet with nectar thick consistency, leading to coughing and emesis. The error was due to a printing issue on the meal tray ticket, which was missed by staff. The facility's policy required adherence to prescribed diets, but this was not followed.
A resident with severe cognitive impairment and a history of falls was not provided with consistent one-on-one supervision as required by the facility's policy. Despite being at high risk for falls, the resident experienced multiple falls, culminating in a serious injury due to a lack of supervision during a shift change. Staff interviews confirmed that the facility's process for managing fall risks was not followed, leading to the resident's avoidable fall and hospitalization.
A resident with severe cognitive impairment was administered insulin without a physician's order due to incorrect documentation by an LVN. The resident, who had no history of diabetes, was at risk for hypoglycemia. The error was identified the next day, highlighting the importance of accurate medication administration and adherence to facility policies.
A resident with moderate cognitive impairment was neglected when a CNA refused to assist her to the restroom, instructing her to wet her brief instead. This led to the resident feeling humiliated and in pain. Other staff confirmed this was against facility policy, which mandates assisting residents with their needs.
A resident with a high fall risk and Parkinson's disease experienced multiple unwitnessed falls due to inadequate supervision and delayed implementation of fall prevention protocols. Despite being identified as high risk upon admission, necessary interventions such as neuro checks and a fall program were not promptly initiated, leading to significant injuries and hospitalization. Staff interviews revealed a lack of communication and documentation, contributing to the facility's failure to adhere to its policies.
A resident with multiple medical conditions experienced an unwitnessed fall resulting in a dislocated finger. The facility failed to document the resident's change of condition or complete a post-fall assessment, contrary to its policies. The lack of documentation and assessment was confirmed by the LVN and DON, highlighting a lapse in adherence to professional standards.
The facility failed to implement enhanced barrier precautions during wound care for two residents, despite having a policy in place. One resident with diabetes and an open wound received care without a gown from an LPN unaware of the precautions. Another resident with cognitive impairment also received wound care without proper precautions. The Infection Preventionist was unfamiliar with the specifics of the precautions, and the facility had not implemented them.
A facility failed to update a Level I PASARR for a resident after a new diagnosis of bipolar type schizoaffective disorder. Despite the facility's policy requiring updated screenings for new mental health diagnoses, the resident's PASARR was not revised, as confirmed by interviews with the MDS Director, Medical Records, and the DON. This oversight meant the resident's care plan did not reflect the new diagnosis, potentially affecting the care provided.
The facility failed to accurately complete Level I PASARR screenings for two residents, omitting key mental health diagnoses. One resident's screening missed bipolar and anxiety disorders, while another's inaccurately indicated no mental disorder despite a history of delusional disorder and psychosis. Staff interviews confirmed these inaccuracies, highlighting the need for accurate PASARR screenings to determine appropriate care.
A facility failed to follow pharmacy recommendations for a resident on antipsychotic medication, neglecting to conduct an AIMS assessment as advised in May and June 2024. The resident, with a history of dementia and agitation, was on a care plan requiring monitoring for medication side effects. Despite this, staff interviews revealed confusion over assessment responsibilities, and the facility's transition to a new electronic system was cited as a possible reason for the oversight.
The facility exceeded the acceptable medication error rate with two errors out of 32 opportunities. One resident received docusate sodium at the wrong time, and another was at risk of receiving an incorrect insulin dose due to improper priming of the insulin pen by an LPN. The errors were identified during a survey, highlighting the need for adherence to medication administration protocols.
A long-term care facility failed to prevent significant medication errors involving insulin administration and adherence to vital sign parameters for medications. An LPN incorrectly primed an insulin pen, risking an incorrect dose for a diabetic resident. Additionally, medications were administered to a resident with heart conditions despite orders to hold them if the heart rate was below 60 bpm. Staff interviews revealed misunderstandings about the importance of following these parameters, highlighting a need for improved adherence to medication protocols.
Two residents with dysphagia were not evaluated or treated according to professional standards, leading to a risk of choking and aspiration. One resident was found unresponsive with food obstructing the airway, resulting in death. The facility failed to consult Speech Therapy, conduct swallow evaluations, supervise meals, or provide modified diets.
Failure to Implement and Document Speech Therapy Diet Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to follow and document recommended dietary changes according to professional standards of practice and the facility’s Diet Changes policy for one resident with dysphagia and dementia. The resident was admitted with diagnoses including dysphagia and dementia, and an MDS dated 11/26/2025 showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s Order Summary Report for diet listed a regular diet with minced and moist texture and mildly thick liquids, while a Speech Therapy Evaluation and Plan of Treatment dated 12/6/26 recommended puree solids and nectar thick liquids, creating a discrepancy between the active diet order and the speech therapy recommendations. Interviews with nursing staff and the DON confirmed that the facility’s established process required nursing staff to assess swallowing concerns, notify the physician to request a speech therapy evaluation, and, once recommendations were received, notify the physician of the new recommendations, update the diet order in the medical record, and notify dietary staff. LVN 1 and LVN 2 both described this process, stating that after speech therapy completed an evaluation and provided new recommendations, nursing staff were responsible for notifying the physician, changing the diet order, and communicating the change to dietary. The DON similarly stated that once speech therapy recommendations were received, the licensed nurse should notify the physician to obtain new diet orders, change the diet order in the record, and notify dietary immediately. The speech therapist confirmed that the new diet recommendations for puree solids and nectar thick liquids differed from the previous diet order and stated that the new diet should have been changed by facility staff on the day the evaluation was completed, with nursing staff following up with the physician and ensuring the diet was changed in the medical record. Review of the facility’s Diet Changes policy indicated that Nursing Services must notify the Food & Nutrition Department in writing of any diet change. A professional reference from the American Nurses Association on Principles for Nursing Documentation emphasized that documentation must be clear, accurate, complete, and properly authenticated. Despite these standards and policies, the resident’s diet order in the medical record was not updated to reflect the speech therapy recommendations, and the physician was not notified of the recommended diet change.
Failure to Administer Scheduled Morning Medications to Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors when a contracted RN did not administer any scheduled morning medications to nine sampled residents on 12/26/25. Interviews with facility staff confirmed that the facility’s process required nurses to follow physician orders and administer medications within one hour before or after the scheduled time, and that not doing so created a potential for harm. The Director of Staff Development stated that the RN working that morning did not administer any scheduled morning medications for the nine residents for an unknown reason, and emphasized the importance of following the rights of medication administration, including right dose, right time, and right route. The DON reported being notified that the scheduled morning medications were still in the medication cart and that the RN would not provide an explanation. In a telephone interview, the RN who worked that morning acknowledged she was responsible for administering medications to the nine residents and stated she was not aware of the facility’s medication administration schedule times, resulting in medications not being administered as ordered. She stated that medications should have been given within one hour before or after the scheduled time and admitted she knew some residents did not receive medications and that she did not address the missing doses or notify the physicians. She acknowledged that it was wrong not to administer medications as scheduled and that there was a potential for adverse side effects for the affected residents when medications were not administered as ordered. Record review showed that each of the nine residents had multiple ordered medications that were not administered on the morning of 12/26/25, as documented on their Medication Administration Records (MARs) and supported by SBAR notes indicating that morning medications were not given. These residents had significant medical diagnoses including hypertension, diabetes, heart failure, respiratory failure, COPD, atrial fibrillation, kidney failure, sepsis, lupus, necrotizing vasculopathy, and other chronic conditions. The missed medications included antihypertensives, anticoagulants (including Eliquis and aspirin), insulin and other diabetes medications, diuretics, heart failure medications, dementia medications, psychiatric medications, antibiotics, and various supplements and GI medications. SBAR documentation for each resident noted that morning medications were not administered and that residents were assessed later with no adverse effects or complications noted at that time, with recommendations that one-time-a-day medications be given immediately. Review of the facility’s RN job description and medication administration policy confirmed that RNs were required to administer medications according to practitioner orders and that medications were to be administered within 60 minutes of the scheduled time in accordance with written physician orders. The facility’s policy titled “Medication Administration–General Guidelines” specified that medications are to be administered as prescribed, in accordance with good nursing principles, by authorized personnel who are familiar with the medications, and within 60 minutes of the scheduled time. The policy also stated that the facility must have sufficient staff to allow medication administration without unnecessary interruptions and that medications are to be administered according to the established medication administration schedule. Despite these requirements, the contracted RN on the morning of 12/26/25 did not administer any of the scheduled morning medications for the nine residents, leaving all of their ordered morning doses documented as not given on the MARs. This failure to follow physician orders and facility policy regarding medication administration times constituted the medication error deficiency identified by the surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted with multiple significant diagnoses, including chronic kidney failure, heart failure, hypertension, diabetes mellitus, bacterial infections, obesity, muscle weakness, and bradycardia. Review of the resident's admission record and Minimum Data Set (MDS) confirmed that the resident was cognitively intact and had complex medical needs. However, the electronic medical record showed that no baseline care plan was completed for this resident, despite facility policy requiring such a plan to be developed within 48 hours of admission. Interviews with facility staff, including the MDS nurse, LVN, director of staff development, and director of nursing, revealed inconsistencies in understanding and implementing the baseline care plan process. Staff acknowledged the importance of completing a baseline care plan upon admission to ensure all resident needs were met and to guide appropriate care. The facility's policy specified that the baseline care plan should include physician orders, dietary orders, therapy services, social services interventions, PASARR recommendations, and initial goals. The absence of a baseline care plan for this resident meant that care and services were not formally planned or communicated to staff as required by facility policy.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to honor a resident's right to access and obtain medical records when the resident's representative requested records and the facility did not provide them within the required timeframe. The request for records was made on 1/8/25, but due to the absence of a medical records director (MRD) since 1/23/25 and lack of a designated staff member to handle such requests, the records were not provided within the 30-60 day period outlined in the facility's policy. The director of nursing (DON) and the administrator (ADM) both stated they were unaware of the request, as the former administrator and MRD had not communicated the request before leaving their positions. Facility policy required that requests for medical records be fulfilled within 30 days, or 60 days if the records were not maintained on site, with a possible 30-day extension if written notice was provided. However, the facility did not act on the request within these timeframes, and no written notice of delay was given. As a result, the resident's representative was not provided with the necessary medical records, and the resident's right to access their own health information was not respected.
Resident Served Incorrect Diet Leading to Potential Choking Hazard
Penalty
Summary
The facility failed to ensure that a resident was free from accidents when the resident was served a meal tray with a regular consistency, despite having an order for a full liquid diet with nectar thick consistency. This incident occurred on 2/20/25 and involved a resident who was admitted with acute respiratory failure, shortness of breath, dementia, and altered mental status. The resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status score of 0 out of 15. On the day of the incident, the charge nurse observed the resident having difficulty swallowing, accompanied by coughing. The resident was able to spit out the food with verbal cues, preventing a choking incident, but experienced a small emesis of undigested food. Although there was no respiratory distress or decline in oxygen saturation, the resident was sent to the emergency room as a precaution to rule out aspiration or other complications. The facility's process required nurses to check meal trays before they were served to residents, but this protocol was not followed, leading to the resident receiving the incorrect meal. Interviews with facility staff, including licensed vocational nurses and certified nursing assistants, revealed that the meal tray checking process was not adhered to, as CNAs served the meal trays without waiting for nurses to verify them. The director of staff development confirmed that the resident's diet slip had the incorrect diet listed, and the dietary staff served a regular diet instead of the ordered full liquid diet. The facility's policy and procedure required that all diet orders be checked against meal tray tickets to ensure accuracy, but this was not done, resulting in the resident receiving the wrong diet.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that therapeutic diets were followed according to physician orders for a resident who was served a meal tray with a regular consistency, despite having physician orders for a full liquid diet with nectar thick consistency. This incident occurred on 2/20/25 and resulted in the resident experiencing an episode of coughing and emesis, with the potential to cause choking, aspiration, and death. The resident, who was admitted with diagnoses including acute respiratory failure, shortness of breath, dementia, and altered mental status, had a severely impaired cognitive level as indicated by a Brief Interview for Mental Status score of 0 out of 15. The error was traced back to a printing issue on the meal tray ticket, where the full liquid diet was printed in small letters under the regular diet, leading to it being missed by all staff involved in the meal service process. The director of staff development and the certified dietary manager both acknowledged the mistake, noting that the meal tray ticket was printed with the incorrect diet order due to an error in the facility's meal tracking system. The dietary staff, including the cook, were expected to check the meal tray tickets to ensure the correct diet was served, but this process failed in this instance. The facility's policy and procedure on therapeutic diets, dated 10/2022, required that all residents have a diet order prescribed by the attending physician or a delegated registered or licensed dietitian. The policy emphasized the importance of preparing diets in accordance with the guidelines in the approved diet manual and the individualized plan of care. Despite these guidelines, the failure to follow the prescribed therapeutic diet for the resident led to the incident, highlighting a breakdown in the facility's processes for ensuring accurate meal service according to physician orders.
Failure to Provide Adequate Supervision Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was admitted with a history of gait and mobility abnormalities, severe cognitive impairment, and a need for assistance with mobility. The resident experienced multiple falls within a short period, specifically on 11/7/24, 11/8/24, 11/11/24, 11/14/24, and 11/15/24. Despite being assessed as high risk for falls, the facility did not implement effective interventions or provide consistent one-on-one supervision as required by their policies. The resident's care plan and fall risk evaluations indicated a high risk for falls, and the interdisciplinary team recommended interventions such as placing a fall mat, changing the resident's room for better visibility, and assigning one-on-one care. However, these interventions were not consistently implemented. On the night of 11/14/24 to the morning of 11/15/24, there was a lapse in one-on-one supervision, which led to the resident falling and sustaining serious injuries, including fractures that required surgical intervention. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed that the facility's process for managing residents with multiple falls was not followed. The staff acknowledged that the resident should have been under one-on-one supervision after experiencing two or more falls within 24 hours, but this was not consistently provided. The lack of supervision during a critical time led to the resident's avoidable fall and subsequent hospitalization.
Medication Error: Insulin Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when insulin was administered without a physician's order or diagnosis. The resident, who was admitted with multiple diagnoses including syncope, Parkinson's disease, and hypertension, was given insulin lispro, a medication intended for another resident. This error occurred due to incorrect documentation by an LVN, who mistakenly recorded the physician's order for insulin on the wrong resident's electronic medical record. The resident in question had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 4 out of 15. The error was identified the following day when the LVN realized the mistake and contacted the physician. The resident did not have a history of diabetes and was not receiving blood sugar checks prior to the medication error, which increased the risk of hypoglycemia. Interviews with facility staff, including the DON and other nurses, highlighted the importance of accurate documentation and administration of medications to the correct resident. The facility's policy and procedure documents emphasized the need for safe and timely medication administration and the prevention of adverse consequences and medication errors. However, the error in this case was a result of a failure to adhere to these policies, leading to the administration of an unauthorized drug to the resident.
Neglect of Resident's Restroom Needs
Penalty
Summary
The facility failed to protect a resident from neglect when a certified nursing assistant (CNA) did not provide necessary assistance to a resident who requested help to use the restroom. The incident involved Resident 2, who has a diagnosis of dementia and moderate cognitive impairment, and was reported by Resident 1, who is cognitively intact. Resident 1 observed CNA 1 telling Resident 2 to wet her brief in bed because CNA 1 did not have time to assist her to the restroom. This led to Resident 2 feeling humiliated and neglected, as she held her urine until she was in pain and eventually urinated on herself. Interviews with other staff members, including CNA 2, CNA 3, CNA 4, and LVN 1, confirmed that it was the facility's expectation for staff to assist residents with their needs, especially those who are continent and require assistance to the restroom. These staff members stated that refusing to assist Resident 2 was a form of neglect and not in line with the facility's policies. The facility's policy and procedure documents also emphasize the residents' right to be free from abuse and neglect, and the importance of treating residents with kindness, respect, and dignity. The facility's Director of Staff Development and the administrator acknowledged the incident as neglect and abuse. The administrator confirmed that CNA 1 was removed from the facility pending investigation. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention program, as well as the resident rights policy, were reviewed, highlighting the residents' rights to be free from abuse and neglect.
Failure to Implement Fall Prevention Protocols
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for a resident with a known history of falls and Parkinson's disease. Upon admission, the resident was identified as having a high risk for falls, with a fall risk score of 21. Despite this, the facility did not implement necessary fall prevention protocols immediately, as required by their policy. The resident experienced multiple unwitnessed falls, resulting in significant injuries, including a dislocated finger, a subdural hematoma, and a traumatic brain injury, which ultimately led to hospitalization. The facility's care plan for the resident, which included interventions such as neuro checks, non-skid footwear, and a low bed, was not implemented in a timely manner. The fall program, which should have been initiated upon admission, was delayed by several days. Staff interviews revealed that the resident exhibited behaviors such as self-transferring and ambulating without assistance, yet appropriate monitoring and supervision were not consistently provided. The facility's failure to adhere to its own policies and procedures for fall prevention and supervision contributed to the resident's injuries. Interviews with staff, including LVNs and CNAs, highlighted a lack of communication and documentation regarding the resident's condition and fall incidents. The Director of Nursing was not made aware of the resident's fall with injury until several days later, indicating a breakdown in the facility's process for reporting and addressing changes in resident condition. The facility's policy on managing falls and fall risks was not effectively implemented, resulting in inadequate supervision and safety measures for the resident.
Failure to Document Resident's Fall and Condition
Penalty
Summary
The facility failed to adhere to its policies and procedures and meet professional standards of quality care for a resident who experienced an unwitnessed fall with injury. The incident involved a resident with a history of multiple medical conditions, including acute gastroenteropathy, abnormalities of gait and mobility, muscle weakness, encephalopathy, and a history of falling. The resident was found kneeling on the floor and later complained of pain in the left little finger, which was diagnosed as a dislocation after being sent to the hospital. The nursing staff did not document the resident's change of condition or complete a post-fall assessment, which was required by the facility's process for handling falls. The Licensed Vocational Nurse (LVN) on duty acknowledged that there was no documentation regarding the fall, and the Director of Nursing (DON) confirmed that no change of condition assessment, post-fall assessment, or neurological checks were completed. This lack of documentation and assessment was contrary to the facility's policy, which mandates thorough documentation of any changes in a resident's condition and incidents involving the resident. The facility's policy on charting and documentation emphasizes the importance of complete and accurate records to facilitate communication among the interdisciplinary team and ensure appropriate care. The failure to document the resident's fall and subsequent condition could lead to an inaccurate assessment and delay in care, as noted by the DON and the Administrator. This deficiency highlights a significant lapse in the facility's adherence to its own standards and professional nursing practices.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during high-contact resident care activities, specifically during wound care for two residents. Resident #81, admitted with a medical history including type 2 diabetes mellitus, cellulitis, and an open wound on the right foot, was observed receiving wound care without the use of a gown by LPN #5, who was unaware of the EBP requirements. The resident's care plan indicated an infection caused by methicillin-susceptible staphylococcus aureus and the presence of a peripherally inserted central catheter, necessitating the use of EBP to prevent the spread of multi-drug resistant organisms (MDROs). Similarly, Resident #22, with a history of type 2 diabetes mellitus and severe cognitive impairment, was observed receiving wound care for an open area on the left big toe by LPN #1, who also did not use a gown and was unfamiliar with EBP. The facility's Infection Preventionist admitted to not knowing the specifics of EBP, and the facility had not implemented these precautions, despite their policy indicating the necessity of gown and glove use during high-contact care activities to reduce MDRO transmission.
Failure to Update PASARR Following New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a status change to a Level I Pre-Admission Screening and Resident Review (PASARR) following a new mental health diagnosis for a resident. The resident, who was admitted on June 12, 2020, had a medical history that included bipolar disorder, major depressive disorder, and anxiety disorder. On April 14, 2024, the resident was diagnosed with bipolar type schizoaffective disorder, but the facility did not update the Level I PASARR evaluation to reflect this new diagnosis. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process. Interviews with facility staff, including the MDS Director, Medical Records personnel, and the Director of Nursing, revealed that a new Level I PASARR should have been completed when the resident received the new diagnosis of schizoaffective disorder. The MDS Director and Medical Records personnel acknowledged that the new diagnosis was missed, and the Director of Nursing confirmed that the PASARR process is intended to determine if residents with mental illness would benefit from additional services. The failure to update the PASARR evaluation meant that the resident's care plan did not reflect the new diagnosis, potentially impacting the services and care provided.
Inaccurate PASARR Screenings for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Level I Pre-Admission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in capturing all mental health diagnoses. Resident #62 was admitted with a history of bipolar type schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder. However, the PASARR screening only noted major depressive disorder, omitting the bipolar and anxiety disorders. Interviews with the MDS Director, Medical Records staff, and the Director of Nursing confirmed the inaccuracies in the PASARR screening, which should have included all relevant mental health diagnoses. Similarly, Resident #12 was admitted with a history of delusional disorder, psychosis, major depressive disorder, recurrent depressive disorders, and hallucinations. The PASARR screening for this resident inaccurately indicated no diagnosed mental disorder. The MDS Director and Medical Records staff acknowledged the discrepancies, noting that the PASARR screening failed to reflect the resident's mental health diagnoses accurately. The Director of Nursing also confirmed that the PASARR process should have identified the resident's mental health conditions to determine the need for additional psychiatric care. The VP of Clinical Operations stated that PASARR screenings are completed prior to admission and should be reviewed for accuracy regarding diagnoses, medications, and resident history. Both residents' PASARR screenings were found to be inaccurate, as they did not capture all the necessary mental health diagnoses, which is essential for determining the appropriate level of care and services required for residents with mental disorders.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident who was reviewed for unnecessary medications. Specifically, the facility did not respond to pharmacy recommendations made in May and June 2024 for an AIMS (Abnormal Involuntary Movement Scale) assessment for a resident who was on antipsychotic medication. The facility's policy on antipsychotic medication use required nursing staff to monitor and report side effects and adverse consequences to the attending physician, but this was not adhered to in the case of the resident. The resident, admitted in March 2017, had a medical history including unspecified dementia, restlessness, agitation, and major depressive disorder. The resident's care plan, initiated in October 2022, included the use of antipsychotic medication for agitation, with specific interventions for monitoring side effects and consulting with the pharmacy. Despite these directives, the resident's medication regimen reviews in May and June 2024 indicated that an AIMS assessment was due, but the facility did not conduct the assessment as recommended. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for conducting AIMS assessments. LPNs and RNs were unsure of the frequency of AIMS assessments and the process for implementing pharmacy recommendations. The Director of Nursing acknowledged that the facility did not perform the AIMS assessment as recommended, and the VP of Clinical Operations suggested that a transition to a new electronic medical record system may have contributed to the oversight.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 2 errors out of 32 opportunities, resulting in a 6.25% error rate. The first error involved a resident with a history of constipation and rectal prolapse, who was administered docusate sodium 100 mg in the morning instead of the prescribed 250 mg in the evening. The LPN responsible acknowledged the mistake, noting that the medication was not due at the time it was given and was not ordered as needed. The second error involved a resident with type 2 diabetes mellitus, who was to receive insulin lispro before meals. An LPN prepared the insulin using a KwikPen, priming it with 2 units and then setting it to 14 units, which would have resulted in an incorrect dose. The VP of Clinical Operations intervened, and the LPN admitted the resident would receive extra units if administered. The Pharmacy Consultant confirmed the importance of priming the needle correctly to ensure the accurate dose. The DON and VP of Clinical Operations expressed expectations for adherence to physician orders and medication administration protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during the administration of insulin. A Licensed Practical Nurse (LPN) was observed preparing insulin lispro for a resident with type 2 diabetes mellitus. The LPN incorrectly primed the insulin pen by turning the dial to 14 units instead of the required 2 units for priming, which could result in administering an incorrect dose. The Vice President of Clinical Operations confirmed the error and indicated that the LPN would be retrained. Another deficiency was identified in the administration of medications to a resident with congestive heart failure and hypertension. The resident's medication orders included specific parameters to hold medications if the heart rate was below 60 beats per minute. Despite these instructions, the resident received amlodipine and furosemide on multiple occasions when their heart rate was below the prescribed threshold. Interviews with nursing staff revealed a misunderstanding of the importance of adhering to these parameters, as one LPN admitted to administering the medications despite the low heart rate. The Pharmacy Consultant and Nurse Practitioner emphasized the risks associated with administering these medications when the resident's heart rate was already low, which could lead to adverse effects such as dizziness and increased fall risk. The Director of Nursing and the VP of Clinical Operations both expressed expectations that nurses follow physician orders and vital sign parameters to prevent such errors. These deficiencies highlight a lack of adherence to medication administration protocols and the need for staff education on the importance of following prescribed parameters.
Failure to Provide Adequate Supervision and Services for Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision and services for the prevention of accidents for two residents diagnosed with dysphagia. Both residents were not evaluated or treated in accordance with professional standards of practice and their comprehensive care plans. Specifically, Speech Therapy was not consulted, swallow evaluations were not conducted, meals were not supervised, and modified meals to prevent the risk of choking and aspiration were not served. These failures resulted in a risk of choking and aspiration, and for one resident, it could have contributed to a fatal event where the resident was found pulseless while eating, with the coroner's preliminary report indicating the cause of death as asphyxia due to aspiration from food. Resident 1 was admitted with a diagnosis of dysphagia and had a severe cognitive impairment. Despite this, the resident was not evaluated by a speech therapist, and the facility staff did not monitor for signs of dysphagia such as pocketing or choking. The resident's meal plan included foods that were not appropriately modified for dysphagia, and the resident was left unsupervised during meals. This lack of supervision and failure to provide a suitable diet led to an incident where the resident was found unresponsive with food pocketed in the cheeks, which obstructed the airway and required emergency intervention. Resident 2, also diagnosed with dysphagia, was not evaluated by a speech therapist since admission. The resident had a regular diet order despite having dental issues and experiencing facial nerve pain that affected swallowing. The facility did not refer the resident to speech therapy for evaluation, nor did they monitor the resident's eating habits, which could have identified the need for dietary adjustments. The facility's failure to adhere to its policy and procedure for managing residents with dysphagia contributed to the risk of choking and aspiration for Resident 2.
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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