Highland Springs Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, California.
- Location
- 1441 Michigan Avenue, Beaumont, California 92223
- CMS Provider Number
- 555135
- Inspections on file
- 38
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Highland Springs Care Center during CMS and state inspections, most recent first.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive appropriate treatment and services, as the care plan lacked individualized interventions and documentation to address their specific needs.
A resident with dementia and anxiety disorder, placed on 1:1 sitter watch after an altercation, was left unsupervised on two occasions: once when a CNA was observed with eyes closed and not fully attentive, and again when another CNA left the resident alone to get supplies. Both actions were contrary to facility policy and expectations for continuous, close monitoring.
The facility failed to implement a respiratory protection program, resulting in 47 out of 106 direct care staff not being fit tested for N95 masks, as required by policy and CDC guidelines. This deficiency was discovered during an investigation of a COVID-19 outbreak, where 32 residents and 12 staff tested positive. Interviews revealed that fit testing was not prioritized, with some staff not tested since 2020. The Administrator confirmed the absence of a proper program, posing a risk to residents and staff.
A facility failed to separate two residents with a history of altercations, resulting in one resident pulling another from a wheelchair, causing a clavicle fracture. Despite care plans indicating the need for separation and redirection, staff did not prevent the interaction, leading to the incident.
The facility failed to ensure that call lights were within reach for two residents, potentially leading to unmet needs. One resident, with fluctuating decision-making capacity and self-care deficits, had her call light out of reach while sitting in her wheelchair. Another resident, with cognitive and communication deficits, also had her call light placed out of reach. A CNA confirmed the inaccessibility of the call lights, which contradicted the facility's policy requiring accessible call lights for residents.
A resident with dementia and schizophrenia, identified as high risk for falls, tripped on an in-ground planter in the patio area, resulting in a nasal fracture and periorbital hematoma. The planter, approximately 3.25 to 3.5 inches deep, posed a tripping hazard due to its unevenness. The facility's policy emphasized addressing environmental hazards, but the area was not maintained safely.
The facility failed to complete comprehensive assessments for six residents within the required 14 days after admission, as confirmed by the MDS nurse and DON. This delay in completing the Minimum Data Set (MDS) assessments, crucial for resident-centered care planning, was contrary to the facility's policy and federal guidelines.
A facility failed to ensure privacy for two residents during medication administration and did not properly document the administration of controlled medications for two other residents. An LVN assessed a resident for back pain and applied topical medication to another without closing doors or drawing privacy curtains. Additionally, narcotic and anti-anxiety medications were signed out for two residents, but there was no documentation in the eMAR to confirm administration, contrary to facility policies.
The facility failed to ensure dietary staff could safely and effectively carry out food cooling procedures. Staff members provided incorrect information about the cooldown process for hot and ambient temperature foods, which could risk foodborne diseases. The Registered Dietitian clarified the correct procedures, which were not followed by the staff, indicating a failure in training or adherence to facility policies.
The facility failed to maintain a sanitary kitchen environment, with grime on a toaster, damaged cutting boards, rust on oven surfaces, and corroded meal tray carts. These issues, acknowledged by the Dietary Manager and Registered Dietician, pose risks of cross-contamination and foodborne illnesses, contrary to facility policies and FDA Food Code standards.
The facility failed to maintain kitchen equipment, including a toaster, oven, and meal tray carts, in a safe condition, posing a risk for foodborne illnesses. Observations revealed chipped and peeled surfaces and rust, which could lead to contamination. The Dietary Manager and Registered Dietician acknowledged these issues, highlighting the potential for bacterial growth and cross-contamination.
A resident's room had multiple damaged window blinds, causing excessive brightness and discomfort. The resident used curtains to block the light. Both the Maintenance Supervisor and Facility Administrator were aware of the issue, acknowledging the need for repair or replacement to maintain a homelike environment, as per the facility's maintenance policy.
A facility failed to provide education and resources about Advance Directives (AD) to a resident with severely impaired cognitive skills and their representative. The Social Service Director admitted to not offering the necessary information, and the Director of Nursing confirmed that the facility's policy requires such education and documentation, which was not followed in this case.
A resident's environment was compromised due to a damaged call light cord and a rusted bathroom cabinet. The call light, essential for alerting staff, was cracked with exposed wires, and the issue was not reported to maintenance. Additionally, the bathroom cabinet had rust buildup, which was acknowledged by staff but not addressed. These deficiencies highlight lapses in maintaining a safe and homelike environment.
A facility failed to notify the LTC Ombudsman of a resident's discharge to an acute hospital, as required by policy. The resident had severe cognitive impairment due to dementia and Alzheimer's. Staff interviews revealed that the Social Service Director missed sending the notification, and both the Medical Records Director and Director of Nursing confirmed the oversight, emphasizing the importance of such notifications for resident safety and continuity of care.
A facility failed to ensure proper medication administration when an LVN did not check a resident's pulse rate before giving Nifedipine ER 20 mg, as required by the physician's order. The LVN lacked the necessary equipment to accurately measure the pulse rate, leading to a potential risk of the resident not receiving the full therapeutic effects of the medication.
A resident with a history of diabetes, COPD, heart disease, and liver cirrhosis experienced untreated edema in the left extremities. Despite complaints of pain and swelling, the facility failed to document an assessment or develop a care plan. The DON confirmed the lack of documentation and monitoring, indicating a deficiency in following facility policies.
A resident with dementia, capable of making his own decisions, did not receive recommended reading glasses due to the facility's failure to follow up on an optometrist's recommendation. Despite a physician's order for a vision consult and the resident's expressed need for glasses, the facility did not act on the recommendation, as confirmed by the SSD and DON. This oversight was not documented, contrary to the facility's policy on consultant services.
The facility failed to properly store medications, resulting in expired and discontinued drugs being readily available for use. A bottle of Nutricia UTI Stat Liquid and acetaminophen suppositories were found in a medication cart despite being expired, and a vial of Comimaly Intramuscular Suspension was stored in the medication refrigerator for a discharged resident. Both LVNs and the DON acknowledged these errors, which violated the facility's medication storage policy.
The facility failed to provide necessary assistive devices, such as plate guards, for two residents during mealtime, leading to difficulties in managing their food. Both residents were observed struggling to keep food on their plates, resulting in spillage. Staff interviews confirmed that these residents should have been evaluated and provided with assistive eating devices to meet their nutritional needs.
A resident with fluctuating decision-making capacity had two expired bags of marshmallows in their closet, which were gifts from the previous Christmas. The marshmallows were readily available for consumption, and both an LVN and a CNA acknowledged the potential for stomach upset if consumed. The DON stated that expired food should be discarded, as per facility policy, which was not followed in this instance.
The facility failed to ensure proper infection control practices when a nurse did not perform hand hygiene during a blood sugar check and insulin administration for a resident, and a physical therapy assistant did not disinfect ankle weights or perform hand hygiene after therapy on a resident with multidrug-resistant organisms. These actions were contrary to the facility's infection control policies.
A facility failed to offer a resident the second dose of the pneumococcal vaccine as per CDC guidelines. The resident, who has COPD, received the first dose (PPSV23) but was not documented as being offered the second dose (PCV20) after one year, as required. This deficiency was identified during an interview and record review with the Infection Preventionist.
A resident with dementia was inadequately monitored, allowing them to wander into another resident's room and engage in inappropriate behavior. Despite having a care plan that required frequent monitoring due to a risk of wandering, the resident's behavior was not documented or communicated to the DON, leading to a failure in supervision and intervention.
The facility failed to ensure that the POLST forms were identifiable, accurate, and updated for three residents, leading to potential inappropriate or delayed treatment. The discrepancies involved missing signatures, outdated POLST statuses, and lack of documentation for decision-making processes.
The facility failed to assign a surrogate decision maker for a resident with schizophrenia who lacked decision-making capacity. The resident was admitted without a completed POLST and Consent to Treat form, and there was no documented evidence that the IDT or Bioethics Committee had taken action to appoint a healthcare decision maker.
Failure to Provide Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified based on the lack of evidence that the resident received necessary care and interventions tailored to their mental health and psychosocial needs, as required by regulatory standards. Surveyors observed that the resident's care plan did not address their specific mental health diagnosis or trauma history, and there was no documentation of individualized interventions or services to support their psychosocial adjustment. This omission resulted in the resident not receiving the comprehensive care needed for their condition.
Failure to Maintain 1:1 Supervision for Resident on Sitter Watch
Penalty
Summary
The facility failed to ensure that a resident requiring 1:1 monitoring was appropriately supervised in two separate instances. In the first instance, a Certified Nursing Assistant (CNA) assigned as a sitter was observed with her eyes closed for several minutes while on duty, and was not paying full attention to the resident as required. The Director of Nursing (DON) confirmed that the sitter was expected to remain within arm's length of the resident at all times and to continuously monitor the resident to prevent harm. The facility's policy also required staff to make routine checks to maintain resident safety and well-being. The CNA admitted to resting her eyes but denied being asleep, and a guard who witnessed the event reported it to management. In the second instance, another CNA assigned to 1:1 monitoring left the resident unattended in her room while he went to get supplies. The CNA acknowledged that he should not have left the resident alone and should have asked for assistance from other staff members. At the time of both incidents, the resident had diagnoses of dementia and anxiety disorder and had been placed on 1:1 monitoring following an altercation with another resident. Observations confirmed that the resident was left without staff supervision, contrary to facility policy and the expectations outlined by the DON.
Failure to Implement Respiratory Protection Program
Penalty
Summary
The facility failed to implement a respiratory protection program, specifically regarding the fit testing of N95 respirators for its direct care staff. Out of 106 direct care staff, 47 were not fit tested for the use of N95 masks, which is a requirement according to the facility's policy and CDC guidelines. This deficiency was identified during an unannounced visit to investigate a COVID-19 outbreak, where 32 residents and 12 staff members tested positive for the virus. Interviews with staff members, including the Infection Preventionist (IP), revealed that fit testing was supposed to occur upon hire, annually, and when new N95 models were introduced. However, several staff members, including Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs), reported not being fit tested for several years, with some last tested in 2020. The IP admitted to not prioritizing fit testing due to focusing on vaccinations and managing the COVID-19 outbreak. The Administrator confirmed the absence of a Respiratory Protection Program that included fit testing for N95 masks. The facility's policy required fit testing at the time of initial assignment and annually thereafter, but this was not adhered to, as evidenced by the lack of current fit testing records for 47 staff members. This oversight had the potential to contribute to the spread of COVID-19 among residents and staff, posing a risk to those not yet affected by the virus.
Removal Plan
- The administrator provided a verbal consult to the IP regarding failure to follow N95 Fit Testing Policy and procedure, including fit testing upon hire and annually thereafter.
- The administrator posted an on-shift message to all staff and requested whoever has not completed a N95 test for the past 12 months must be tested before reporting to work.
- A list of employees not fit tested was posted on the timeclock to ensure that they could not clock in unless the fit testing is completed.
- The administrator, the DON, and the MDS nurse contacted all employees not fit tested, and instructed them to complete their N95 Fit testing.
- The administrator and DON conducted in-services regarding N95 Fit Testing guidelines.
- Two other IPs reported to the facility to assist the facility in N95 fit testing of affected employees.
- The facility added N95 Fit Testing to the annual in-service calendar to ensure that all employees will complete their annual fit tests every January.
- The facility will conduct follow up in-service for N95 Fit Testing monthly for 3 months.
- The administrator and the DON will check 5 randomly selected employee files each week for 3 months, followed by quarterly and as needed to ensure all employees were fit tested.
Failure to Separate Residents Leads to Injury
Penalty
Summary
The facility failed to ensure the separation and distancing of two residents involved in multiple altercations, as indicated in their care plans. This failure resulted in a physical altercation where one resident was pulled from a chair by another, leading to a closed clavicle fracture. The incident was investigated during an unannounced visit on October 2, 2024, following an allegation of physical abuse. Resident 2, diagnosed with schizophrenia and lacking decision-making capacity, had a history of aggressive behavior towards Resident 1. Previous incidents on September 13 and 14, 2024, involved Resident 2 pushing and hitting Resident 1. Both residents' care plans included interventions to keep them apart and provide redirection when needed. Despite these interventions, on September 30, 2024, Resident 2 pulled Resident 1 from a wheelchair, causing a fall and injury. Interviews with facility staff, including the Infection Preventionist and Dietary Manager, revealed awareness of the need to keep the residents apart. However, during the incident on September 30, 2024, staff failed to redirect the residents in opposite directions, leading to the altercation. The Director of Nursing confirmed the staff's awareness of the need to separate the residents and acknowledged the failure to prevent the incident, which resulted in Resident 1's injury.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which could lead to unmet needs due to their inability to call for assistance. During an unannounced visit, it was observed that Resident 4, who was sitting in her wheelchair on the right side of her bed, had her call light hanging above the right side of the head of the bed, making it unreachable. Resident 4 expressed the need for help to be changed but was unable to call for assistance due to the call light's position. Similarly, Resident 5 was observed sitting in her wheelchair at the foot of Resident 4's bed, with her call light placed in the center of the bed, out of her reach. An interview with a CNA confirmed that the call lights were not within reach for both residents. Resident 4's medical records indicated she was admitted with diagnoses including diabetes mellitus type 2, osteoarthritis, and peripheral vascular disease, and had fluctuating capacity to make decisions. Her care plan emphasized the need for the call light to be within reach due to her self-care deficits. Resident 5's medical records showed diagnoses of dementia, diabetes mellitus type 2, major depressive disorder, and a history of falling, with an inability to make decisions. Her care plan also highlighted the necessity for the call light to be accessible due to her extensive assistance needs. The facility's policy required that each resident have a means to call staff directly for assistance, which was not adhered to in these cases.
Resident Falls Due to Tripping Hazard in Patio Area
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident who was at high risk for falls. The resident, who had dementia and schizophrenia and lacked decision-making capacity, tripped on an in-ground planter that was approximately 3.25 to 3.5 inches deep above ground level. This incident occurred in the outer patio area, where the resident fell and hit her head on a picnic table, resulting in a periorbital hematoma and a fracture of the nasal septum. The resident's fall risk assessment had previously indicated a high risk of falling, with a score of 18 or more. Observations and interviews revealed that the in-ground planter posed a tripping hazard due to its unevenness relative to the surrounding pavement. The Director of Nursing acknowledged that the fall could have been avoided if the planter had been fixed. The facility's policy on promoting safety and reducing falls highlighted the importance of addressing extrinsic factors, such as environmental hazards, to enhance residents' quality of life. However, the facility did not maintain the area around the buildings, including the patio, in a safe and orderly manner, as required by their policy.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for six residents within the required 14 calendar days after their admission. This deficiency was identified during a review of the Minimum Data Set (MDS) comprehensive assessments, which are crucial for evaluating residents' health status and developing a resident-centered care plan. The MDS nurse confirmed that the assessments for the affected residents were not completed on time, as mandated by federal and state guidelines. Interviews with the MDS nurse and the Director of Nursing (DON) revealed an acknowledgment of the importance of timely completion of these assessments to ensure appropriate care planning. The facility's policy, dated July 2017, and a document titled RAI OBRA-required Assessment Summary, reiterated the requirement for assessments to be completed no later than the 14th calendar day following a resident's admission. Despite these guidelines, the assessments for the six residents were delayed, potentially impacting the delivery of resident-centered care.
Privacy and Documentation Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure privacy for two residents during medication administration. One resident, who was alert and interviewable, was assessed for back pain by an LVN without the door being closed or the privacy curtain being drawn, leaving the resident visible from the hallway. Another resident had a topical pain medication applied to her knee by an LVN, again without privacy measures being taken, as the door was left open and the resident was visible from the hallway. Both LVNs acknowledged the oversight in providing privacy during these procedures. The facility also failed to properly document the administration of controlled medications for two residents. For one resident, the narcotic medication Norco was signed out on two occasions, but there was no documentation in the electronic Medication Administration Record (eMAR) to confirm that the medication was administered. Similarly, for another resident, the anti-anxiety medication Ativan was signed out, but again, there was no documentation in the eMAR to confirm administration. The LVN interviewed confirmed that the documentation was missing and should have been completed. The facility's policies and procedures require that medication administration be documented immediately after administration, including the date, time, and signature of the administering nurse. The lack of documentation for the controlled medications could lead to delays in identifying drug discrepancies and potential medication diversion. The facility's failure to adhere to its own policies and procedures regarding privacy and documentation contributed to these deficiencies.
Deficiency in Food Cooling Procedures
Penalty
Summary
The facility failed to ensure that dietary staff could safely and effectively carry out the functions of food and nutrition services, specifically regarding the cooldown process for hot food and ambient food temperatures. During interviews, Dietary Aide (DA) 3 and DA 4, as well as Cook (CK) 1, were unable to accurately describe the correct procedures for cooling down hot and ambient temperature foods. DA 3 incorrectly stated that the cooldown process for hot food starts at 186 degrees and should reach 140 degrees after two hours, and 34 degrees after another two hours. DA 3, DA 4, and CK 1 also provided incorrect information regarding the cooldown process for ambient food temperatures, such as tuna salad, indicating a misunderstanding of the required procedures. The Registered Dietitian (RD) clarified that the correct process for cooling hot food is to cool from 140 degrees to 70 degrees within two hours, and then to 40 degrees within four hours, totaling six hours. For ambient food temperatures, the food should reach 40 degrees or less within four hours, and if not, it must be discarded. The facility's policy, dated 2019, aligns with the RD's explanation, indicating a failure in staff training or adherence to these policies. This deficiency had the potential to place residents at risk for foodborne diseases due to improper food handling and cooling procedures.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, leading to potential risks of foodborne illnesses. During an inspection, a toaster was found with a brown-yellowish grime buildup on its dial control, which the Dietary Manager (DM) acknowledged as grime that should not have been present due to the risk of cross-contamination. Additionally, multiple cutting boards were observed with yellowish discoloration, deep cuts, and damage, which the DM confirmed could harbor bacteria and lead to foodborne illness. Further observations revealed that the left and right sides of the oven, as well as the front inside surfaces of the oven doors, had brown discoloration identified as rust. The DM stated that the rust could fall into food, causing cross-contamination. Meal tray carts were also found with brown discoloration and corrosion, which the Registered Dietician (RD) and Maintenance Assistant (MA) attributed to wear and corrosion, posing a risk of bacterial growth and cross-contamination. The facility's policies and procedures, as well as the FDA Food Code, emphasize the importance of maintaining clean and undamaged equipment to prevent the growth of microorganisms and ensure food safety. However, the facility failed to adhere to these standards, as evidenced by the presence of grime, rust, and damaged equipment in the kitchen, which could potentially lead to foodborne illnesses among residents.
Deficient Maintenance of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, which posed a risk for foodborne illnesses. During an inspection, it was observed that a toaster had a chipped and peeled plastic film on its dial, which the Dietary Manager acknowledged as a potential site for bacterial growth and cross-contamination. Additionally, the left and right sides of the oven, as well as the inside surfaces of the oven doors, were found to have chipped and peeled paint with brown discoloration, identified as rust. The Dietary Manager confirmed that the rust and peeled paint could fall into food, leading to contamination. Further observations revealed that four meal tray carts had chipped and peeled vinyl stickers, and two of the carts had brown discoloration on their metal areas, indicating corrosion. The Registered Dietician and Maintenance Assistant confirmed these findings, noting that the rust and deterioration could lead to bacterial growth and cross-contamination. The facility's policies and the FDA Food Code emphasize the importance of maintaining kitchen equipment in good repair to prevent such risks, but the facility failed to adhere to these standards.
Failure to Maintain Homelike Environment Due to Damaged Blinds
Penalty
Summary
The facility failed to provide a comfortable homelike environment for a resident due to multiple damaged window blinds in the resident's room. During an observation and interview, the resident expressed that the room was too bright and had to use curtains to block the light coming through the damaged blinds. The Maintenance Supervisor acknowledged awareness of the issue and stated that the blinds needed replacement. Similarly, the Facility Administrator was aware of the need for repair or replacement to maintain a homelike environment. The facility's policy, dated December 2009, requires the maintenance department to keep the building in good repair, which was not adhered to in this instance.
Failure to Provide Advance Directive Education and Documentation
Penalty
Summary
The facility failed to provide education and resources regarding Advance Directives (AD) to a resident and their representative. The resident, who was admitted to the facility, was documented as having severely impaired cognitive skills and was unable to make decisions. Despite this, there was no evidence in the medical record that education or information about AD was provided to the resident or their representative. The Social Service Director (SSD) acknowledged that she did not provide the necessary resources and education, which should have been documented in the resident's records. The Director of Nursing (DON) stated that upon admission, licensed nurses are responsible for screening residents regarding AD, and the SSD is expected to follow up. If a resident does not have an AD, the facility's policy requires that assistance in establishing ADs be offered, and the offer or decline of assistance should be documented in the medical record. However, in this case, the facility did not adhere to its policy, resulting in a deficiency related to the lack of education and documentation concerning AD for the resident and their representative.
Deficiencies in Resident Environment and Maintenance Reporting
Penalty
Summary
The facility failed to provide a clean, safe, and comfortable environment for a resident, identified as Resident 28, due to two specific deficiencies. Firstly, the resident's call light button cord was found to be damaged and cracked, with exposed wires, during an observation. The resident was unaware of the damage, which had not been reported to the maintenance department for replacement. Interviews with the Maintenance Supervisor and a Certified Nurse Assistant (CNA) revealed that there was no work order for the call light, and the staff had not informed maintenance about the issue, which could potentially prevent the resident from receiving timely assistance. Secondly, the cabinet above the sink in the resident's bathroom had rust buildup on the bottom shelf. This was observed during an inspection, and both the Maintenance Supervisor and the CNA acknowledged the rust, stating that the cabinet should not be in such a condition. The Director of Nursing (DON) confirmed that the cabinet should be clean and free of rust, and emphasized that staff should report maintenance needs to ensure resident comfort and safety. The facility's policy on maintenance service indicates that the maintenance department is responsible for keeping the building and equipment in safe and operable condition, which was not adhered to in this case.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a discharge for a resident, which was identified during a review of closed records. The resident, who had been admitted with dementia and Alzheimer's, was discharged to an acute hospital. Despite the facility's policy requiring notification to the LTC Ombudsman at the time of discharge, there was no documented evidence that this notification occurred for the resident. Interviews with facility staff, including the Social Service Director, Medical Records Director, and Director of Nursing, confirmed that the discharge notice was not sent to the LTC Ombudsman. The Social Service Director acknowledged the oversight, stating that she missed sending the notification. The Medical Records Director and Director of Nursing reiterated the importance of this notification for resident safety and continuity of care, and confirmed that the notification should have been sent within 72 hours of the discharge.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) administered the medication Nifedipine ER 20 mg as ordered by the physician for a resident with hypertension. During a medication administration observation, the LVN did not check the resident's pulse rate, which was a required parameter before administering the medication. The medication label instructed to hold the medication if the systolic blood pressure was below 110 mmHg or the pulse rate was below 60 beats per minute. The LVN was observed to lack the necessary equipment to accurately check the pulse rate and admitted to not obtaining an accurate reading before administering the medication. The Director of Nursing confirmed that the LVN should have checked the pulse rate prior to administering the medication, as per the physician's order. The facility's policy and procedure for medication administration also required vital signs to be taken just before medication administration by the medication nurse. The failure to follow these procedures had the potential to prevent the resident from receiving the full therapeutic effects of the medication.
Failure to Assess and Care Plan for Edema
Penalty
Summary
The facility failed to appropriately assess and develop a care plan for a resident experiencing edema in the left upper and lower extremities. On July 23, 2024, during an observation and interview, the resident was found with a swollen left arm and hand, which was not supported or treated. The resident confirmed that no treatment, such as elevation or icing, had been applied. The resident's medical history includes diabetes, chronic obstructive pulmonary disease, atherosclerotic heart disease, and cirrhosis of the liver. The resident's records revealed that on July 4, 2024, a licensed nurse noted the resident's complaint of pain and swelling in the left arm, with an edema grading of +6. However, there was no documented assessment of the size and appearance of the swelling, nor was there a care plan initiated to address the edema. On July 13, 2024, the resident's condition was noted to include a blister on the left upper arm, and a new order for Lasix was received, but again, no assessment or care plan was documented. The Director of Nursing confirmed the lack of documentation for an appropriate assessment and care plan for the resident's edema. The facility's policy on edema assessment and care planning was not followed, as there was no evidence of monitoring or documentation of the edema's progression or any care plan to address the resident's needs. This oversight in documentation and care planning represents a deficiency in the facility's compliance with its own policies and procedures.
Failure to Follow Up on Vision Care Recommendation
Penalty
Summary
The facility failed to address the vision needs of a resident, identified as Resident 54, who had a recommendation for reading glasses that was not followed up. Resident 54, who has dementia but retains the capacity to make his own decisions, expressed a desire for reading glasses to help him read better. Despite a physician's order for an eye-health and vision consult, and a subsequent recommendation from an optometrist for new reading glasses, the facility did not act on this recommendation. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) confirmed that the recommendation for reading glasses was not followed up, and there was no documentation indicating that the issue had been addressed. The SSD acknowledged the oversight and the potential for this lack of follow-up to lead to vision problems for the resident. The facility's policy on Ancillary/Consultant Physician Services requires that consultant recommendations be documented and acted upon, but this was not adhered to in this case.
Improper Storage of Expired and Discontinued Medications
Penalty
Summary
The facility failed to ensure that medications were stored properly, leading to the availability of expired and discontinued medications. During an inspection, it was observed that a bottle of Nutricia UTI Stat Liquid and acetaminophen suppositories were stored in a medication cart despite being expired. The Nutricia UTI Stat Liquid had an expiration date that had passed, and the acetaminophen suppositories were labeled for a resident who had been discharged. Licensed Vocational Nurse (LVN) 3 acknowledged that these medications should not have been readily available for use and should have been disposed of properly. Additionally, a vial of Comimaly Intramuscular Suspension was found in the medication refrigerator, labeled for a resident who had already been discharged. LVN 4 confirmed that this medication should have been removed and stored in a designated cabinet for discontinued medications. The Director of Nursing (DON) also stated that the expired and discontinued medications should have been pulled out and wasted to prevent potential medication errors. The facility's policy on medication storage was reviewed, indicating that discontinued or outdated drugs should be returned to the pharmacy or destroyed.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide necessary assistive devices, such as plate guards, for two residents during mealtime, which was observed by surveyors. Resident 13 was seen struggling to keep food on her plate, resulting in food spilling onto the floor. During an interview, the resident expressed difficulty in managing her food, and a Licensed Vocational Nurse (LVN) confirmed that a plate guard should have been provided to assist the resident. The Director of Nursing (DON) acknowledged that Resident 13 should have been evaluated for and provided with an assistive eating device to ensure her nutritional needs were met. Similarly, Resident 58 was observed having difficulty keeping food on her plate, with food spilling onto the overbed table. The resident expressed confusion about the location of her food, indicating a need for assistance. An Infection Preventionist (IP) noted the necessity of a plate guard for Resident 58 to prevent food from falling off the plate. The DON also confirmed that Resident 58 should have been evaluated and provided with an assistive eating device. The facility's policy on assistive devices, dated January 2020, states that specialized eating utensils and equipment should be provided to assist residents, but this was not adhered to in these cases.
Expired Food Storage in Resident's Room
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of personal food for a resident, identified as Resident 56, when two expired bags of marshmallows were found in the resident's closet. The marshmallows, which were gifts from the previous Christmas, were readily available for consumption. Resident 56, who has a fluctuating capacity to understand and make decisions, admitted to occasionally snacking on the marshmallows. During observations and interviews, both a Licensed Vocational Nurse (LVN) and a Nursing Assistant (CNA) confirmed the presence of the expired marshmallows and acknowledged the potential for stomach upset if consumed. The Director of Nursing (DON) stated that expired food should have been discarded and not accessible to residents. The facility's policy on food storage specifies that expired items should be discarded, yet this was not adhered to in the case of Resident 56. The failure to discard the expired marshmallows posed a risk of foodborne illness to the resident, highlighting a lapse in the facility's adherence to its own food storage policies.
Infection Control Lapses in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper infection control practices during a blood sugar check and insulin administration for a resident. A registered nurse did not perform hand hygiene before, in between, and after resident contact. The nurse was observed not washing hands before and after pushing the resident's wheelchair, checking blood sugar, and administering insulin. Despite wearing gloves, the nurse did not follow the facility's policy on hand hygiene, which requires washing hands before and after these procedures. In another instance, a physical therapy assistant did not perform hand hygiene or disinfect ankle weights after using them on a resident under enhanced barrier precautions. The resident had multidrug-resistant organisms and extended spectrum beta-lactamase in their urine, necessitating strict infection control measures. The assistant failed to wash hands and disinfect equipment after therapy, contrary to the facility's infection control policies. The infection prevention nurse confirmed the expectations for hand hygiene and equipment disinfection, emphasizing the importance of these practices to prevent infection spread. The facility's policies clearly outline the need for hand hygiene and disinfection of non-critical resident-care items, which were not adhered to in these cases.
Failure to Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine as per CDC guidelines. Resident 58, who is of advanced age and has a diagnosis of chronic obstructive lung disease (COPD), was admitted to the facility and had received one dose of the pneumococcal vaccine (PPSV23) in April 2023. According to the facility's policy and CDC guidelines, a second dose of pneumococcal vaccine (PCV20) should be offered one year after the initial dose. However, during an interview and record review, it was found that there was no documentation indicating that Resident 58 was offered the second dose of the vaccine after the one-year interval. This oversight was confirmed by the Infection Preventionist during the review of the resident's immunization record.
Inadequate Monitoring Leads to Resident Wandering Incident
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident with dementia, leading to an incident where the resident wandered into another resident's room. Resident 2, who had a history of severely impaired cognition and was at risk for wandering due to dementia, was not frequently monitored as required by their care plan. This lack of supervision allowed Resident 2 to enter Resident 1's room, where they were found on top of Resident 1, who is non-verbal and unable to make decisions. Interviews with staff revealed that Resident 2 had previously exhibited behavior of entering other residents' rooms, but this was not documented or communicated to the Director of Nursing (DON) or other licensed staff. The DON was unaware of Resident 2's behavior until the incident occurred, indicating a breakdown in communication and documentation within the facility. The incident highlights the facility's failure to implement and follow through with the necessary interventions to prevent such occurrences, as outlined in Resident 2's care plan.
Failure to Update and Maintain Accurate POLST Documentation
Penalty
Summary
The facility failed to ensure that the Physician's Orders for Life Sustaining Treatment (POLST) were identifiable, accurate, and updated for three residents. Resident 2's POLST, dated March 4, 2024, indicated a Do Not Attempt Resuscitation (DNR) status, but during an Interdisciplinary Team (IDT) meeting on March 12, 2024, the resident's family member gave verbal consent for a full code status. However, the POLST was not updated, and the resident was transferred to an acute hospital with the incorrect DNR status. The Director of Nursing (DON) confirmed that the updated POLST should have been in the chart since March 12, 2024, and acknowledged the potential for serious adverse events due to this oversight. The Social Services Director (SSD) and a Registered Nurse (RN) also confirmed the discrepancy and the lack of an updated POLST in the resident's record. Resident 6's POLST, dated May 11, 2022, indicated full treatment but lacked the resident's or their representative's signature. The IDT met with the resident's responsible party on January 22, 2024, but the POLST was not updated to reflect this meeting. The DON confirmed that the POLST should have been updated and signed by the resident's assigned responsible party after the IDT meeting. There was no documented evidence explaining why the SSD/Bioethics committee had signed the POLST initially, and the updated POLST was missing from the resident's medical chart. Resident 7, who was admitted with severe cognitive impairment, did not have a completed and signed POLST or Consent to Treat form in their medical record. The SSD confirmed that the facility's process involved the Bioethics Committee acting as the healthcare decision-maker when no other decision-maker was available. However, there was no documented evidence of the IDT's determination or the Bioethics Committee's involvement in Resident 7's case. The facility's policies on POLST and the Bioethics Committee were reviewed, but the required documentation and updates were not present in the resident's records.
Failure to Assign Surrogate Decision Maker for Resident
Penalty
Summary
The facility failed to ensure a resident representative or surrogate decision maker was assigned for decision making for a resident diagnosed with schizophrenia who lacked the capacity to understand and make decisions. The resident was admitted without a completed and signed Physician's Orders for Life Sustaining Treatment (POLST) and Consent to Treat form. The Medical Records (MR) staff confirmed the absence of these documents and acknowledged the resident's lack of decision-making capacity. Despite the facility's policy requiring the Interdisciplinary Team (IDT) to appoint a decision maker, there was no documented evidence that the IDT or the Bioethics Committee had taken action to assign a healthcare decision maker for the resident. The Social Service Director (SSD) confirmed that the facility's process involves the IDT meeting to determine if the Bioethics Committee should be the appointed healthcare decision maker when no other decision maker is available. However, the SSD was unable to provide documented evidence that the IDT had reviewed the resident's case or that the Bioethics Committee had been involved in making healthcare decisions for the resident. The facility's policies on admission to a secured unit and the role of the Bioethics Committee were reviewed, but there was no documentation showing that these procedures had been followed for the resident in question.
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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