Harvest Crossing Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Manteca, California.
- Location
- 469 East North Street, Manteca, California 95336
- CMS Provider Number
- 055917
- Inspections on file
- 24
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Harvest Crossing Post Acute during CMS and state inspections, most recent first.
A long-term resident with multiple chronic conditions, including NSTEMI, DM2, Alzheimer’s disease, hypothyroidism, and anxiety, was transferred to a hospital after an unwitnessed fall, with documentation indicating discharge with return anticipated and a representative requesting the resident’s return. Despite available bed capacity and existing care plans that already addressed the resident’s fall risk, aggression, and wandering, the DON and marketing staff informed the hospital that the resident required a higher level of care and refused readmission, without nurse-to-nurse communication or a nursing assessment. Hospital and psychiatric records documented confusion but no current aggressive behaviors or serious mental illness, while the facility’s own policy required allowing residents to return from hospitalization if they still needed the facility’s services and remained eligible, resulting in the resident not being allowed to return home to the facility.
A resident with a history of aggressive behavior and dementia physically assaulted another resident, causing facial injuries that required stitches. Despite prior incidents and medical orders for close monitoring, staff did not consistently track or document the resident's behaviors, and behavior monitoring was not implemented until after the assault. This failure to follow care plans and provider recommendations resulted in a resident being physically abused and injured.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including the safe delivery of daily living supports and treatments for a resident.
A resident was prescribed methadone for pain management, but staff did not develop or update a comprehensive care plan to address the use of this opioid, its potential side effects, or monitoring requirements. Interviews and record reviews confirmed that the care plan should have been revised when the medication was started, in accordance with facility policy.
Three residents with complex medical conditions received pain medications without documented use of non-pharmacological interventions, as required by facility policy. The DON confirmed that pain care plans did not include alternatives such as heat therapy or repositioning before administering medications like acetaminophen, methadone, or morphine.
The facility failed to meet professional standards for diabetic care by using an expired QC solution for the glucometer on the East Unit. Two LNs confirmed the expiration, and the DON acknowledged the risk of incorrect blood sugar readings. This violated the facility's policy on blood glucose monitoring system calibration.
The facility failed to properly label, store, and dispose of medications, including expired narcotics and tuberculin PPD, leading to potential medication errors. Staff clothing was improperly stored with medical supplies, posing a cross-contamination risk. Additionally, expired blood glucose QC solutions were not discarded as per policy, highlighting lapses in medication management and infection control practices.
The facility failed to provide qualified oversight of its food and nutrition services, as the Interim Certified Dietary Manager (ICDM) was not certified and the Registered Dietician (RD) worked less than 35 hours per week. The ICDM, who was previously a cook, had only completed a ServSafe Certification and was still in school to become a Certified Dietary Manager (CDM). The regular CDM was on medical leave, and the Administrator acknowledged the lack of a qualified CDM, which is essential for ensuring the quality of nutrition services and monitoring kitchen staff.
The facility failed to maintain food safety standards, impacting 87 residents. Spoiled produce was found in the refrigerator, and staff personal items were improperly stored in the kitchen. Metal pans were stored wet, and the ice machine was not properly cleaned, posing a risk for foodborne illness. Additionally, resident freezer temperatures were not monitored due to missing thermometers.
The facility failed to implement proper infection control measures, including the absence of Enhanced Barrier Precautions signage and PPE for a resident with severe sepsis, leading to staff providing care without protection. Dirty coffee cups were placed alongside clean ones on a cart, risking cross-contamination, and a pair of pants was improperly stored in a respiratory treatment cart, violating infection control policies.
A resident with dementia and a history of fractures experienced significant pain and swelling in her left knee, but the facility failed to adequately assess and manage her pain. Despite signs of distress, the resident did not receive the prescribed Tramadol, and there was a delay in obtaining x-ray results, which revealed a fracture and dislocation. This delay potentially prolonged her suffering and led to her transfer to the hospital.
A resident with Alzheimer's and dementia was not treated with dignity during meal assistance when a CNA stood over her while feeding. The resident expressed discomfort, and the DON confirmed that staff should sit at eye level to maintain dignity, as per facility policy.
A resident with osteoarthritis, urinary retention, and stress incontinence did not have a working call light system in her room, as confirmed by staff. The facility's policies required a functional call system, but the resident was left without an alternative means of communication, such as a bell, leading to unmet needs and potential risks.
The facility failed to protect residents' privacy by improperly discarding meal tickets containing sensitive information in the garbage. A Dietary Aide was observed throwing these tickets away, and the Interim Certified Dietary Manager confirmed the practice. The Registered Dietician acknowledged the issue, noting that the tickets should have been shredded to comply with HIPAA regulations.
The facility failed to maintain a clean and safe environment for two residents, as their room vents were found full of dust and debris. The Maintenance Director confirmed the vents were dirty and in use, while the Housekeeping Supervisor admitted they were not cleaned weekly as required. Resident 340, with pleural effusion, expressed fear of inhaling particles, and staff acknowledged the potential for respiratory issues. The facility's policy emphasized a clean environment, which was not upheld.
The facility failed to complete the required PASRR evaluations for two residents. One resident's Level I PASRR did not reflect his autism diagnosis or psychotropic medication use, preventing a Level II evaluation. Another resident's Level II PASRR was not completed due to isolation precautions, despite a positive Level I screening. These oversights potentially delayed necessary specialized services for both residents.
A facility failed to notify a physician when a resident on fluid restriction exceeded the prescribed intake. The resident, with chronic health conditions, had a fluid restriction of 1 liter per day but consistently consumed more, averaging 1390 cc daily. Despite facility policies requiring notification, there was no documentation of physician contact regarding the excess intake.
A resident with multiple diagnoses, including autism and dementia, requested new dentures but was unable to tolerate dental services within the facility. Despite repeated unsuccessful attempts to take denture impressions, the facility did not refer the resident to an outside dentist for specialized care. This failure potentially delayed the resident's access to necessary dental services, impacting their dental and nutritional needs.
A facility failed to educate a resident about the Pneumococcal vaccine before administration, violating the resident's right to informed consent. The Infection Preventionist confirmed the lack of education, and the resident stated she did not understand the vaccine's risks and benefits. Interviews with the DON and DSD revealed that the facility's policy required education on vaccines, which was not followed in this case.
Two residents in the facility were found without a functioning call light system, preventing them from calling for assistance. One resident, with osteoarthritis and incontinence, and another with a leg fracture and walking difficulties, were unable to alert staff due to non-working call lights. Staff confirmed the issue, and care plans emphasized the need for a reachable call light due to their fall risks. Facility policy requires a functional call system at all times.
A resident with autism did not receive specialized care due to the facility's failure to provide staff training on autism. The resident exhibited behaviors such as yelling and crawling on the floor, which staff struggled to manage without proper training. The Speech Therapist attempted to use behavioral methods, but the lack of formal training led to reliance on medication. The Director of Staff Development was unaware of the resident's autism diagnosis and had not conducted relevant training.
The facility failed to notify the Ombudsman on the same day a resident was served with a 30-Day Notice of Transfer or Discharge, did not include the transfer location on the notice, and provided incorrect appeal rights information. These actions were not in accordance with the facility's policy and procedure for transfer or discharge documentation.
Failure to Honor Resident’s Right to Return After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to return to the facility following a hospital transfer, despite documentation that a return was anticipated and a bed was available. The resident was a long-term resident with no discharge plan in place and considered the facility to be their home. The resident had multiple diagnoses, including non-ST elevation myocardial infarction, type 2 diabetes mellitus, Alzheimer’s disease, hypothyroidism, difficulty in walking, muscle weakness, hypertension, and anxiety disorder. The resident’s MDS Nursing Home Discharge Item Set indicated a discharge with return anticipated, and general notes documented that the resident’s representative wanted the resident to return to the facility after being sent to the hospital for an unwitnessed fall. While the resident was hospitalized, the facility’s Director of Marketing sent a referral communication to the hospital stating that the resident required a higher level of care and that the facility could not provide the needed level of care. The DON reported that the facility had a bed capacity of 99, a census of 94, and one bed hold, confirming that a bed was available. Nonetheless, the DON stated the facility would not accept the resident back due to perceived safety concerns, including aggressiveness, wandering, and fall risk. The DON also stated that a non-clinical staff member checked on the resident’s status at the hospital and that there was no nurse-to-nurse communication or nursing assessment between the hospital and the facility regarding the resident’s condition. Record review showed that the resident’s care plans, initiated prior to the hospital transfer, already identified risks for unavoidable falls related to confusion and poor safety awareness, episodes of aggressive behaviors, and wandering behaviors. The DON acknowledged that these behaviors were present before the transfer and stated that if the facility had known about them, the resident would not have been admitted, despite the resident being a long-term resident. The SSD confirmed there was no discharge plan and that the resident was considered long term with no plans for discharge. Hospital documentation, including a physician progress note and a psychiatric follow-up visit, indicated the resident remained confused due to Alzheimer’s disease but did not exhibit physical or verbal aggression, hallucinations, homicidal or suicidal ideation, and had only low to moderate anxiety managed with buspirone and non-pharmacological interventions. A PASRR notice indicated no serious mental illness requiring specialized mental health services. The facility’s own bed-hold and returns policy stated that residents must be permitted to return following hospitalization if they still require services provided by the facility and are eligible for Medicare or Medicaid services, but the resident was not allowed to return.
Failure to Protect Resident from Physical Abuse Due to Lack of Behavior Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known history of aggressive behavior and dementia struck another resident in the face with a water pitcher, resulting in significant injuries. The injured resident sustained a facial contusion, lacerations to the upper lip and right eyebrow requiring stitches, and reported pain and emotional distress. Staff interviews and medical record reviews confirmed that the aggressor had previously exhibited aggressive behaviors, including yelling and striking at staff, and that these behaviors were known to the facility. Despite documented behavioral disturbances and medical provider notes recommending close monitoring and behavior tracking, the facility failed to implement consistent behavior monitoring for the resident with aggressive tendencies. Behavior monitoring was not initiated until after the incident, even though prior altercations and medical documentation indicated the need for such interventions. The Medication Administration Record (MAR) and care plans did not reflect daily behavior monitoring or tracking as ordered by the medical provider following earlier aggressive episodes. Staff and the Director of Nursing confirmed that behavior monitoring logs were not in place as required, and that the lack of monitoring prevented timely identification and intervention for escalating behaviors. The facility's policies required providing a safe environment and monitoring for aggressive behaviors, but these were not followed, directly contributing to the incident where one resident was physically abused by another.
Failure to Ensure Safe, Clean, and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Develop Care Plan for Methadone Use
Penalty
Summary
The facility failed to develop or revise a comprehensive care plan for a resident who was prescribed methadone for pain management. Despite the resident receiving methadone for approximately 25 days, there was no care plan created to address the use of this strong pain medication, its potential side effects, or to guide staff in monitoring for medication effectiveness and adverse reactions. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Director of Nursing, confirmed that the care plan should have been updated when methadone was initiated, and that it is standard practice to update care plans when new controlled medications are started, dosages are changed, or gradual dose reductions are considered. Record reviews and staff interviews further revealed that the facility's own policies require ongoing assessment and revision of care plans as residents' conditions change, and specifically call for monitoring when opioids are used. The absence of a care plan for methadone use meant that staff did not have documented guidance to monitor for side effects such as headaches, dizziness, nausea, impaired coordination, unconsciousness, or death, nor to assess the medication's effectiveness or set goals related to its use.
Failure to Implement Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to provide effective pain management for three residents by not implementing non-pharmacological interventions as part of their pain care plans. Each resident had significant medical conditions, including muscle weakness, acute kidney failure, pressure ulcers, dependence on renal dialysis, Parkinson's disease, neoplasm of the kidney, gout, obstructive and reflux uropathy, and hydronephrosis. Despite having physician orders for pain medications such as acetaminophen, methadone, and morphine, their care plans did not include non-pharmacological pain management strategies like heat therapy, cold therapy, or repositioning. During interviews and record reviews, the DON confirmed that the pain care plans for all three residents lacked non-pharmacological interventions, and acknowledged that such interventions should have been included prior to administering pain medications. The facility's own policy indicated that non-pharmacological interventions may be appropriate alone or in conjunction with medications, but these were not documented or implemented for the residents in question.
Expired QC Solution for Glucometer in Diabetic Care
Penalty
Summary
The facility failed to provide services meeting professional standards of quality for diabetic residents due to the use of an expired quality control (QC) solution for the glucometer on the East Unit. During an observation and interview, it was confirmed by two licensed nurses that the QC solution had an open date and an expiration date, indicating it was expired. The Director of Nursing (DON) acknowledged that using an expired QC solution could lead to incorrect QC testing results, potentially causing inaccurate blood sugar readings for diabetic residents. This was a violation of the facility's policy and procedure for blood glucose monitoring system calibration, which requires that test strips and control solutions not be used past their expiration date and be discarded 90 days after opening.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications, which led to several deficiencies. Expired medications, including a vial of tuberculin PPD and a bottle of oral Lorazepam liquid, were found in the medication storage room refrigerators. These medications were not discarded according to the facility's policy, which requires expired narcotics to be disposed of by the Director of Nursing (DON) and a pharmacist. Additionally, two vials of tuberculin PPD were opened but not labeled with an opened date, contrary to the facility's policy that mandates labeling upon opening. Further observations revealed that staff clothing was improperly stored in a treatment cart alongside medications and resident care equipment, posing a risk of cross-contamination. A pair of pants belonging to a Respiratory Therapist was found in a cart containing respiratory inhalation medications and treatment equipment. This was acknowledged by a Licensed Nurse (LN) who removed the clothing and disinfected the cart. The facility's policy on infection control was not adhered to, as personal items should not be stored with medical supplies to prevent infection risks. The facility also failed to follow its policy regarding blood glucose quality control (QC) solutions. An expired QC solution was found in a medication cart, which should have been discarded according to the policy that requires labeling with an opened date and discarding 90 days after opening. The DON confirmed that the facility's policies for medication storage, labeling, and infection control were not followed, which could lead to medication errors and affect the well-being of residents.
Deficiency in Qualified Oversight of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure qualified staff oversight of its food and nutrition services, which is a requirement under federal and state regulations. The Interim Certified Dietary Manager (ICDM) was not certified, as she was still in the process of completing her education to become a Certified Dietary Manager (CDM). The ICDM had only completed a ServSafe Certification, which provides basic food safety training, and had no additional training or certifications. The regular CDM had been on medical leave since earlier in the year, and the ICDM was assigned all duties and tasks in the interim. Additionally, the Registered Dietician (RD) worked less than 35 hours per week, specifically two days each week for six to eight hours a day. This staffing arrangement did not meet the requirements for qualified oversight of the facility's food and nutrition services. The Administrator acknowledged the absence of a qualified CDM and stated that the role of the CDM is crucial for ensuring the quality of nutrition services and monitoring kitchen staff. The facility's job description for the Food & Nutrition Services Director required qualifications that were not met by the current staffing arrangement.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, impacting the 87 residents who consumed meals prepared by the facility. During an inspection, spoiled produce, specifically bell peppers with black fuzzy spots and a mushy texture, was found in the walk-in refrigerator. The Registered Dietician (RD) confirmed that the quality of the produce was unacceptable and posed a risk for foodborne illness. Additionally, staff personal items, such as an insulated cup and eyeglass cases, were improperly stored in the kitchen, which the RD stated could lead to food contamination. Further observations revealed that several metal pans were stacked and stored while still wet, sitting in a pool of water. The RD noted that this practice could lead to mildew and increase the risk of foodborne illness. The facility's ice machine was also found to be in poor condition, with black and brown substances present, indicating improper cleaning and sanitization. The Maintenance Director acknowledged the machine was not operable, and the RD confirmed that its condition was unacceptable and posed a risk to residents. Lastly, the facility failed to monitor the temperatures of resident freezers, as thermometers were missing, and no temperature logs were maintained. The RD confirmed that the freezers should have thermometers and that temperatures should be documented daily. These deficiencies collectively put residents at risk for foodborne illnesses due to improper food storage, preparation, and equipment maintenance.
Infection Control Deficiencies in PPE Use and Cross-Contamination
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for Resident 30, who was admitted with severe sepsis, chronic obstructive pulmonary disease, and gastrostomy status. Enhanced Barrier Precautions (EBP) signage and personal protective equipment (PPE) were not placed outside Resident 30's room, and staff, including a respiratory therapist, provided care without wearing PPE. Interviews with various staff members, including the Licensed Nurse, Respiratory Therapist, Infection Preventionist, Director of Nursing, and Director of Staff Development, confirmed the absence of EBP signage and PPE, acknowledging the potential risk of infection spread due to these oversights. In the resident dining room, dirty coffee cups were observed placed alongside clean cups on a coffee cart, posing a risk of cross-contamination. Certified Nursing Assistant 3 and the Activity Assistant confirmed the inappropriate placement of dirty cups next to clean ones and the coffee urn. The Director of Nursing also acknowledged the risk of infection from cross-contamination due to this practice. Additionally, on the [NAME] Unit, a pair of jean pants was found stored in a respiratory treatment cart alongside respiratory inhalation medications and percussion treatment equipment. Licensed Nurse 5 confirmed the presence of the pants, which belonged to the Respiratory Therapist, and recognized the risk of infection from cross-contamination. The Director of Nursing confirmed that storing clothing in the respiratory treatment cart violated the facility's infection control policy.
Failure to Provide Timely Pain Management and Diagnosis
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident 6, who was experiencing significant pain and swelling in her left knee. Despite exhibiting signs of pain through facial grimacing and screaming during care, the nursing staff did not adequately assess the source of Resident 6's pain or provide effective pain management. The resident, who had a history of dementia, osteoarthritis, and multiple fractures, was not given the prescribed Tramadol for moderate to severe pain, and only received acetaminophen for mild pain, which was insufficient given her condition. The delay in obtaining an x-ray result further exacerbated the situation. Although an x-ray was ordered on the evening of 11/16/24, the results were not received until the evening of 11/17/24, nearly 20 hours later. This delay in diagnosis and treatment potentially prolonged Resident 6's pain and suffering. The x-ray eventually revealed a distal femur supracondylar fracture and a dislocated left knee joint, necessitating her transfer to the hospital for further evaluation and treatment. Interviews with staff and family members highlighted a lack of prompt and effective communication and assessment. CNA 4 reported Resident 6's pain to the nursing staff, but the response was inadequate, with some staff attributing her symptoms to other causes like constipation. The DON confirmed that the x-ray results were delayed and that the resident only received two doses of acetaminophen during this period. The physician covering the facility over the weekend expressed concern over the delay in receiving x-ray results, indicating that such a delay placed the resident at risk for further complications.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during meal assistance. On the morning of November 19, 2024, a Certified Nursing Assistant (CNA) was observed assisting a resident with breakfast while standing over her at her bedside. The resident, who had been diagnosed with Alzheimer's disease and dementia, was being fed by the CNA who held a spoon with food in one hand and a carton of milk in the other. The resident expressed her discomfort by pushing the milk carton away and shouting "No!" The CNA admitted to standing while assisting the resident and acknowledged that staff should sit at the resident's bedside during meal assistance, although she was unaware of the reason for this requirement. The Director of Nursing (DON) confirmed that the facility's procedure was not followed, as the expectation is for staff to sit beside residents at eye level when assisting with meals to maintain the residents' dignity and respect. The facility's policy on Resident Rights, revised in February 2021, emphasizes treating all residents with kindness, respect, and dignity, and guarantees certain basic rights, including a dignified existence. The failure to adhere to these procedures and policies had the potential to negatively impact the resident's psychosocial well-being.
Failure to Provide Working Call Light System for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 31, by not ensuring the availability of a working call light system in her room. Resident 31, who was admitted with diagnoses including osteoarthritis of the hip, retention of urine, and stress incontinence, was observed without a functioning call light. This was confirmed by a certified nursing assistant (CNA) and the Maintenance Director. The CNA mentioned that Resident 31 could scream for help, but this was not considered an appropriate method for residents to request assistance. The Director of Staff Development and the Director of Nursing both acknowledged the importance of a working call light system to prevent risks such as unmet needs and potential falls. The resident's care plan emphasized the need for a reachable and working call light to ensure a safe environment and prompt response to requests for assistance. The facility's policy and procedure documents also highlighted the requirement for a functional resident call system at all times, with regular maintenance and testing by the maintenance department. Despite these guidelines, the call light system in Resident 31's room was not operational, and no alternative means of communication, such as a bell, was provided, leading to a deficiency in accommodating the resident's needs.
Improper Disposal of Meal Tickets Violates Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information when meal tickets containing sensitive data were improperly discarded. During an observation and interview, a Dietary Aide was seen throwing residents' meal tickets into the garbage bin in the dishwashing area. The Interim Certified Dietary Manager confirmed this practice and acknowledged that multiple residents' meal tickets were returned with meal trays to the kitchen. The meal tickets contained detailed personal and medical information, including residents' names, identification numbers, room and bed numbers, diet orders, allergies, and food preferences. The Registered Dietician was aware of the improper disposal practice and stated that it did not meet her expectations. She emphasized that the meal tickets should have been shredded to comply with HIPAA regulations, which protect sensitive patient health information. Despite several meetings with the dietary and nursing departments about the proper disposal of meal tickets, the facility reverted to discarding them in the garbage bin, violating their own Confidentiality of Information and Personal Privacy Policy.
Failure to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable living environment for two residents, as observed in the condition of the floor vents in their rooms. The vents, which provide cold and warm air, were found to be full of dust and debris. This was confirmed during an observation and interview with the Maintenance Director, who acknowledged that the vents were dirty and in use, and stated that the housekeeping staff were supposed to clean them weekly. However, the Housekeeping Supervisor revealed that the vents were only cleaned if noticed during a spot check, not on a weekly basis as required. Resident 340, who was admitted with diagnoses including pleural effusion and other heart and lung symptoms, expressed fear of inhaling particles from the dirty vents. Similarly, Resident 31, with a history of cough and contracting Covid-19, was also affected by the unclean environment. Interviews with staff, including a Licensed Nurse and the Director of Nursing, confirmed awareness of the issue and its potential to trigger allergies and respiratory problems. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to accurately complete and ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) for two residents, which is a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions. For Resident 72, the Level I PASRR did not reflect his diagnosis of autism or his use of psychotropic medications, resulting in a Level II PASRR never being completed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the PASRR Level I screening was filled out inaccurately, impacting Resident 72's ability to qualify for a Level II evaluation and subsequent specialized services. Resident 72 was admitted with multiple diagnoses, including autistic disorder, anxiety disorder, and depression. Despite these conditions, the PASRR Level I screening incorrectly marked 'no' for autism and did not list his anxiety disorder or mood disturbance. The DON stated that had the PASRR been completed accurately, Resident 72 could have qualified for programs related to his behaviors and autism diagnosis. The failure to complete the PASRR process potentially delayed necessary services for Resident 72, who exhibited behaviors such as mood lability and crawling on the floor, which were temporarily managed with medications. For Resident 60, a positive Level I PASRR screening indicated the need for a Level II evaluation, which was not completed due to the resident being in transmission-based precautions for a medical illness. The facility's Admissions Coordinator confirmed that the PASRR Level II was not completed and that nursing staff were responsible for requesting a new PASRR screen once the resident's medical condition improved. The DON confirmed that the facility policy was not followed, resulting in a failure to complete the necessary PASRR Level II evaluation for Resident 60, who was admitted with diagnoses including bipolar disorder and major depressive disorder.
Failure to Notify Physician of Excess Fluid Intake for Resident on Restriction
Penalty
Summary
The facility failed to notify the physician when a resident on fluid restriction exceeded the prescribed fluid intake. The resident, who had chronic obstructive pulmonary disease, chronic congestive heart failure, and chronic respiratory failure, was on a fluid restriction of 1 liter per 24 hours as per the physician's order. However, the resident's fluid intake consistently exceeded this limit over a seven-day period, with daily intakes ranging from 1100 cc to 1420 cc, averaging 1390 cc per day. Despite this, there was no documentation indicating that the physician was notified of the excess fluid intake. Interviews with the facility's Infection Preventionist and the Director of Nursing confirmed that the facility's policy required licensed nurses to monitor and document fluid intake and notify the physician if the intake exceeded the restriction. The Director of Nursing acknowledged that the facility policy was not followed, as there was no record of physician notification in the resident's electronic medical record. The facility's policy and procedure documents also outlined the requirement for accurate recording and reporting of fluid intake, which was not adhered to in this case.
Failure to Provide Necessary Dental Services for a Resident
Penalty
Summary
The facility failed to assist a resident, identified as Resident 72, with obtaining necessary dental services, specifically new dentures. Despite the resident's request for new dentures during a dental exam, the facility did not facilitate a referral to an outside dental service when the resident was unable to tolerate dental services provided within the facility on multiple occasions. This inaction potentially delayed the resident from receiving the required dental care and obtaining dentures, which could have impacted their dental and nutritional needs. Resident 72 was admitted to the facility with multiple diagnoses, including autistic disorder, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and dementia. The resident had a history of weight loss and was on a pureed diet due to swallowing difficulties. The resident expressed a desire for new dentures during a dental exam, but subsequent attempts to take impressions for dentures were unsuccessful due to the resident's inability to tolerate the procedure. The facility's social services director acknowledged that it would have been appropriate to refer the resident to an outside dentist for specialized care, considering the resident's multiple diagnoses. Interviews with facility staff, including a speech therapist, social services director, nurse practitioner, and registered dietician, highlighted the challenges faced by Resident 72 due to their autism and other conditions. The resident's behavior, including refusal to eat and screaming, further complicated the situation. The facility's policy on dental services indicated that residents should be referred for dental services within three days if dentures are damaged or lost, but this was not adhered to in Resident 72's case, leading to a delay in receiving necessary dental care.
Failure to Educate Resident on Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide necessary education to a resident regarding the Pneumococcal vaccine before its administration, which violated the resident's right to make an informed choice. During an interview and record review with the Infection Preventionist (IP), it was confirmed that Resident 23's Immunization Report indicated no education was provided prior to the administration of the Pneumovax vaccine. The IP acknowledged that without education, residents would not understand the vaccines they were receiving. Resident 23 also confirmed in an interview that she did not understand the risks and benefits of the Pneumococcal vaccine. Further interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that the facility's policy required residents to be educated about the vaccines they receive, including the benefits and potential side effects. Both the DON and DSD stated that education should be provided to allow residents the opportunity to refuse a vaccine if they choose. A review of the facility's Policy and Procedure on the Pneumococcal Vaccine, revised in October 2019, supported this requirement, indicating that education should be documented in the resident's medical record.
Failure to Provide Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents, Resident 31 and Resident 45, which resulted in their inability to call for assistance when needed. Resident 31, who was admitted with diagnoses including bilateral primary osteoarthritis of the hip, retention of urine, and stress incontinence, was found without a working call light system in her room. This was confirmed by a Certified Nursing Assistant (CNA) and the Maintenance Director, who acknowledged the system had been non-functional since a specific date. Resident 31's care plans emphasized the importance of having a reachable call light due to her risk of falls and self-care performance deficits. Similarly, Resident 45, who had a diagnosis of an unspecified fracture of the left lower leg and difficulty walking, also did not have a working call light system. During an observation and interview, Resident 45 confirmed the lack of any means to contact staff for assistance, which was corroborated by the Maintenance Director and a CNA. Resident 45's care plans highlighted the necessity of a working call light to anticipate and meet her needs, given her risk for falls and the need for prompt assistance. Interviews with various staff members, including the Director of Staff Development, Director of Nursing, and the Administrator, revealed a consensus that the call light system should be functional at all times to prevent risks such as unmet needs and potential falls. The facility's policy and procedure document also stipulated that each resident should have a means to call staff directly for assistance, and the call system should remain functional at all times.
Lack of Autism Training Leads to Inadequate Care
Penalty
Summary
The facility failed to provide staff education regarding autism, which affected the quality of care for a resident diagnosed with autism. The resident, identified as Resident 72, was admitted with multiple diagnoses including autistic disorder, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and dementia. Despite these complex needs, the facility did not ensure that staff were trained to recognize and respond to the signs of autism, leading to inadequate care and potential escalation of the resident's behaviors. Observations and interviews revealed that staff were unprepared to manage the resident's behaviors, which included mood lability, yelling, screaming, and crawling on the floor. The Speech Therapist (SLP) and other staff attempted to assist the resident, but without formal training, their efforts were limited. The SLP, who did not have a background in autism, took the initiative to research and apply behavioral methods, but noted that formal training for staff would be beneficial. The lack of training led to the use of medication to manage behaviors, which the SLP believed was unnecessary if proper behavioral interventions were applied. Interviews with various staff members, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that there was no training provided for handling residents with autism. The DSD was unaware of the resident's autism diagnosis and stated that training would have been implemented if she had known. The facility's policies required staff to participate in regular in-service education, including behavioral health training, but this was not adhered to in the case of Resident 72. The absence of appropriate training and awareness resulted in the resident not receiving the specialized care needed for his condition.
Failure to Provide Timely and Accurate Discharge Notification
Penalty
Summary
The facility failed to provide timely notification to the appropriate parties regarding a facility-initiated discharge for a resident. Specifically, the facility did not inform the Office of the State Long-Term Care Ombudsman on the same day the resident was served with a 30-Day Notice of Transfer or Discharge form. The Director of Nursing (DON) acknowledged that the policy and procedure for transfer or discharge documentation was not followed, as the Ombudsman was notified five days later. This delay prevented the Ombudsman from acting as an advocate for the resident and assisting with the appeal process in a timely manner. Additionally, the 30-Day Notice of Transfer or Discharge form given to the resident did not include the location to which the resident was being transferred. The Ombudsman highlighted the importance of this information for the resident and their responsible party to have peace of mind and to alert others of the new residence. The DON confirmed that the policy and procedure requiring detailed documentation of the transfer was not adhered to in this case. Furthermore, the appeal rights information provided on the 30-Day Notice of Transfer or Discharge form was incorrect. The Administrator admitted that the appeal information was not accurate and that he should have ensured the correct information was filled out on the form. This error was identified by the state agency, and the resident and their responsible party were not given the correct information needed to file an appeal. The DON acknowledged that the policy and procedure for transfer or discharge documentation was not followed in this regard as well.
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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