Heartwood Avenue Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Vallejo, California.
- Location
- 1044 Heartwood Ave., Vallejo, California 94591
- CMS Provider Number
- 555184
- Inspections on file
- 21
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Heartwood Avenue Healthcare during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and a moderate elopement risk score had a care plan that only directed staff to check the resident’s whereabouts without specifying frequency or timing, despite facility policy requiring measurable, person-centered interventions. A cognitively intact resident and a CNA reported seeing this resident open a conference room door and walk outside, but staff documented zero exit-seeking attempts on the MAR, contrary to a physician order to monitor and record the number of exit-seeking behaviors each day shift, and the DON later acknowledged the documentation should have reflected the elopement attempt.
A resident with impaired cognition was physically assaulted by another resident, resulting in a minor lip injury. The incident was witnessed by a CNA, and the aggressor admitted to being provoked. Despite facility policies prohibiting abuse, the event occurred and was confirmed by staff interviews and medical assessment.
An incident involving two residents with cognitive impairments resulted in one resident making physical contact with another's arm during a dispute over a glove box. Although the event was witnessed and reported to the ombudsman and police, facility staff did not report the allegation of abuse to the State Agency as required, due to a misunderstanding of reporting obligations. This failure delayed the abuse investigation process.
The facility failed to protect resident privacy and dignity, as privacy curtains did not fully enclose personal spaces and vertical blinds were broken or missing for several residents. A resident with muscle weakness and impaired memory expressed concerns about privacy due to missing blinds. Two residents shared a room where curtains did not provide adequate privacy, confirmed by a CNA. Another resident with severe memory impairment also lacked sufficient privacy curtains. Staff interviews confirmed these deficiencies, indicating non-compliance with the facility's dignity and privacy policy.
The facility failed to follow its medication storage policy, resulting in unlabeled and expired medications in the medication carts. Observations revealed unlabeled inhalers and insulin, as well as expired eye drops. Nurses confirmed the labeling issues, and the DON emphasized the importance of proper labeling and disposal of expired medications.
A long-term care facility failed to adhere to infection prevention protocols, including a CNA not wearing a gown for a resident on Enhanced Barrier Precautions, another CNA not washing hands after caring for a resident with C Diff, and an unlabeled gastrotomy tube feeding bottle. These actions could contribute to the spread of infections among residents.
A resident with multiple health issues, including a high risk for falls, was found to have their call light placed out of reach, contrary to their care plan and facility policy. A CNA confirmed the oversight, and the DON stated that call lights should always be accessible.
The facility failed to follow physician orders for two residents. A resident's PICC dressing was not changed as required, increasing infection risk, while another resident received metformin without food, contrary to orders. The DON confirmed the importance of adhering to these orders to prevent health risks.
A dietary staff member in an LTC facility was observed touching a fork with bare hands and putting on gloves without hand hygiene, violating infection control protocols. The Dietary Manager and DON confirmed these actions were unacceptable, especially given the vulnerability of immunocompromised residents.
The facility failed to maintain a clean and safe environment, with observations of sticky floors, feces on bathroom surfaces, and improperly stored items posing infection control issues. Staff confirmed these conditions were unacceptable and violated residents' rights. Additionally, a hole in a bathroom door was identified as a safety risk, with a lack of communication leading to delayed repairs.
The facility failed to provide the required two-person assistance to a resident during care, resulting in a fall and a left tibia fracture. Additionally, the facility did not respond promptly to another resident's call light, leading to a fall and subsequent hospital visit for neck pain and dizziness.
Failure to Develop Specific Elopement Care Plan and Accurately Monitor Exit-Seeking Behavior
Penalty
Summary
The deficiency involves the facility’s failure to provide quality care to a resident at risk for elopement by not developing specific and measurable care plan interventions and not accurately following physician orders for monitoring elopement attempts. Resident 1, admitted 29 days prior and diagnosed with respiratory failure, falls, and Alzheimer’s disease, had an elopement risk assessment score of 7, indicating a moderate elopement risk. The resident’s care plan identified risk for elopement and wandering due to a history of elopement/wandering and impaired cognitive function and safety perception, with an intervention to “check resident’s whereabouts,” but it did not specify how often or when staff should check on the resident. During an interview and record review, the DON acknowledged that the care plan intervention was not specific. The facility’s care plan policy required comprehensive, person-centered care plans with measurable objectives and timetables. The facility also failed to follow a physician order related to monitoring elopement attempts. The order summary included an order to monitor the number of times per shift the resident attempted exit-seeking behavior on every day shift, starting on 1/30/26. On 2/19/26, a grievance documented that a family member was informed by another resident that Resident 1 had left the building. Resident 2, who was cognitively intact per a BIMS score of 15, and CNA 1 both stated they saw Resident 1 open the conference room door and walk outside. However, review of the MAR for February showed that staff documented “0” exit-seeking attempts for that date, and the DON stated staff should have charted a “1” for the elopement attempt. The facility’s wandering and elopement policy stated that residents identified as at risk for wandering or elopement would have care plans including strategies and interventions to maintain safety, which was not fully implemented for this resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition was physically abused by another resident with intact cognition. The incident took place in a shared room, where a certified nursing assistant (CNA) observed one resident standing beside the other, making closed fist contact with the resident's chest while the latter was lying in bed. The assaulted resident sustained a minor laceration to the upper lip, which was confirmed by a licensed nurse upon assessment. The resident who committed the act admitted to being provoked by something the other resident said. The facility's policy and procedures on abuse prevention state that residents have the right to be free from abuse, including physical abuse, and that the administration is responsible for protecting residents from abuse by anyone, including other residents. Despite these policies, the facility failed to prevent the physical abuse, resulting in injury to the resident. Interviews with staff and both residents confirmed the occurrence of the incident and the resulting injury.
Failure to Timely Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for one of four sampled residents. Specifically, an incident occurred in which two residents, both with cognitive impairments including dementia, were involved in a physical interaction over a box of gloves. One resident made contact with another's arm, witnessed by staff, and both residents were assessed with no injuries noted. The incident was documented and reported to the ombudsman and police, but not to the State Agency as required by regulations and the facility's own policy. Interviews with the Administrator and Director of Nursing revealed a misunderstanding of reporting requirements, as both believed that incidents involving residents with dementia and no injuries only needed to be reported to the ombudsman and police, not to the State Agency. Review of facility policy indicated that all alleged violations involving abuse must be reported to the State licensing/certification agency. The failure to report the incident to the State Agency resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from harm.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and their privacy was protected, as evidenced by inadequate privacy curtains and broken or missing vertical blinds for five residents. Resident 19, who was admitted in the spring of 2023 with muscle weakness and a moderately impaired memory, expressed concerns about privacy due to missing vertical blind slats and inadequate privacy curtains. Similarly, Resident 7 and Resident 31 shared a room where the divider curtains did not provide sufficient privacy, verified by a CNA who acknowledged the lack of coverage. Resident 14, admitted in the winter of 2024 with severe memory impairment, also had inadequate privacy curtains. Resident 16, who was alert and oriented, had missing and broken vertical blind slats in their room. Interviews with staff, including a CNA, the Maintenance Supervisor, the Environmental Services Manager, and the Director of Nurses, confirmed the deficiencies in privacy measures. The facility's policy on dignity and privacy was not adhered to, as staff failed to ensure complete privacy for residents during personal care.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several medications being improperly labeled and stored. During an observation and interview, it was found that medication cart two contained unlabeled opened medications, including an inhaler of budesonide/formoterol, an inhaler of fluticasone furoate/vilanterol, and a vial of insulin lispro. Additionally, an expired bottle of cromolyn sodium eye drops was found in the same cart. The facility's document, Abridged List of Medications with Shortened Expiration Dates, indicated specific discard timelines for these medications, which were not followed. Licensed Nurse 5 confirmed the presence of the undated medications and the expired eye drops, acknowledging the importance of labeling medications with the opened date to prevent decreased effectiveness. Another observation with Licensed Nurse 6 revealed an unlabeled inhaler in medication cart one. The Director of Nursing expressed the expectation that staff should dispose of expired medications and label opened medications. The facility's policy on labeling medication containers, revised in April 2019, requires all medications to be properly labeled according to state and federal guidelines.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observed deficiencies. In one instance, a Certified Nursing Assistant (CNA) did not wear a gown while providing high-contact care to a resident who was on Enhanced Barrier Precautions (EBP) due to a peripherally inserted central catheter (PICC) and a methicillin-susceptible Staphylococcus aureus infection. Despite clear signage indicating the need for gown and glove use during specific care activities, the CNA admitted to not wearing the required protective equipment while changing the resident's clothes, briefs, and bed linens. Another deficiency was observed when a CNA failed to wash hands after providing care to a resident with a Clostridium Difficile (C Diff) infection, who was on contact precautions. The CNA was seen moving between rooms without performing hand hygiene, which is a critical step in preventing the spread of C Diff. The facility's Infection Preventionist confirmed the requirement for handwashing with soap and water after contact with residents on C Diff precautions, as outlined in the facility's policy. Additionally, a gastrotomy tube feeding bottle for a resident was found unlabeled, contrary to the facility's policy that requires labeling with the date, time, and rate of feed. The Licensed Nurse confirmed the oversight, acknowledging that the bottles are only viable for a certain period once opened. These lapses in infection control practices could potentially contribute to the spread of infections among the facility's residents.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 27, by not ensuring that the call light was within reach. Resident 27, who was admitted in the fall of 2017, had multiple diagnoses including lung disease, muscle weakness, and was at high risk for falls. The resident's care plan specifically indicated that the call light should be within reach and that the resident should be encouraged to use it for assistance. However, during an observation and interview, it was noted that the call light was placed on a chest of drawers behind the resident, making it inaccessible. A Certified Nurses Assistant (CNA) confirmed that the call light was not within reach and acknowledged that it should have been. The Director of Nurses (DON) also stated that call lights should be accessible at all times. The facility's policy and procedure on answering call lights, dated September 2024, also required that call lights be within easy reach when a resident is in bed. This oversight increased the risk that Resident 27's needs would go unmet, as the resident was unable to call for assistance when needed.
Failure to Follow Physician Orders for PICC Dressing and Medication Administration
Penalty
Summary
The facility failed to meet professional standards for two residents. For Resident 206, the facility did not change the peripherally inserted central catheter (PICC) dressing as per physician orders. The dressing was supposed to be changed every seven days, but it was observed that the dressing dated 2/17/25 was not changed by 2/24/25, as required. The Director of Nursing (DON) confirmed that the dressing change was overdue and emphasized the high risk of infection due to the central line's proximity to the heart. The facility's policy also indicated that midline catheter dressings should be changed every 5-7 days to prevent infections. For Resident 19, the facility administered metformin, a diabetes medication, without food, contrary to the physician's orders which specified that it should be given with breakfast and dinner. An observation confirmed that the medication was given without any food or snacks present. The DON acknowledged that diabetes medications should be given with food to prevent hypoglycemia, and the facility's policy stated that medications should be administered according to prescriber orders, considering the resident's needs rather than staff convenience.
Infection Control Breach by Dietary Staff
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by the dietary staff. During an observation, a dietary staff member was seen touching the part of a fork that goes into a resident's mouth with bare hands. This action was acknowledged by the dietary staff and confirmed by the Dietary Manager, who stated that such practice was not acceptable for infection control purposes. Additionally, the dietary staff member was observed putting on a glove without performing hand hygiene beforehand. This was verified by both the dietary staff and the Dietary Manager, who emphasized the importance of hand hygiene, especially in a facility caring for immunocompromised residents. The Director of Nursing also confirmed that staff should not touch utensils with bare hands and should perform hand hygiene before putting on gloves, as failure to do so could transfer bacteria to residents or their food.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary conditions in several rooms. Sticky floors were noted in various rooms, and brownish stains, identified as feces, were found on bathroom floors and toilet seats. Additionally, clothes were improperly stored on towel racks and floors, and tissue paper was found touching the bathroom floor, all of which were confirmed by multiple staff members as significant infection control issues. Interviews with staff, including unlicensed staff, licensed staff, housekeeping, and the Director of Nursing (DON), consistently highlighted the unacceptable nature of these conditions. Staff members acknowledged that sticky floors indicated inadequate cleaning, and the presence of feces and improperly stored items posed a risk of cross-contamination. The DON and other staff members affirmed that these conditions violated residents' rights to a clean and safe environment. Furthermore, a hole in a bathroom door was observed, which had been present for some time without being reported to maintenance. This was identified as a safety risk, potentially causing cuts and splinters to residents. The Maintenance Director confirmed that the hole had not been reported, and staff interviews revealed a lack of communication regarding the need for repairs. The facility's policies on cleaning and maintenance were not adhered to, contributing to the deficiencies observed.
Failure to Provide Adequate Assistance and Supervision
Penalty
Summary
The facility failed to ensure that Resident 1 received the required two-person assistance during care, which resulted in the resident falling out of bed and sustaining a left tibia fracture. Resident 1 was admitted with diagnoses including cerebral infarction and muscle weakness and was totally dependent on staff for all activities of daily living (ADLs). Despite this, Unlicensed Staff C provided care without the assistance of another staff member, leading to the resident rolling over and falling off the bed during perineal care. This incident was corroborated by interviews with other staff members who confirmed that Resident 1 required two-person assistance for turning and repositioning in bed. The facility also failed to respond promptly to Resident 2's call light, which resulted in the resident attempting to get out of bed without assistance and subsequently falling. Resident 2, who had left-side hemiplegia and hypertension, required substantial assistance with toileting and transfers. On the day of the incident, Resident 2 turned on her call light for assistance to use the toilet but waited for over an hour without receiving help. This delay led Resident 2 to attempt to get out of bed on her own, resulting in a fall that caused neck pain, headache, and dizziness, necessitating a hospital visit. Interviews with staff and the Director of Nursing (DON) revealed that the facility's failure to provide timely assistance and adequate supervision contributed to the accidents involving both residents. The DON acknowledged that Resident 1 required two-person assistance for turning in bed and that Resident 2's call light was not answered promptly due to staff being occupied with other residents. These deficiencies highlight the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents.
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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