Golden San Andreas Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Andreas, California.
- Location
- 900 Mountain Ranch Road, San Andreas, California 95249
- CMS Provider Number
- 056132
- Inspections on file
- 51
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Golden San Andreas Care Center during CMS and state inspections, most recent first.
A resident's medical record was found to have multiple missing CNA documentation entries for ADL tasks across several shifts, including areas such as continence, mobility, hygiene, and fluid intake. Staff interviews confirmed that while care was sometimes provided, it was not always documented as required, and oversight by nursing staff was inconsistent. Facility leadership verified the documentation gaps and acknowledged that the facility's policy requires complete and accurate charting of all care and services provided.
Nursing staff discontinued CPR for a resident with a full code status before EMS arrived and without a physician's order or confirmation of death. Despite facility policy requiring CPR to continue until emergency personnel assume care, staff stopped resuscitation efforts and a nurse declared the time of death. Interviews confirmed that only a physician should pronounce death and that the protocol was not followed.
A resident with a history of aggression and multiple mental health diagnoses was not adequately supervised according to their care plan, which required separation from female residents. Staff were unaware of these care plan instructions, resulting in the resident grabbing another resident's wrist and shirt and attempting to strike her in a hallway. The DON confirmed that the care plan was not fully implemented and one-to-one monitoring was not provided after a prior incident.
Two residents at risk for pressure ulcers did not receive proper assessment, documentation, or implementation of preventative measures, resulting in the worsening of wounds. In both cases, staff failed to consistently turn and reposition the residents, did not document wound changes or interventions, and did not notify the physician when conditions deteriorated. One resident required surgical intervention for a worsened coccyx wound, while the other developed a deep tissue injury on the heel.
The facility did not consistently document or discuss advance directives with residents or their legal representatives, failed to ensure code status orders in the EMR matched POLST forms, and left required sections of POLST forms incomplete. These actions led to residents' treatment preferences not being known or followed, including an incident where a resident received CPR despite a DNR order.
Three residents did not have appropriate care plans developed or implemented: two residents with active MDRO infections were placed on Enhanced Barrier Precautions without corresponding care plans, and another resident with a DNR order had her wishes disregarded when staff initiated CPR. These actions were not in accordance with facility policy requiring comprehensive, person-centered care plans.
Several residents did not receive their prescribed diets, including fortified mashed potatoes for those needing added calories and appropriate finger foods for a resident requiring self-feeding support. Regular menu items were served instead, contrary to dietary orders and facility policy.
Surveyors found multiple deficiencies in food safety and sanitation, including unclean kitchen equipment, improper food labeling and storage, use of expired foods, unsanitary surfaces, and serving food prepared in contaminated pans. The Dietary Manager and Registered Dietician confirmed these practices did not meet professional standards and posed risks of contamination for all residents receiving facility-prepared meals.
Multiple infection control lapses were observed, including a physical therapy assistant not wearing an N95 respirator in a COVID-19 positive resident's room, a CNA transferring a resident on enhanced barrier precautions without a gown, two residents with MDROs not placed on EBP, and a nurse failing to properly disinfect a glucometer between uses by not allowing the required wet contact time. These actions were inconsistent with facility policy and infection prevention protocols.
Three residents were found without access to their call lights, including one with limited mobility whose call light was under pillows, another whose call light was attached to the bottom of the bed rail and out of reach, and a third whose call light was left on a chair. Staff confirmed in each case that the call lights were not accessible and acknowledged the expectation that call lights should always be within reach, as outlined in facility policy.
A resident with a documented DNR status on their POLST received CPR after staff relied on outdated code status information in the EHR, leading to resuscitation efforts that were not in accordance with the resident's wishes. The discrepancy between the POLST and EHR, along with inconsistent staff practices for verifying code status, resulted in the resident receiving care contrary to their documented preferences.
A resident was left without water within reach, despite expressing thirst and showing signs of dehydration such as dry, cracked lips. Both nursing and CNA staff confirmed the water was not accessible, and the care plan required fluids to be available and staff to cue the resident to drink. The facility's hydration policy also mandated bedside water and monitoring for dehydration symptoms.
Two residents received oxygen therapy without adherence to professional standards, including one instance where oxygen was administered without a physician order and both cases lacking required 'oxygen in use' signage outside their rooms. Staff and the DON confirmed these actions were not in line with facility policy, which mandates physician orders for oxygen and proper signage to alert staff and visitors.
A resident with a history of cancer and rheumatoid arthritis experienced unrelieved pain when an LPN failed to apply a physician-ordered Lidocaine patch at the scheduled time, instead documenting it as given and only applying it three hours later. The resident was observed in pain without the patch, and the facility's pain management policy was not followed.
Two residents did not receive medications as prescribed: one had PRN acetaminophen left at the bedside without nurse observation, and another received Sucralfate during a meal instead of before as ordered. Nursing staff acknowledged these deviations from physician orders and facility policy.
A garbage dumpster bin was found with its lid propped open, as confirmed by both the DM and RD, contrary to expectations for proper waste management. This failure to keep the dumpster closed had the potential to attract rodents and insects, affecting the facility's 89 residents.
Two residents were affected by failures in medical record-keeping: one had another individual's lab results mistakenly placed in their file, and another did not have complete informed consent documentation for psychotropic medications, lacking details on frequency, dose, and duration as required by facility policy. The DON confirmed these deficiencies during record reviews and interviews.
A resident with chronic health conditions, including COPD and diabetes, was not offered the PPSV23 pneumococcal booster vaccine despite being eligible and having previously received the PCV13 vaccine. Both the IP and DON confirmed the oversight during interviews, and CDC guidelines reviewed by staff supported the need for the additional vaccination.
A steamer in the kitchen was repeatedly observed leaking water onto the floor, with staff needing to frequently empty an overflowing tray beneath it. The leak persisted despite previous repairs, and no wet floor caution signs were in use. The Dietary Manager confirmed the ongoing issue and acknowledged the risks associated with the wet floor and leaking equipment, which was not maintained as required by facility policy.
A CNA in an LTC facility provided a resident with a vape pen containing THC, despite the resident's history of anxiety and COPD. The resident, who was on supplemental oxygen, used the vape pen after expressing anxiety. Facility policies prohibited staff from providing smoking items to residents, and the CNA admitted to the action. The facility's Administrator and DON acknowledged the policy breach, and the Physician Assistant instructed staff to remove the vape pen and monitor the resident for adverse effects.
A resident at high risk for falls due to Parkinson's disease and muscle weakness fell from bed and sustained injuries because the facility failed to implement care plan interventions, including a fall mat and two-person assistance. The CNA involved was unaware of the care plan requirements, leading to the resident's fall and increased dependency on staff for daily activities.
Incomplete CNA Documentation of Resident ADL Tasks
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident when multiple shifts lacked Certified Nursing Assistant (CNA) documentation for various Activities of Daily Living (ADL) tasks throughout July 2024. A review of the resident's clinical documentation revealed missing entries across a wide range of care areas, including behavior, bladder and bowel continence, bowel movements, fall interventions, fluid intake, and numerous GG assessment items such as transfers, hygiene, and ambulation. These omissions were present on multiple dates and shifts, indicating a pattern of incomplete documentation. Interviews with facility staff confirmed the documentation lapses. A CNA acknowledged that there were times when ADL tasks were completed but not documented, despite being aware of the expectation to finish charting by the end of each shift. The CNA also recognized that incomplete documentation could result in miscommunication about the resident's care, such as the risk of unnecessary medication administration. A licensed nurse stated that CNAs were responsible for documenting every shift and that charge nurses were expected to ensure this was done, but admitted that this oversight was not always performed. Further confirmation came from the Director of Staff Development and the Director of Nurses, both of whom verified the presence of multiple missing documentation entries for the resident. They stated that the lack of complete CNA documentation could lead to miscommunication between shifts, difficulty in proving that care tasks were completed, and challenges for other departments in accurately assessing the resident. The facility's policy and procedure on charting and documentation required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately in the medical record.
CPR Discontinued Prematurely Without Physician Order
Penalty
Summary
Nursing staff failed to follow established protocols for the initiation and discontinuation of CPR for a resident with diagnoses including orthopedic aftercare and hypertension. The resident had a valid POLST indicating full code status, meaning all resuscitative efforts were to be made in the event of cardiac or respiratory arrest. When the resident was found unresponsive with no signs of life, the licensed nurse verified the absence of an apical pulse and respirations, and, after confirming the full code status, CPR was initiated. However, CPR was discontinued by the nursing staff before the arrival of EMS, and the time of death was declared by a licensed nurse without a physician's order or confirmation of death. Interviews with the involved nurses revealed that CPR was stopped because there were no signs of viability, and the nurse believed the resident had already expired. Both the nurses and the Director of Nursing acknowledged that, according to facility policy, only a physician is authorized to pronounce death, and CPR should have been continued until EMS arrived. The facility's policies also required that CPR/BLS be continued until emergency medical personnel assumed care, which was not followed in this instance.
Failure to Implement Supervision and Safety Interventions for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for a resident with a history of aggressive behavior. Specifically, a resident diagnosed with Dementia, Paranoid Schizophrenia, and Alzheimer's Disease, who had previously been involved in an incident with another resident, was not kept away from female residents as directed in their care plan. Three days after the initial incident, this resident grabbed another resident's wrist and shirt and attempted to strike her while both were sitting in the hallway. The care plan clearly stated that the resident should be kept away from female residents and not be left alone with them, but this was not followed. Staff interviews revealed that both the licensed nurse and the certified nursing assistant involved were unaware of the care plan instructions regarding the resident's required separation from female residents. The Director of Nursing acknowledged that the care plan was not fully implemented and that the resident was not placed on one-to-one monitoring after the first incident. This lack of communication and supervision allowed the incident to occur, potentially affecting the physical and psychosocial well-being of the resident who was grabbed.
Failure to Prevent and Manage Pressure Ulcers Due to Incomplete Assessment, Documentation, and Implementation of Preventative Measures
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for two residents who were at risk for pressure injuries. One resident was admitted with a shearing wound on the coccyx and was assessed as being at risk for pressure ulcers. However, the initial skin assessments and wound documentation were incomplete, and the physician was not notified when the wound worsened. Preventative measures, such as turning and repositioning every two hours, were not properly identified or implemented upon admission. The nurse responsible for wound care did not document wound measurements, location, or description after the initial assessment and admitted to missing required charting. There was also no evidence that the resident was turned every two hours or that refusals were documented. As a result, the resident's wound worsened, causing pain and requiring surgical intervention and wound vacuum placement at a hospital. Another resident, also at risk for pressure ulcers due to immobility and incontinence, developed a shearing wound on the coccyx and blanchable redness on both heels while in the facility. The skin assessments and wound documentation for this resident were incomplete, and interventions to prevent pressure ulcer development, such as turning every two hours and the use of heel lift boots, were not consistently implemented. Certified Nursing Assistants (CNAs) were unaware of the care plan requirements for turning and repositioning, and there was no documentation to show that these interventions were carried out. During observation, the resident was found with only one heel boot in place, and a deep tissue injury with eschar was discovered on the left heel. The nurse confirmed that the wound had worsened without proper documentation or notification. Interviews with nursing staff and the Director of Nursing revealed that documentation of turning and repositioning was not routinely performed, and changes in wound condition were not always promptly recorded or communicated to the physician. Facility policies required documentation of services provided, changes in condition, and timely notification of the physician, but these were not followed. The lack of adherence to care plans, incomplete documentation, and failure to implement preventative measures led to the development and worsening of pressure ulcers in both residents.
Failure to Document and Honor Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that residents' rights regarding treatment choices and advance directives were known and protected for seven residents. For three residents with cognitive impairments or serious illnesses, there was no documented evidence that an advance directive was requested or discussed, as required in Section D of their POLST forms. The Social Services Director (SSD) was unaware of her responsibility to inquire about advance directives, and the Director of Nursing (DON) confirmed that social services should be responsible for obtaining this information and ensuring it is documented. Facility policy also required that residents' choices regarding treatment be incorporated into their care plans, but this was not consistently done. In two cases, there were discrepancies between the code status documented in the electronic medical record (EMR) and the code status listed on the POLST forms. One resident's POLST indicated Do Not Resuscitate (DNR), while the EMR listed them as Full Code, and another resident's POLST and EMR had conflicting code statuses. Staff interviews revealed that the process for determining code status was inconsistent, with some staff checking both the POLST and the EMR, but not always ensuring they matched. This led to an incident where a resident received CPR despite having a DNR order on the POLST. Additionally, for a resident with a Power of Attorney (POA) in place, the facility discussed advance directives with the resident rather than the legally recognized representative, despite the resident lacking decision-making capacity. Another resident's POLST form was incomplete, with Section D left blank, and the SSD confirmed this omission. Facility policies reviewed indicated the importance of documenting and honoring residents' treatment wishes, but these procedures were not consistently followed, resulting in failures to respect residents' rights and preferences regarding emergency treatment.
Failure to Develop and Implement Care Plans for Infection Control and Advance Directives
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies related to infection control and honoring advance directives. Two residents, who were roommates, were admitted with active multi-drug resistant organism (MDRO) infections, specifically Escherichia coli producing Extended Spectrum Beta Lactamase. Although both residents were placed on Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care and identification with an orange dot, their care plans did not initially include specific interventions or goals related to MDRO management. The Infection Preventionist confirmed that the EBP care plans for these residents were not developed until after the precautions were already in place, which meant staff may not have been fully informed or consistent in following the necessary infection control measures. Additionally, a third resident with a diagnosis of atrial fibrillation had a Physician Orders for Life Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR) status, which was signed by the responsible party and a physician's assistant. Despite this, the resident's care plan, which documented the DNR status and the goal to have her wishes followed, was not implemented. As a result, staff initiated full cardiopulmonary resuscitation (CPR) on the resident against her documented wishes. Facility policies required that comprehensive, person-centered care plans be developed and implemented for each resident, including measurable objectives and timeframes to meet their needs. The failure to create and implement these care plans as required led to lapses in infection control for the two residents with MDROs and a failure to honor the advance directive for the resident with DNR status.
Failure to Provide Prescribed Fortified and Finger Food Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of several residents during a lunch meal. Specifically, three residents who were prescribed a fortified diet to increase caloric intake were served regular mashed potatoes instead of the required fortified mashed potatoes. The fortified mashed potatoes, as described by the Dietary Manager, should have included extra butter and half and half for additional calories, but these were not provided. The Dietary Manager acknowledged the importance of following ordered diets to prevent unintended weight loss or worsening medical conditions, but could not locate a fortified diet policy. Additionally, a resident who was ordered a finger food diet received a regular meal tray that included items not suitable for finger feeding, such as an open-faced pork sandwich with gravy, mashed potatoes, and glazed carrots. The Registered Dietician confirmed that the resident's meal card indicated a finger food diet and that the facility's policy for finger foods was not followed, despite appropriate finger foods being available in the kitchen. The facility's policy specified that finger foods should be easy to pick up and eat, and that foods like mashed potatoes and sauced vegetables should be avoided for residents on this diet.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe food storage, preparation, and maintenance of kitchen equipment and food contact surfaces in accordance with professional standards for food safety for all 89 residents receiving facility-prepared meals. Surveyors observed that the stove, oven, convection oven, backsplash, and sides of the oven contained grease, food particles, and encrusted grime. The Dietary Manager (DM) and Registered Dietician (RD) both confirmed that these areas should be cleaned after each use and at least weekly, and that the lack of cleanliness did not meet expectations. The RD emphasized that unclean equipment and surfaces could lead to bacterial growth and cross-contamination. During the kitchen tour, it was found that sliced yellow cheese had been removed from its original packaging and stored in an unlabeled, undated container in the refrigerator. Additionally, containers of pumpkin and cranberry sauce were available for use beyond their use-by dates. The DM and RD both stated that this practice was unacceptable and increased the risk of illness from expired or contaminated foods. Other unsanitary conditions included a floor sink with rust-colored stains, chipped paint, debris, and liquid splatter, as well as a damaged wall behind a food preparation table with chipped paint, exposed drywall, and dried food particles. Clean metal sheet pans were found with food particles and grease, and the steam table had encrusted food residue and stains. Further observations revealed that an industrial meat slicer and mixer, both wrapped in dirty clear plastic and considered clean, were actually stained and splattered with food particles. A baked cake was not properly sealed and was stored on a shelf with dried food particles, and another cake was prepared in a pan with encrusted residue and rust, then served to residents. The DM and RD confirmed that these practices did not meet expectations and posed risks of contamination. Facility policies and FDA Food Code requirements reviewed by surveyors indicated that equipment and food contact surfaces must be clean, food must be labeled and dated, and all food must be properly covered and stored to prevent cross-contamination.
Infection Control Lapses in PPE Use, EBP Implementation, and Equipment Disinfection
Penalty
Summary
The facility failed to maintain its infection prevention and control program for its residents, as evidenced by multiple observed lapses in infection control practices. A physical therapy assistant was observed entering the room of a COVID-19 positive resident while wearing only a surgical mask, rather than the required N95 respirator. The infection preventionist confirmed that facility policy required staff to wear an N95 respirator, gown, gloves, and face shield when entering rooms of COVID-19 positive residents, and that a surgical mask would not provide sufficient protection. Additionally, a certified nurse assistant was observed transferring a resident who was on enhanced barrier precautions (EBP) due to an indwelling urinary catheter, without wearing a gown. The CNA acknowledged the omission and the infection preventionist explained that gowns are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Furthermore, two residents with documented MDRO infections were not placed on EBP, and there was no signage or PPE on their doors until the infection preventionist intervened. Facility policy indicated that EBP should be initiated for residents known to be colonized or infected with MDROs or who have indwelling medical devices. During a medication pass, a licensed nurse was observed cleaning a glucometer with a bleach wipe but did not allow the required four-minute wet contact time for effective disinfection, instead wrapping the device in a paper towel immediately after wiping. The nurse was unaware of the required dwell time, and the infection preventionist confirmed that improper sanitization could expose residents to bacteria and bloodborne pathogens. Facility policy and the bleach wipe manufacturer’s instructions both specified the need for a four-minute wet contact time between uses on different residents.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents by not ensuring their call lights were within reach. In one instance, a resident with limited mobility was observed trying to find the call light, which was found under the pillows and not accessible. The licensed nurse confirmed the call light was not in reach and acknowledged the resident would not have been able to locate it independently. The resident's care plan indicated a history of attempting to get out of bed independently and emphasized the importance of timely call light response and reminders to use the call light for assistance. In another case, a resident's call light was attached to the bottom of the bed rail, a few inches from the floor, making it inaccessible while the resident was in bed. Both a CNA and an LVN confirmed the call light was out of reach and stated that residents should always have access to their call lights. In a third instance, a resident's call light was found on a chair, not within reach, and the licensed nurse present confirmed it should have been accessible. The facility's policy required call devices to be placed within the resident's reach before staff left the room.
Failure to Honor DNR Status Due to Inconsistent Documentation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atrial fibrillation and dementia did not receive care in accordance with their Physician Orders for Life-Sustaining Treatment (POLST). The resident's POLST, signed by the responsible party and a physician's assistant, indicated a Do Not Resuscitate (DNR) status. However, the resident's electronic health record (EHR) and physician's orders still reflected a full code status, which led to confusion among staff regarding the resident's resuscitation wishes. When the resident was found unresponsive, staff checked the EHR, which indicated full code, and initiated CPR, including chest compressions, use of a backboard, bag-valve mask, and administration of epinephrine. Emergency Medical Services (EMS) arrived and continued resuscitation efforts. It was only after these interventions that staff discovered the resident's POLST indicated DNR, but by then, life-saving measures had already been performed for several minutes. Interviews with nursing staff revealed inconsistent processes for verifying code status, with some staff relying solely on the EHR and others referencing the POLST. The facility's policies required honoring advanced directives and POLST forms, but the failure to update the EHR to reflect the resident's current DNR status resulted in the resident receiving CPR against their documented wishes.
Failure to Ensure Resident Hydration Due to Inaccessible Fluids
Penalty
Summary
A deficiency occurred when a resident was not provided with adequate hydration according to facility policy and the resident's care plan. During an observation and interview, the resident expressed thirst and was unable to find any fluids within reach on her bedside table. Both a licensed nurse and a certified nursing assistant confirmed that the resident's water was not accessible and acknowledged the risk of dehydration. The resident was observed to have dry, cracked, and peeling lips, which are signs of dehydration. The certified nursing assistant also confirmed these symptoms during the observation. The resident's care plan, revised previously, specified that the resident should not exhibit signs or symptoms of dehydration and that nursing staff should cue the resident to take frequent sips of fluid. The facility's hydration policy required that water be available at the bedside for residents not on fluid restrictions and that staff observe for signs of dehydration, including dry, cracked lips. The director of nursing confirmed that fluids should always be within reach, especially for residents showing signs of dehydration.
Failure to Provide Physician-Ordered Oxygen Therapy and Required Signage
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents. For one resident with a diagnosis of chronic obstructive pulmonary disease (COPD), oxygen therapy was administered via nasal cannula at a flow rate of 1.5 liters per minute without a current physician order. The resident confirmed ongoing oxygen use since admission, and a licensed nurse acknowledged the absence of a physician order, stating this could result in the resident receiving an incorrect dosage. Additionally, there was no 'oxygen in use' sign posted outside this resident's room, which was confirmed by both the nurse and the Director of Nursing (DON) as a deviation from facility expectations. For another resident receiving oxygen therapy, there was also no 'oxygen in use' sign posted outside the room. A certified nurse assistant and a licensed nurse confirmed the absence of the sign, with the DON stating that facility policy requires such signage to alert staff and others to the presence of oxygen due to its flammability. The facility's policy on respiratory care and oxygen administration specifies that oxygen is to be administered per physician order and that appropriate signage must be posted in accordance with regulations. These observations and interviews demonstrate that the facility did not follow its own policy or professional standards in these instances.
Failure to Timely Administer Pain Patch as Ordered
Penalty
Summary
A deficiency occurred when a licensed nurse failed to apply a Lidocaine patch for pain management to a resident as ordered by the physician. The nurse signed off in the medical record that the patch had been applied at the scheduled time, but in reality, the patch was not placed until three hours later. During this period, the resident, who had a history of malignant neoplasm and rheumatoid arthritis, reported being in pain and was observed without the prescribed patch in place. The nurse acknowledged the delay and the importance of timely application for effective pain control. The resident's care plan included interventions for chronic pain related to knee pain and scoliosis, with goals for satisfactory pain control and administration of pain medications as ordered. Facility policy required residents to receive pain management according to physician orders and documentation of pain levels. The failure to apply the Lidocaine patch as scheduled resulted in the resident experiencing unrelieved pain, as confirmed by both the resident and staff interviews, as well as direct observation.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure proper administration of medications for two residents. For one resident with a history of malignant neoplasm and rheumatoid arthritis, a nurse left a PRN acetaminophen tablet at the bedside without observing the resident take it. The resident later showed that the medication had not been ingested, and the nurse confirmed she did not watch the resident take the medication. Facility policy requires that medications be administered as prescribed and that the person administering the medication observe the resident to ensure ingestion. For another resident with gastro-esophageal reflux disease and a history of gastrointestinal bleeding, a nurse administered Sucralfate during the resident's meal instead of before the meal as prescribed. The nurse acknowledged the medication was due before the meal and was administered late. Facility policy states that medications should be given within a specific time frame and in accordance with physician orders, including timing related to meals.
Improper Disposal of Garbage Due to Open Dumpster Lid
Penalty
Summary
A deficiency was identified when a garbage dumpster bin located outside behind the building was observed with its lid propped open during a concurrent observation and interview with the Dietary Manager (DM). The DM confirmed that the lid was open and acknowledged that it should be kept closed and secured to prevent attracting rodents. In a subsequent interview, the Registered Dietician (RD) also stated that the expectation was for the dumpster bin to be closed and noted the risk of attracting rodents if left open. A review of the 2022 Food Code indicated that outside receptacles must have tight-fitting lids or covers to prevent the entry of rodents and the breeding of flies. This failure had the potential to lead to insect and rodent infestation for the 89 residents living at the facility.
Incomplete Medical Records and Inadequate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, laboratory results belonging to another individual were found in their medical record. This error was confirmed by the Director of Nursing (DON), who acknowledged that the incorrect laboratory results were placed in the resident's file by accident, which could have led to the wrong results being reported to the physician. For another resident, the facility did not ensure that psychotropic medication informed consent documents included the required details of frequency, dose, and duration for multiple medications, including trazodone, abilify, and divalproex sodium. The DON confirmed that the consent forms were incomplete and that no progress notes were made in accordance with the facility's policy and procedure for informed consent for psychotropic drugs. The policy required documentation of the drug, dose, frequency, rationale, risks, and the individuals involved in the consent process, none of which were fully documented in this case.
Failure to Offer Pneumococcal Booster Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of twenty-five sampled residents was offered the pneumococcal booster vaccine (PPSV23) despite being eligible. The resident in question had a medical history that included muscle weakness, anemia, Type 2 Diabetes Mellitus, and chronic obstructive pulmonary disease. The resident's immunization record showed receipt of the PCV13 vaccine, but there was no documentation that the PPSV23 vaccine was offered or administered as recommended for adults over 65 years old with certain chronic conditions. During interviews and record reviews, both the Infection Preventionist and the Director of Nursing confirmed that the resident was eligible for the PPSV23 vaccine and acknowledged that it should have been offered. The CDC guidelines reviewed by the facility staff indicated that adults 65 years or older, especially those with chronic lung conditions, should receive the PPSV23 vaccine even if they had previously received the PCV13 vaccine. The failure to offer the vaccine was identified through review of the resident's records and staff interviews.
Failure to Maintain Kitchen Equipment and Ensure Safe Environment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically a steamer that was observed leaking water onto the floor during multiple observations. The leak caused water to collect on a maroon kitchen tray, which then overflowed onto the ground, creating a wet floor. Staff confirmed that the tray needed to be emptied repeatedly to prevent overflow, and that the steamer had been repaired several times but continued to leak. No wet floor caution signs were present in the area during these observations. The Dietary Manager acknowledged that the leaking steamer could harbor bacteria or create a fall hazard and confirmed that the equipment required further repair and that the floor should remain dry. Review of the facility's policy indicated that all equipment should be routinely cleaned and maintained according to manufacturer’s directions, and that maintenance requests should be submitted as needed.
CNA Provides Resident with THC Vape Pen
Penalty
Summary
The facility failed to ensure a resident remained free from accidents and hazards when a Certified Nursing Assistant (CNA) provided the resident with a vape pen containing tetrahydrocannabinol (THC). This incident involved a resident with a history of anxiety and chronic obstructive pulmonary disease (COPD), who was on supplemental oxygen. The resident, who did not use marijuana or vape products according to their smoking assessment, informed staff that they had used the vape pen given by the CNA, which could have been laced with an unknown substance. Interviews with staff revealed that the CNA was not supposed to share personal vape pens with residents, as it could lead to potential health risks such as lung injury or confusion. The facility's policy prohibited staff from providing smoking items to residents, and the use of electronic cigarettes was considered a risk due to potential health effects. The CNA admitted to giving the resident the vape pen after the resident expressed feelings of anxiety and a desire for marijuana or alcohol. The facility's Administrator and Director of Nursing acknowledged that the facility's policies were not followed. The Drug-Free Workplace Policy, which the CNA had signed, prohibited the possession or use of illegal drugs, including marijuana, on company property. The Physician Assistant was informed after the incident and instructed staff to remove the vape pen from the facility and monitor the resident for adverse effects. The facility's failure to adhere to its policies and procedures resulted in a deficiency related to accident hazards and supervision.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of care plan interventions for a resident, leading to a fall and subsequent injuries. The resident, who had a history of falls and was at high risk due to conditions such as Parkinson's disease and muscle weakness, was not provided with the necessary fall mat and two-person assistance during activities of daily living. On the day of the incident, a CNA was changing the resident's brief without the required assistance, resulting in the resident falling from the bed and sustaining multiple injuries, including a broken clavicle. The resident's care plan, which included interventions like fall mats and two-person assistance, was not followed. The CNA involved was unaware of the care plan requirements and did not know where to find this information in the resident's records. This lack of knowledge and adherence to the care plan contributed to the resident's fall and subsequent decline in physical abilities, including the loss of independence in feeding herself. Interviews with staff, including the DON and the MDS Nurse, confirmed that the care plan was not followed, and the necessary precautions were not in place. The facility's policies and procedures, which required staff to review and follow care plans, were not adhered to, leading to the resident's injuries and increased dependency on staff for daily activities.
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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