Jerold Phelps Comm Hosp Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Garberville, California.
- Location
- 733 Cedar Street, Garberville, California 95542
- CMS Provider Number
- 555516
- Inspections on file
- 17
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Jerold Phelps Comm Hosp Snf during CMS and state inspections, most recent first.
An allegation of financial abuse involving a resident with dementia and Parkinson's disease was not reported to the State Survey Agency within the required two-hour timeframe. Staff became aware of the alleged financial exploitation after the resident contacted her bank and became upset about debits from her account, and the abuse coordinator was notified shortly thereafter. However, the abuse coordinator later stated she did not know if the state agency had been called as required, and state records showed no timely voicemail report from the facility. The formal abuse report form was completed by the DON and faxed to the state several days after the facility first became aware of the allegation, resulting in noncompliance with federal reporting requirements.
The facility's policies and procedures did not specify the required 2-hour timeframe for reporting abuse allegations or the 5-day deadline for submitting investigation summaries to CDPH. The DON confirmed these omissions after being informed by the Chief Quality Officer and a CDPH Surveyor, affecting a census of 8 residents.
A CNA shaved a resident's pubic hair without obtaining consent or consulting with licensed staff, despite the resident's severe cognitive impairment and lack of medical indication for the procedure. The incident was witnessed by another CNA and reported to nursing leadership, revealing a failure to respect the resident's rights and to follow facility protocols.
A resident with severe cognitive impairment and multiple health conditions was subjected to unauthorized shaving of pubic hair by a CNA, which was witnessed by another CNA and later observed by an LN. The incident was not reported to CDPH within the required 2-hour timeframe, and the facility did not submit an investigation summary within 5 business days. Facility policies lacked clear guidance on these reporting requirements, contributing to the deficiency.
The facility failed to develop baseline care plans for six residents within 48 hours of their admission. No baseline care plans signed by the residents or their representatives were found, and the facility's policies did not mention this requirement. Interviews with staff confirmed the lack of baseline care plans and documentation.
The facility failed to develop person-centered comprehensive care plans for five residents, impacting their quality of life and care. Residents with multiple diagnoses, including Dementia, Anxiety Disorder, Depression, and Diabetes, lacked care plans for psychotropic drug use and other critical areas. The facility did not adhere to its policy on resident care planning, leading to these deficiencies.
The Governing Body failed to appoint a California Licensed Nursing Home Administrator (NHA) responsible for the facility's management. The Chief Nursing Officer (CNO) confirmed through a phone call and a verification search that the Administrator did not possess an NHA license.
The facility failed to ensure that medication irregularities noted by the pharmacist during the drug regimen review for two residents were properly documented and communicated. The pharmacist's recommendations to taper Trazodone and lower the dose of Quetiapine were not followed up, and the attending physician did not document any review or action taken. This lack of documentation and communication had the potential to adversely affect the residents' health.
The facility failed to ensure that a resident was informed in advance about the use, risks, and benefits of the psychotropic medication Diazepam, as well as other medication options. The informed consent was obtained only after the medication was administered, contrary to the facility's policy and regulatory requirements.
The facility failed to complete a smoking assessment on admission for a resident to determine their functional capacity to safely smoke with or without assistance and the need for protective devices. The resident was observed smoking outside with a security staff member, and neither the resident nor the Licensed Nurse could confirm if a smoking assessment had been conducted. This failure had the potential to result in inappropriate care and supervision, as well as a fire hazard.
The facility failed to maintain a safe smoking environment and provide necessary protective equipment for a resident who smoked. The resident was not wearing a protective apron, and the blanket proposed for use was unsuitable. The designated smoking area was inconsistently defined, and the facility's smoking policy lacked provisions for smoking assessments and adaptive equipment.
Failure to Timely Report Allegation of Financial Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of financial abuse was reported to the State Survey Agency within two hours of becoming aware of the allegation, as required by regulation and facility policy. The resident involved had dementia associated with Parkinson's disease and had been admitted with these diagnoses. The facility became aware of the alleged financial abuse on 2/19/26 at 3:30 p.m., when the resident called her bank to check her balance and became upset due to debits from her account. The abuse coordinator was notified at 3:49 p.m. that same day. The facility’s short-term care plan documented the resident’s upset related to the debits, and the facility’s policy stated it would promptly prevent, identify, and report suspected abuse, neglect, and exploitation. Despite this, the allegation was not reported to the California Department of Public Health (CDPH) within the required two-hour timeframe. The Chief Nursing Officer, who served as the abuse coordinator, stated she did not know if CDPH was called on 2/19/26 and acknowledged it was her expectation that staff report suspected abuse to CDPH within two hours and that it was her responsibility to verify timely reporting. CDPH records showed no voicemail messages from the facility between 2/19/26 and 2/24/26. CDPH ultimately received a faxed Report of Suspected Dependent Adult/Elder Abuse (SOC 341) on 2/23/26 at 4:49 p.m., which had been completed and dated 2/20/26 by the DON, confirming the resident as an alleged victim of financial abuse, demonstrating that the report was not made within the required reporting window.
Failure to Include Timely Abuse Reporting Requirements in Facility Policies
Penalty
Summary
The facility failed to ensure that its policies and procedures regarding resident abuse included the requirement to report allegations of abuse to the California Department of Public Health (CDPH) within 2 hours of awareness and to submit an investigation summary within 5 business days. A review of the facility's policies titled 'Abuse and Neglect Investigation' and 'Abuse Reporting Requirements' revealed that neither document specified these mandatory reporting timeframes. During an interview, the Director of Nursing (DON) acknowledged the omission of these requirements in the facility's policies and stated that she became aware of the 2-hour and 5-day reporting requirements only after being informed by the Chief Quality Officer and a CDPH Surveyor. These failures affected a census of 8 residents, as the facility's policies did not align with state reporting requirements for abuse allegations.
Resident Shaved Without Consent by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) shaved a resident's pubic hair without obtaining the resident's consent or consulting with licensed nursing staff. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5, and was dependent on staff for toileting hygiene. The resident also had diagnoses of dementia, Parkinson's disease, anxiety, and depression. The CNA used the resident's personal beard shaver to perform the shaving during incontinent care, despite the resident not requesting this care and not being scheduled for any procedure that would require shaving. Another CNA witnessed the incident and later reported it to a licensed nurse, who then informed the Director of Nursing (DON) and Human Resources (HR). Interviews with staff confirmed that the CNA did not provide a reason for shaving the resident and that the resident appeared agitated during the incident. The facility's policies and job descriptions require CNAs to act under the supervision of licensed nurses and to respect residents' rights to informed consent and dignified care. The incident was reported internally, and the CNA acknowledged understanding that a violation had occurred. The failure to obtain consent and to follow proper procedures resulted in the resident not being treated with respect and dignity, as required by facility policy and patient rights.
Failure to Timely Report and Investigate Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment, dementia, Parkinson's disease, anxiety, and depression. A Certified Nursing Assistant (CNA) was observed by another CNA shaving the resident's pubic hair without medical reason or consent, using the resident's personal beard shaver. The resident appeared agitated during the incident, and the CNA who witnessed the event did not immediately report it. The incident was later observed by a Licensed Nurse (LN), who noticed the resident's pubic area was shaved in a sloppy manner and the skin was red. The LN submitted an incident report to Human Resources and informed the Director of Nursing (DON) the following day. Despite multiple staff members becoming aware of the incident, the facility did not report the suspected abuse to the California Department of Public Health (CDPH) within the required 2-hour timeframe from the time of awareness. The facility's policies and procedures did not specify the 2-hour reporting requirement, and staff interviews revealed a lack of clarity regarding the appropriate steps to take when abuse is suspected. The DON later acknowledged that staff are mandated reporters and should have reported the suspicion of abuse immediately or within 2 hours, but this was not reflected in the facility's written policies. Additionally, the facility failed to submit a summary of the investigation to CDPH within 5 business days, as required. The facility's policies did not include this 5-day reporting requirement, and the DON confirmed that a 5-day follow-up report was not provided. The lack of timely reporting and incomplete policy guidance contributed to the deficiency identified by surveyors.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for six residents within 48 hours of their admission. This deficiency was identified during a review of records and interviews with facility staff. Specifically, no baseline care plans signed by the residents or their representatives were found among the facility documents. The Chief Nursing Officer (CNO) confirmed that there were no baseline care plans developed within the required timeframe and that there were no records of any care plans signed by new residents or their Resident Representatives (RR). The facility's policies on admission documentation and resident care planning did not mention the requirement to develop a baseline care plan within 48 hours of admission. During interviews, Licensed Nurse K stated that new residents signed documents in an admission packet but was unaware if a care plan was developed within 48 hours of admission. The CNO also consulted with Health Information Management (HIM), who were unable to find any documentation for the six residents indicating they received and signed for a baseline care plan. The regulatory Health and Safety Code S483.21 requires the facility to develop and implement a baseline care plan within 48 hours of a resident's admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The facility must also provide the resident and their representative with a summary of the baseline care plan, which was not done in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for five residents, which had the potential to negatively impact their quality of life and care. Resident 1, who was admitted with multiple diagnoses including Hypertension, Anxiety Disorder, Depression, Type 2 Diabetes, and Parkinson's Disease, did not have a care plan for the use of psychotropic drugs Sertraline and Trazodone. Similarly, Resident 3, diagnosed with Dementia, Anxiety Disorder, Depression, Bipolar Disorder, Diabetes, and Hyperlipidemia, lacked a care plan for the psychotropic drug Risperidone. Resident 5, admitted with Coronary Artery Disease, Hypertension, and Dementia, had no individualized care plans until they were developed on 2/29/24, after the issue was identified by the Chief Nursing Officer (CNO). Resident 4, admitted with conditions such as debility, cachexia, Dementia, malnutrition, and adult failure to thrive, had care areas like cognitive loss/dementia and psychotropic drug use triggered during the admission assessment, but no corresponding care plans were found. Additionally, Resident 57, who smokes after meals and was observed being administered Diazepam, did not have care plans for smoking or Diazepam use. The Health Information Manager (HIM) and the CNO acknowledged that the care plans provided for Resident 57 were completed the night before the surveyors' review. The facility's policy on resident care planning indicates that nurses gather data upon admission, input it into the electronic medical record (EMR) system, and complete weekly summaries to generate data for the Minimum Data Set (MDS). The MDS is supposed to auto-populate appropriate plans of care, which are then reviewed monthly by the Director of Nursing (DON). However, the facility failed to adhere to this policy, resulting in the absence of comprehensive care plans for the residents mentioned above.
Failure to Appoint Licensed Nursing Home Administrator
Penalty
Summary
The Governing Body failed to appoint a California Licensed Nursing Home Administrator (NHA) responsible for the management of the facility. During an interview, the Chief Nursing Officer (CNO) was unable to provide a copy of the Administrator's license and confirmed through a phone call with the Administrator that he did not possess an NHA license. The Administrator also confirmed in a separate interview that he did not have a license. A verification search through the California Department of Public Health (CDPH) confirmed the absence of an NHA license for the Administrator.
Failure to Document and Address Medication Irregularities
Penalty
Summary
The facility failed to ensure that irregularities noted by the pharmacist during the drug regimen review (DRR) for two residents were properly documented and communicated to the attending physician, medical director, and Director of Nursing (DON). Specifically, the pharmacist recommended tapering Trazodone for one resident and lowering the dose of Quetiapine for another resident. However, there was no documentation or follow-up on these recommendations, and the pharmacist did not provide a separate, written report of the irregularities as required by the facility's policies and procedures. Additionally, the attending physician did not document any review or action taken regarding the identified irregularities in the residents' medical records. During interviews, the Pharmacy Tech and Pharmacy Consultant confirmed the process of monthly DRR and acknowledged the need for improved documentation and communication. The pharmacist's recommendations were recorded in an Excel spreadsheet, but this method lacked the necessary detail and formal reporting required to ensure proper follow-up and action. The failure to document and address these medication irregularities had the potential to result in adverse effects on the residents' health and well-being.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 57 was informed in advance by the physician or other practitioner about the use, risks, and benefits of the psychotropic medication Diazepam, as well as other medication options. This deficiency was observed during a medication administration on 2/29/24, when Licensed Nurse H administered a 5 mg tablet of Diazepam to Resident 57 without prior informed consent. The informed consent was only obtained later on the same day, as confirmed by the Chief Nursing Officer (CNO) during a record review and interview on 3/1/24. The facility's policy, dated 3/30/23, requires that informed consent be obtained and documented by the physician before initiating the administration of psychoactive drugs. Additionally, Title 22 CCR Section 72528(c) mandates that facility staff verify the presence of such documentation in the patient's health record prior to starting the therapy. The failure to adhere to these protocols deprived Resident 57 of her right to be fully informed about her medication and treatment options, which is essential for making an informed decision about her care.
Failure to Complete Smoking Assessment on Admission
Penalty
Summary
The facility failed to complete a smoking assessment on admission for one of six residents to determine the resident's functional capacity to safely smoke with or without assistance and the need for protective devices. This deficiency was identified during an observation and interview where the resident was seen smoking outside the facility with a security staff member. The resident had a portable ashtray positioned by the right side of her wheelchair and stated she smoked after meals outside the facility. When asked, the Licensed Nurse (LN) could not provide the smoking assessment and referred to the Health Information Management (HIM)/Information Technician (IT) to print out the document from the facility's electronic medical records. The resident herself could not confirm if she had undergone a smoking assessment for safety purposes. A review of the facility's policy on resident assessment indicated that a comprehensive assessment of the resident's needs should be made by the interdisciplinary team within fourteen or eight days of the resident's admission. This assessment is intended to describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity. The information derived from the comprehensive assessment enables staff to plan care that allows the resident to reach their highest practicable level of functioning, including determining the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities. However, in this case, the facility failed to adhere to its policy, resulting in the potential for inappropriate care and supervision, as well as a fire hazard to both the resident and the facility.
Failure to Provide Safe Smoking Environment and Protective Equipment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide necessary assistive devices to a resident who smoked. During observations and interviews, it was noted that the resident smoked outside the facility with a portable ashtray positioned by her wheelchair. The resident's cigarettes and lighter were kept in a locked medication room, and she was accompanied by staff during smoke breaks. However, the resident was not wearing a protective apron during these breaks, and the staff could not provide a smoking assessment for the resident. Additionally, the blanket proposed as a protective apron was found to be unsuitable for preventing cigarette burns. The designated smoking area was observed to be inconsistently defined, with discrepancies in its distance from the building and emergency exit door. The facility's smoking policy required a written order for smoking and designated smoking areas but did not include the need for a smoking assessment or adaptive equipment. Interviews with staff and a customer service representative confirmed that the blanket intended for use as a protective apron was not appropriate for this purpose. The facility's failure to provide a safe smoking environment and necessary protective equipment posed a risk of cigarette burns and fire hazards.
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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