Heritage Gardens Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Loma Linda, California.
- Location
- 25271 Barton Rd, Loma Linda, California 92354
- CMS Provider Number
- 055183
- Inspections on file
- 31
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Heritage Gardens Health Care Center during CMS and state inspections, most recent first.
A CNA engaged in a verbal altercation with a resident who has hemiplegia and hemiparesis, after the CNA forcefully pulled the resident's pillow, prompting the resident to use profanity. The CNA responded with repeated expletives, escalating the situation and violating facility policy requiring staff to treat residents with respect and dignity. The incident was witnessed by another staff member and confirmed by facility leadership.
The facility failed to store the ice scoop for the kitchen's ice machine in a clean and sanitary manner, as required by policy. The ice scoop was found in an uncovered container, posing a risk of contamination. Staff acknowledged the oversight, which could impact the health and safety of all residents receiving food and beverages from the kitchen.
The facility failed to follow infection control policies, including not changing or labeling medical equipment for residents and neglecting hand hygiene practices. A resident's CVC dressing was overdue for a change, and another's oxygen tubing was not changed for 17 days. Staff did not perform hand hygiene during medication administration and meal assistance, increasing infection risks.
A facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident admitted to hospice care, delaying the update of the resident's care plan. The resident, with cerebrovascular and atherosclerosis heart disease, was enrolled in hospice, but the SCSA was not conducted, resulting in a delay of over six months. This oversight was acknowledged by the MDS Nurse, indicating non-compliance with facility policy and OBRA regulations.
Two residents in the facility had inaccuracies in their MDS assessments. One resident with Type 2 diabetes mellitus did not have their insulin injections coded, despite receiving them on six days within the look-back period. Another resident on a prescribed antibiotic regimen for osteomyelitis had their antibiotic use omitted from the MDS assessment, despite daily administration. The errors were acknowledged by the MDS nurses, and the facility's policy for certifying assessment accuracy was not followed.
A facility failed to ensure a physician's order for a Speech Therapy evaluation was communicated to the hospice provider for a resident with severe cognitive impairment and difficulty chewing. The order, made on November 23, 2024, was not documented as completed, and the facility's policy requiring coordination with hospice was not followed, potentially risking the resident's health.
The facility failed to implement RNP recommendations for two residents, leading to a deficiency in care. A resident with muscle weakness did not receive recommended ambulation with a walker, and another with muscle contracture did not receive ROM exercises. The DON and DOR were unaware of these recommendations due to poor communication between departments, resulting in a lack of documented evidence and non-compliance with the facility's policy on Restorative Nursing Services.
A resident was administered oxygen therapy without a physician's order, contrary to the facility's policy. The resident, who had dementia and other medical conditions, was observed using a nasal cannula with an oxygen concentrator. The DON confirmed the absence of a physician's order and acknowledged the policy was not followed.
A facility failed to ensure a Licensed Vocational Nurse (LVN) maintained an active license, allowing the LVN to work with an expired license. The Director of Nursing (DON) admitted responsibility for checking licenses but did not verify expiration dates, leading to the LVN working without a valid license. The job description required current licensure, which was not followed.
A facility failed to adhere to its policy for blood glucose monitoring for a resident with type 2 diabetes, leading to a delayed blood sugar check. The resident, who had moderate cognitive impairment, was supposed to have blood sugar checks before meals and at bedtime, but the check was conducted later than scheduled. This failure potentially led to a change in the resident's condition and transfer to a hospital for evaluation.
A facility failed to follow its ADL policy, resulting in a resident with dementia having long and unclean fingernails. The resident required assistance with personal hygiene, and both the Administrator and Resident Assessment Coordinator acknowledged the issue, stating it was the CNAs' responsibility. The facility's policy required providing necessary services for grooming and hygiene.
A CNA wrapped a resident's waist and legs in linen sheets, failing to follow the facility's restraint policy. The resident, with severe cognitive impairment and other medical conditions, was found in this state by another CNA, who reported it to an LVN. The facility's policy states that restraints should only be used for safety and well-being after other alternatives have been tried, and never for staff convenience. The DON confirmed the policy was not followed.
CNA Engages in Verbal Altercation with Resident, Violating Dignity and Respect
Penalty
Summary
A Certified Nursing Assistant (CNA) engaged in a verbal altercation with a resident who had hemiplegia and hemiparesis. The incident began when the CNA pulled the resident's pillow forcefully, which upset the resident and led him to use profanity toward the CNA. In response, the CNA used expletives multiple times in return, escalating the exchange of offensive language. This interaction was witnessed by another staff member and was later validated by the CNA involved. The facility's policy requires all employees to treat residents with kindness, respect, and dignity, and prohibits the use of expletives in interactions with residents. The Director of Nursing and Administrator confirmed that the CNA's actions were in violation of this policy. The resident involved was alert and oriented at the time of the incident and expressed that such behavior should not occur in the facility.
Improper Storage of Ice Scoop in Kitchen
Penalty
Summary
The facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner, as required by the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), the ice scoop was found resting inside an uncovered blue container near the ice machine. The DSS confirmed that the ice scoop should always be stored in a clean, covered container to prevent contamination. This oversight posed a potential risk for contamination of ice, which could lead to foodborne illness and negatively impact the health and safety of all 96 residents who received food and beverages from the kitchen. Further interviews and record reviews revealed that the facility's policy, titled 'Ice Machines and Ice Storage Chest' dated January 2012, was not followed. The Maintenance Director (MD-1) acknowledged that the ice scoop should have been stored in a covered container, as per the policy. The Infection Control Prevention Nurse (ICP Nurse) also confirmed that the ice scoop placement did not follow protocol, emphasizing that ice is considered a food item and must be protected with a lid to prevent contamination. The failure to adhere to these protocols was acknowledged by the staff involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies for several residents, leading to potential cross-contamination and infection risks. Resident 44's Central Venous Catheter (CVC) dressing was not changed according to the facility's policy, which requires a change every seven days or when soiled. The dressing was last changed on January 1, 2025, but should have been changed by January 8, 2025. Additionally, Resident 44's intravenous (IV) tubing was not dated as required by the facility's policy, which mandates labeling with the date, time, and initials upon assembly. Resident 33's oxygen tubing was not changed for 17 days, contrary to the facility's policy of changing it every seven days. Similarly, Resident 65's oxygen tubing was not labeled with the date, violating the same policy. These oversights in labeling and changing medical equipment increase the risk of infection among residents. Furthermore, staff members failed to perform proper hand hygiene during care activities. LVN 1 did not wash hands after touching Resident 5 and before administering medication, while CNA 1 did not change gloves or perform hand hygiene between assisting two residents with breakfast. These actions contravene the facility's hand hygiene policy, which requires handwashing before and after resident contact and before handling medications.
Failure to Complete Timely SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period after the resident was admitted to hospice care. This oversight was identified during a review of the resident's clinical records and interviews with the Minimum Data Set (MDS) Nurse. The resident, who was admitted with diagnoses including cerebrovascular disease and atherosclerosis heart disease, was enrolled in hospice care on May 24, 2024. However, the SCSA, which should have been completed by June 6, 2024, was not conducted, resulting in a delay of over six months. The failure to complete the SCSA meant that the resident's care plan was not updated to reflect her current status, potentially delaying the identification and implementation of necessary care and support. The facility's policy, which aligns with the OBRA regulations and the CMS RAI manual, mandates a comprehensive assessment when a significant change in a resident's condition occurs, such as enrollment in hospice care. The MDS Nurse acknowledged that the facility did not adhere to this policy, which is crucial for ensuring a coordinated plan of care between the hospice and the nursing home.
Inaccurate MDS Assessments for Insulin and Antibiotic Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in identifying their care and support needs. Resident 9, who was admitted with Type 2 diabetes mellitus and required long-term insulin use, had insulin injections that were not coded on the MDS assessment. Despite receiving insulin injections on six days within the seven-day look-back period, the MDS assessment inaccurately indicated that no insulin was administered. This discrepancy was acknowledged by the MDS Nurse 2 during a review of the Medication Administration Record (MAR) and the MDS Section N - Medications. Similarly, Resident 19, who was admitted with complications related to an orthopedic implant and osteomyelitis, was on a prescribed antibiotic regimen. The MDS assessment for Resident 19 failed to reflect the administration of antibiotics, despite the MAR indicating daily antibiotic administration throughout December. The MDS Nurse 1 acknowledged the error during a review of the MAR and MDS Section N, admitting it was a mistake. The Director of Nursing (DON) confirmed that the facility's policy and procedure for certifying the accuracy of resident assessments were not followed in both cases. The CMS RAI manual guidelines, which require accurate recording of medication administration during the look-back period, were also not adhered to. These failures in accurately coding the MDS assessments for both residents were identified through interviews and record reviews with the MDS nurses and the DON.
Failure to Communicate Speech Therapy Order for Hospice Resident
Penalty
Summary
The facility failed to ensure a physician's order for a Speech Therapy (ST) evaluation was carried out timely for a resident receiving hospice care. The resident, who was admitted with diagnoses including cerebral atherosclerosis, unspecified dementia, and was receiving palliative care, had a severe cognitive impairment as indicated by a BIMS score of 6. A Nutrition/Dietary Note dated November 22, 2024, recommended an ST evaluation due to the resident's difficulty chewing, which was subsequently ordered by the physician on November 23, 2024. However, the order was not communicated to the hospice provider, and there was no documentation of the ST evaluation being conducted. During interviews and record reviews, the Director of Nursing (DON) confirmed the lack of documentation for the ST evaluation and identified that a Registered Nurse from the registry failed to communicate the order with the facility or the hospice provider. The facility's policy and procedure for hospice care, which requires coordination with the hospice provider and documentation of communication, was not followed. This oversight had the potential to place the resident at risk for aspiration, weight loss, and further nutritional decline.
Failure to Implement Restorative Nursing Program Recommendations
Penalty
Summary
The facility failed to implement the Restorative Nursing Program (RNP) recommendations for two residents, leading to a deficiency in providing necessary care and services for maintaining or improving their activities of daily living. Resident 44, who was admitted with muscle weakness and difficulty walking, did not receive the recommended ambulation with a front wheel walker as suggested by the Physical Therapist (PT). The Director of Nursing (DON) and the Director of Rehabilitation (DOR) were unaware of the PT's recommendation, indicating a lack of communication between the nursing and rehabilitation departments. Similarly, Resident 54, who was admitted with muscle contracture and weakness, did not receive the recommended Range of Motion (ROM) exercises as advised by both the PT and Occupational Therapist (OT). The DON and DOR confirmed the absence of documented evidence showing the implementation of these recommendations. The lack of communication between the nursing and rehabilitation departments was again highlighted as the reason for this oversight. The facility's policy on Restorative Nursing Services, which emphasizes the need for individualized and resident-centered care, was not followed. The policy outlines that residents should receive restorative nursing care to promote optimal safety and independence, and that such care should be documented in the resident's plan of care. The failure to adhere to this policy resulted in a delay in the continuity of care for the residents involved.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident, identified as Resident 33, who was admitted with diagnoses including dementia, retropharyngeal and parapharyngeal abscess, and shortness of breath. During an observation, Resident 33 was found using a nasal cannula attached to an oxygen concentrator set at 2 liters per minute, without a corresponding physician's order documented in their clinical record. This oversight was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the necessary order. The facility's policy and procedure for oxygen administration, which requires verification of a physician's order before administering oxygen, was not adhered to in this instance. The DON reviewed the policy, which was last revised in October 2010, and confirmed that it was not followed. This failure to comply with the established protocol had the potential to expose Resident 33 to risks associated with unmonitored oxygen therapy, such as oxygen toxicity.
Expired Nursing License Overlooked
Penalty
Summary
The facility failed to ensure that their professional staff maintained an active and current nursing license, as evidenced by a Licensed Vocational Nurse (LVN) working with an expired license. The LVN worked from a specified date through another specified date with a delinquent license, which was not renewed within the required timeframe. During an interview and record review, the Director of Nursing (DON) acknowledged that it was her responsibility to verify the nurses' licenses. Although the DON checked the LVN's license the previous month and found it active, she did not verify the expiration date. The facility's job description for the LVN position required current nursing licensure in the state of California, which was not adhered to, resulting in the LVN working without a valid license during the specified period.
Failure to Adhere to Blood Glucose Monitoring Schedule
Penalty
Summary
The facility failed to implement its policy for blood glucose monitoring for a resident with type 2 diabetes mellitus, which potentially led to a change in the resident's condition and subsequent transfer to a general acute hospital for evaluation and treatment. The resident, who was admitted with a diagnosis of type 2 diabetes and had moderate cognitive impairment, was supposed to have blood sugar checks conducted before meals and at bedtime as per physician's orders. However, a review of the resident's Blood Sugar Summary indicated that the blood sugar check was conducted later than the scheduled time, specifically at 1:38 p.m., instead of before meals around 11:30 a.m. During an interview, the Maternal Data Set Assistant Coordinator confirmed the delay in conducting the blood sugar check and acknowledged that the facility did not adhere to the physician's orders. The facility's policy and procedure for glucose monitoring, dated December 2015, stated that the management of individuals with diabetes mellitus should follow relevant protocols and guidelines, and the physician would order the frequency of glucose monitoring. This failure to adhere to the scheduled blood glucose monitoring had the potential to jeopardize the health and well-being of the medically compromised resident.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to adhere to its policy and procedure for activities of daily living (ADL) by not ensuring proper grooming and personal hygiene for a resident. The deficiency was identified during an observation of a resident who had notably long and unclean fingernails. This resident, who was admitted with a diagnosis of unspecified dementia and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, required partial/moderate assistance with personal hygiene according to their MDS Section G assessment. During an observation and interview, both the Administrator and the Resident Assessment Coordinator acknowledged the resident's unclean and untrimmed fingernails. The Administrator stated that it was the responsibility of the CNAs to clean or trim the resident's fingernails. The facility's policy, dated March 2018, indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene. The failure to maintain the resident's fingernails put the resident at risk for infection.
Failure to Follow Restraint Policy
Penalty
Summary
The facility failed to follow its policy and procedure for restraints when a Certified Nursing Assistant (CNA) wrapped a resident's waist and legs in linen sheets. This incident involved a resident with severe cognitive impairment, dementia, an unspecified fracture of the right lower leg, and schizoaffective disorder. The resident was admitted to the facility with a care plan that required all care to be delivered by licensed nursing staff and adjunct professional medical personnel. The resident's care plan also indicated a risk for decline in psychosocial well-being due to involuntary seclusion and required staff education on the use of restraints and types of restraints. On the day of the incident, the resident was observed sitting in a Geri-chair in the activities room, smiling and grabbing at the upper part of her pants. The resident was unable to recall the incident. During a telephone interview, the CNA admitted to placing the sheet around the resident to prevent her from digging into her pants and smearing feces, based on information told to her by someone else. The CNA acknowledged that this was not the right measure. Another CNA reported the incident to an LVN, who conducted a body assessment and found no markings on the resident's skin. The LVN then informed the Director of Nursing (DON). The facility's policy and procedure on the use of restraints, revised in April 2017, stated that restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should never be used for discipline or staff convenience. The policy defined physical restraints and specified that practices preventing resident mobility, such as tucking sheets tightly, are considered restraints and are not permitted. The DON confirmed that the policy and procedure were not followed in this case.
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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