Highland Palms Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland, California.
- Location
- 7534 Palm Ave, Highland, California 92346
- CMS Provider Number
- 056024
- Inspections on file
- 30
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Highland Palms Healthcare Center during CMS and state inspections, most recent first.
A resident with acute respiratory failure, DM, and HTN left AMA after an out-on-pass during which she told a family member she had been sexually abused by staff. The family member reported the allegation to law enforcement and then took the resident home. The DON acknowledged that police came to the facility regarding the allegation but stated the facility did not initiate an investigation or report the allegation to CDPH because the resident had already been discharged, despite facility policy requiring identification, investigation, and timely reporting of all abuse allegations.
The facility failed to investigate or report an allegation of sexual abuse made by a resident with acute respiratory failure, DM, and HTN, who later left AMA. The resident’s family member reported that during an out-on-pass, the resident alleged sexual abuse by a staff member and that he notified law enforcement before taking the resident home. The DON confirmed that police came to the facility regarding the allegation but stated no internal investigation was initiated and no report was made to the state agency because the resident had already been discharged, despite facility policy requiring identification, investigation, and timely reporting of all abuse allegations.
A resident with a history of stroke, diabetes, and benign prostatic hyperplasia experienced moisture-associated skin damage (MASD) but the facility failed to document this change in condition. Despite new physician orders for treatment, the Director of Nursing confirmed the absence of documentation in the resident's records, violating the facility's policy on recording changes in a resident's condition.
A resident with multiple diagnoses, including schizophrenia and anxiety disorder, was found to smoke regularly without a comprehensive care plan in place. The resident kept smoking supplies and a lighter, but the facility failed to document a smoking care plan, as confirmed by the DON. This oversight was contrary to the facility's policy requiring evaluation and documentation of smoking-related concerns.
A resident's enteral feeding was administered at 65 mL/hr instead of the prescribed 60 mL/hr, as observed by surveyors. The discrepancy was confirmed by the DON, who acknowledged that the facility's policy for implementing physician orders was not followed. This failure could result in the resident receiving more calories than ordered.
A resident with a tracheostomy was not monitored for redness, discharge, and discoloration every shift as ordered by the physician. Instead, the monitoring was documented only once per day for two months. The DON confirmed the oversight, which contradicted the facility's policy on ostomy site care, potentially delaying the identification and treatment of complications.
The facility failed to follow its medication disposal policy when six tablets were found on top of the medication waste receptacle instead of inside it. An LVN and an RN confirmed the improper disposal, and the DON acknowledged that the facility's procedures were not followed, as per the 2019 policy on discarding and destroying medications.
An expired IV antibiotic was found in a medication supply room, still available for use. A nurse and the DON confirmed the oversight, acknowledging that expired medications should have been removed according to facility policy.
A CNA failed to don a gown when entering the room of a resident on contact precautions for MRSA, despite clear signage and facility policy requiring it. This breach in infection control was confirmed by the facility's IP and DON, highlighting a potential risk of spreading infectious disease.
A resident with multiple health conditions, including diabetes and HIV, was found to have medications stored unlocked at his bedside, contrary to the facility's policy. The medications, Genvoya and Ozempic, were confirmed by both the LVN and DON to be kept at the bedside, although administered by a nurse. The facility's policy requires medications to be stored in locked compartments, which was not adhered to, potentially risking the resident's health.
A facility failed to follow a physician's order to cover a resident's surgical site with a dry dressing, as the wound treatment nurse did not apply the dressing due to the resident's reported tape allergy. The resident had a history of orthopedic aftercare, alcoholic cirrhosis, a left artificial hip joint, and osteoarthritis. The DON confirmed that nurses are expected to follow orders, and the facility's wound care policy emphasized adherence to physician's orders.
A facility failed to create a care plan for a resident who tested positive for methamphetamine, despite being informed by the hospital. The resident had a history of stroke and drug abuse, and was admitted with multiple health issues. Interviews with staff revealed a lack of communication and care planning, contrary to the facility's policies on behavioral health services.
Failure to Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse and to initiate an investigation as required by its abuse, neglect, exploitation, and misappropriation prevention program. Resident 1 was admitted with diagnoses including acute respiratory failure, diabetes mellitus, and hypertension, and later left the facility against medical advice on February 17, 2026. During an out-on-pass with a family member on February 15, 2026, Resident 1 allegedly reported that she had been sexually abused by a staff member in the facility. The family member stated that he reported the allegation to the sheriff and police department and then took Resident 1 home after discharging her AMA on February 17, 2026. The DON confirmed that law enforcement came to the facility in response to the resident’s allegation of abuse. However, the DON stated that the facility did not initiate its own investigation or report the allegation to CDPH because Resident 1 had already been discharged when the facility became aware of the alleged abuse. A subsequent review of the facility’s policy and procedure on Abuse, Neglect, Exploitation and Misappropriation Prevention Program showed that the facility was required to identify and investigate all possible incidents of abuse and to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the facility did not investigate or report the allegation involving Resident 1.
Failure to Investigate Allegation of Sexual Abuse After Resident Discharge
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one of four sampled residents. The resident was admitted with diagnoses including acute respiratory failure, diabetes mellitus, and hypertension. According to the resident’s AMA (against medical advice) Release Form, the resident left the facility against medical advice on February 17, 2026. During a telephone interview on February 23, 2026, the resident’s family member reported that during an out-on-pass on February 15, 2026, the resident alleged she had been sexually abused by a staff member at the facility. The family member stated he reported the allegation to the sheriff’s and police departments and then took the resident home after discharging her AMA on February 17, 2026. In a subsequent interview, the DON stated that law enforcement came to the facility in response to the resident’s allegation of abuse. The DON acknowledged that the facility did not initiate an internal investigation or report the allegation to the California Department of Public Health because the resident had already been discharged when the facility became aware of the allegation. During a later record review, the DON reviewed and acknowledged the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, which requires the facility to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and to investigate and report any allegations within timeframes required by federal requirements.
Failure to Document Change in Condition for Resident with MASD
Penalty
Summary
The facility failed to document a significant change in condition for one of its residents, identified as Resident 42, who experienced moisture-associated skin damage (MASD). On October 30, 2024, new physician orders were issued for Resident 42 to treat MASD on the right buttocks, which included cleansing with normal saline, applying calcium alginate, and covering with a dry dressing daily for 14 days. However, the Director of Nursing (DON) confirmed that there was no documented evidence of this change in condition in Resident 42's clinical records, indicating a lapse in following the facility's policy and procedure for documenting changes in a resident's condition. Resident 42, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, type 2 diabetes mellitus, and benign prostatic hyperplasia, reported discomfort and redness in the genital area to a nurse on October 28, 2024. Despite this report, the nurse did not document the change in condition, as confirmed by the DON during a review of the facility's policy titled 'Change in a Resident's Condition or Status.' This policy mandates that any change in skin integrity should be recorded in the resident's medical record, which was not adhered to in this case.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was identified as a smoker. The resident, who had been admitted with diagnoses including muscle wasting, schizophrenia, anxiety disorder, and major depressive disorder, reported smoking regularly and keeping smoking supplies, including cigarettes and a lighter, in his possession. Despite these circumstances, there was no evidence of a smoking care plan in the resident's medical record. During an interview, the Director of Nursing confirmed the absence of a smoking care plan for the resident, acknowledging that such a plan should have been created. The facility's smoking policy requires an evaluation of a resident's smoking status upon admission and mandates that any smoking-related privileges, restrictions, and concerns be documented in the care plan. The lack of a care plan for the resident's smoking habits was a deviation from the facility's established policies and procedures, which aim to ensure safe smoking practices and address the resident's needs comprehensively.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to adhere to physician orders for a resident's enteral feeding, resulting in a discrepancy in the feeding rate. Specifically, Resident 44 was observed to have their enteral feeding running at 65 mL/hr instead of the prescribed 60 mL/hr. This deviation from the physician's order was noted during an observation on October 31, 2024, and was confirmed by the Director of Nursing (DON) during a concurrent observation and interview. The physician's order, dated July 13, 2024, clearly specified that the enteral feeding should be administered at 60 mL/hr for 20 hours, totaling 1200 mL and 1440 calories. The facility's policy and procedure for accepting, transcribing, and implementing physician orders were not followed, as acknowledged by the DON. The policy mandates that licensed nursing personnel ensure all physician orders are accurately recorded and implemented. Despite this, the enteral feeding for Resident 44 was not administered according to the specified rate, potentially leading to the resident receiving more calories than ordered. The failure to follow the physician's order was identified through observations and interviews conducted over several days, highlighting a lapse in the facility's adherence to its own procedures.
Failure to Monitor Tracheostomy as Ordered
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with a tracheostomy, as specified by the physician's orders. The resident, who had a tracheostomy due to conditions such as muscle wasting, asthma, dysphagia, and immunodeficiency, was supposed to have their tracheostomy site monitored for redness, discharge, and discoloration every shift. However, the Treatment Administration Records for September and October showed that the monitoring was only documented once per day instead of the required three times per day. During an interview and record review, the Director of Nursing confirmed that the physician's orders were not followed, emphasizing the importance of monitoring to promptly identify and address potential infections. The facility's policy on ostomy site care also highlighted the need for regular assessment to prevent irritation, breakdown, and infection. This oversight in monitoring had the potential to delay the identification and treatment of complications, affecting the resident's health and safety.
Improper Disposal of Medications
Penalty
Summary
The facility failed to adhere to its policies and procedures for the destruction and disposal of medications, as evidenced by the discovery of six medication tablets on top of the medication waste receptacle. During an observation and interview, a Licensed Vocational Nurse (LVN) acknowledged that the tablets, which were not narcotics, were improperly placed on the lid of the receptacle instead of being disposed of inside it. This was confirmed by a Registered Nurse (RN) who also observed the tablets and stated that they should have been properly disposed of within the receptacle. Further investigation with the Director of Nurses (DON) revealed that the facility's policy and procedure, titled "Discarding and Destroying Medications" and revised in 2019, was not followed. The policy mandates that both controlled and non-controlled substances be disposed of in the authorized onsite receptacle and documented on the medication disposition record. The DON confirmed that the facility's procedures were not adhered to, as the tablets were left accessible on top of the waste receptacle, contrary to the established guidelines.
Expired Medication Found in Supply Room
Penalty
Summary
The facility failed to ensure that expired medications were removed from one of its medication supply rooms. During an observation and interview, a registered nurse identified an expired intravenous antibiotic, Daptomycin, in the medication refrigerator. The medication had expired the previous day, yet it was still readily available for use. The registered nurse acknowledged that expired medications should have been removed and discarded. Further investigation with the Director of Nurses confirmed the oversight. The facility's policy and procedure, which mandates the removal and destruction of expired medications, was not followed. The Director of Nurses admitted that the nursing staff was responsible for maintaining medication storage and ensuring expired drugs were not used, highlighting a lapse in adherence to the facility's established protocols.
Infection Control Breach Due to Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices when a Certified Nursing Assistant (CNA 1) did not don a gown upon entering the room of a resident on contact precautions. The resident, identified as Resident 391, was admitted with diagnoses including sepsis, a local infection of the skin and subcutaneous tissue, and a methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident's care plan required contact isolation precautions due to the MRSA infection, which included the use of personal protective equipment such as gowns. Despite a sign at the entryway of the resident's room indicating the need for gowning, CNA 1 entered the room without a gown, touched the resident's phone, and handed it to the resident. The incident was observed on October 29, 2024, and was later discussed with the facility's Infection Preventionist (IP) and Director of Nursing (DON). Both confirmed that staff were expected to don gloves and gowns when entering the room of a resident on contact precautions. The facility's policy on transmission-based precautions, dated September 2022, also required staff and visitors to wear a disposable gown upon entering such rooms. The failure to adhere to these precautions had the potential to spread infectious disease to other residents and staff in the facility.
Improper Medication Storage at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were stored properly according to its policies and procedures and standards of practice. During an observation, a resident was found to have medications stored at his bedside unlocked, including an opened bottle of Genvoya and an injection pen of Ozempic. The resident, who has a medical history of type 2 diabetes mellitus, cirrhosis of the liver, chronic kidney disease, and is HIV positive, stated that he kept the medications with him at his bedside. Both the LVN and the DON confirmed that the resident kept these medications at his bedside, although a nurse administered them. The facility's policy and procedure for medication storage, dated November 2020, requires that all drugs and biologicals be stored in locked compartments under proper conditions. The DON acknowledged that the facility did not follow its policy, as the medications should have been stored in a locked compartment. This oversight had the potential to place the resident's health at risk for drug abuse and ingestion of unsanitary drugs.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the deficiency involved a failure to cover the surgical site on the resident's left hip with a dry dressing as per the physician's order. The resident had been admitted with diagnoses including orthopedic aftercare, alcoholic cirrhosis of the liver, a left artificial hip joint, and osteoarthritis. The physician's order clearly stated that the surgical site should be cleansed with normal saline, patted dry, and covered with a dry dressing daily. However, during a dressing change, the wound treatment nurse did not cover the surgical site because the resident reported an allergy to the tape. The Director of Nursing (DON) confirmed that licensed nurses are expected to verify and follow physician's orders for resident care, and expressed that the nurse should have adhered to the order to cover the surgical site with a dry dressing. The facility's policy and procedure for wound care, revised in October 2010, also emphasized the importance of following physician's orders and assessing any special needs of the resident. This oversight had the potential to delay and promote wound healing for the resident.
Failure to Implement Care Plan for Resident with Illicit Drug Use
Penalty
Summary
The facility failed to provide a comprehensive person-centered care plan for a resident who had tested positive for an illicit drug, specifically methamphetamine. The resident, who had a history of stroke and methamphetamine abuse, was admitted to the facility with diagnoses including shortness of breath, opioid use, respiratory failure, and major depressive disorder. Despite being informed by the hospital about the resident's positive drug test, the facility did not develop a care plan to monitor or provide treatment for the resident's condition. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that there was no formal communication or care plan in place regarding the resident's illicit drug use. The facility's policies on Behavioral Health Services and Behavioral Assessment, Intervention, and Monitoring were reviewed, indicating that a care plan should have been implemented to address the resident's needs. However, the interdisciplinary team did not evaluate the resident's behavioral symptoms or develop a plan of care, leading to a deficiency in meeting the resident's health and safety needs.
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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