Katherine Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Salinas, California.
- Location
- 315 Alameda Avenue, Salinas, California 93901
- CMS Provider Number
- 055311
- Inspections on file
- 20
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Katherine Healthcare during CMS and state inspections, most recent first.
A resident’s controlled medication, Lorazepam 0.5 mg, went missing from a medication cart, with the narcotic record showing 19 tablets remaining but the bubble pack unable to be located during a shift-change narcotic count by two RNs. The medication had been verified as present and correctly counted by two RNs on the prior shift, and a torn label from the missing Lorazepam bubble pack was later found in the bedside table of an empty room, but the tablets were not recovered. As a result, the resident missed two scheduled doses, and the incident constituted misappropriation of the resident’s property in violation of facility policies on controlled substances, resident rights, and investigation of theft/misappropriation.
A resident with a physician’s order for daily lorazepam 0.5 mg for anxiety did not receive two ordered doses when staff discovered the lorazepam bubble pack missing during a narcotic count. An RN and the night shift nurse searched multiple medication carts and resident rooms but could not locate the controlled medication, and the pharmacy reported a refill would be too early without DON authorization. The MAR reflected the missed administrations, the DON confirmed the medication had been missing since a prior night shift and that the resident missed two morning doses, and there was no lorazepam available in any of the E-kits, contrary to the facility’s controlled substances policy.
The facility failed to implement proper infection control practices, including hand hygiene and glove changes, and lacked a comprehensive water management program to prevent water-borne contaminants like Legionella. These deficiencies were confirmed through staff interviews and policy reviews.
The facility failed to ensure the proper use of bed rails for five residents, including not following manufacturers' recommendations, not offering alternatives, not completing entrapment risk assessments, not updating assessments, and not obtaining physician's orders.
The facility failed to maintain kitchen hygiene and food safety standards, with expired food, improper hair net use, unsanitized thermometers, and a rusty ice storage bin screw causing potential contamination. Staff acknowledged these lapses during interviews.
The facility failed to ensure that the daily staffing information posted was current, with outdated postings observed on both the first and second floors. The Director of Staff Development, responsible for updating the postings, was on vacation, leading to the oversight. The Administrator confirmed the postings should reflect the current date.
The facility failed to conduct and act on drug regimen reviews for three residents. An iMRR was not performed for a resident after multiple falls, and the CP did not identify irregularities in monitoring heart rates and blood pressures for two residents. Additionally, the facility did not act on a CP's recommendation to administer Coreg with food for another resident.
The facility failed to ensure residents received necessary care and services as per medical orders. A resident's pacemaker information was missing, and routine check-ups were not scheduled. Multiple residents' medication refusals were not reported to physicians. LVNs did not follow physician orders for treatments and medication administration, leading to potential health risks.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their assessments. Issues included unrecorded hospice care, pressure injuries, nutritional interventions, and behaviors of rejecting care. These inaccuracies were confirmed by the MDS coordinator and social service director during record reviews.
The facility failed to ensure accurate PASARR screenings for two residents, leading to potential inaccuracies in care. One resident with bipolar disorder and major depressive disorder exhibited disruptive behaviors, but no new PASARR was conducted. Another resident with anxiety, depression, and bipolar disorder was not marked for these conditions in the PASARR screening.
The facility failed to accommodate a resident's needs by not placing his urinal within reach, despite his medical conditions and repeated complaints. Staff attempts to reposition the urinal were unsuccessful, and the care plan did not address the issue adequately.
The facility failed to complete and transmit the MDS discharge assessment in a timely manner for a resident. The MDS coordinator and DON confirmed the assessment was completed and transmitted beyond the required 14-day period after discharge, violating the RAI 3.0 User's Manual guidelines.
A resident with chronic respiratory conditions was found to be receiving oxygen at levels lower than the prescribed 3 LPM on two separate occasions. The facility's policy requires adherence to physician's orders for oxygen administration, but this was not followed, leading to a deficiency in the resident's care.
The facility failed to provide sufficient nursing staff on weekends, with CNA DHPPD falling below the required 2.4 hours per patient day on specific dates. The DSD confirmed that CNAs who called off were not replaced, leading to short staffing.
The facility failed to ensure that two residents were free from unnecessary medications. One resident's Carvedilol order lacked hold parameters for blood pressure and heart rate, and another resident's gabapentin order had an incorrect indication, while their amiodarone order lacked heart rate monitoring. These discrepancies were confirmed by the DON and CP, highlighting a failure to adhere to the facility's policies.
The facility failed to ensure a resident was free from unnecessary psychotropic medications by not considering a Gradual Dose Reduction (GDR) after multiple falls, not completing a baseline AIMS for aripiprazole use, and lacking specific target symptoms, interventions, and potential adverse effects in the care plan for bipolar disorder.
The facility had an 11.11% medication error rate when three medication errors were observed during a medication pass for two residents. Carvedilol and Metformin were administered without food, and magnesium oxide and ferrous sulfate were given simultaneously, contrary to manufacturer's specifications and facility policy.
The facility failed to ensure proper medication storage and labeling, as an opened multi-dose insulin vial and an insulin pre-filled pen were found without labeling for their open dates. Additionally, an expired insulin pen and four expired over-the-counter medications were identified. The facility's policy required proper labeling and disposal of outdated drugs, which was not followed.
The facility failed to ensure proper handling of hazardous medications and prevent drug-drug interactions for two residents. Two nurses were observed preparing hazardous medications without gloves, and two residents received medications concurrently that could reduce the effectiveness of their treatments.
The facility failed to maintain accurate documentation for a resident's death. The resident, with multiple serious medical conditions, passed away, but the pronouncement of death was not properly documented. The nurse's notes were inconsistent and lacked a detailed assessment, date, time, and the name of the nurse who pronounced the death. The facility's policy on documenting the death was not followed.
The facility failed to ensure that two residents were offered and/or received the pneumococcal conjugate vaccine 20 (PCV20). The infection preventionist confirmed that both residents had a history of receiving the pneumococcal polysaccharide vaccine (PPSV23) but were not offered the PCV20 as required by the facility's policy and CDC recommendations.
The facility failed to report allegations of verbal and financial abuse involving two residents to Adult Protective Services (APS) as required by their abuse policy. One resident alleged verbal abuse by a CNA, and another reported financial abuse by a caregiver prior to admission. Both incidents were not reported to APS, despite being documented and confirmed by staff.
Several multi-resident rooms in the facility provided less than the required 80 square feet per resident. Despite this, staff and residents were able to move freely, and residents received adequate care without expressing concerns about the room sizes.
A resident with major depressive disorder and bipolar disorder was observed by an LPN yelling and pushing another resident's wheelchair with force. The incident was not reported to the facility's abuse coordinator or relevant authorities, as required by the facility's policy.
Misappropriation of Resident’s Controlled Lorazepam and Resulting Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a controlled medication, Lorazepam 0.5 mg, went missing from the medication cart, resulting in missed doses. During a narcotic count at shift change on 11/30/25, RN A and the night shift nurse (RN B) were unable to locate the resident’s Lorazepam bubble pack, which should have contained 19 tablets according to the narcotic record. RN A reported that three medication carts and 48 resident rooms were checked, but the medication could not be found, and confirmed that the resident missed two scheduled doses on 11/30/25 and 12/1/25. The facility’s controlled substances policy required controlled medications to be reconciled upon receipt, administration, disposition, and at the end of each shift, with incoming and outgoing nurses jointly determining the count. Interviews and record review established that the Lorazepam had been present and accounted for at the end of the prior shift. RN B stated that at the start of her night shift on 11/29/25 all narcotics were accounted for, and at the end of her shift RN A discovered the Lorazepam bubble pack was missing, despite the narcotic record book indicating 19 tablets remained. RN C, who worked the evening shift before RN B, confirmed that all narcotics, including the resident’s Lorazepam, were accounted for during the count with RN B, and both signed the narcotic book indicating no discrepancies. The MDS Coordinator later found a torn medication label from the missing Lorazepam bubble pack in the bottom drawer of a bedside table in an empty room, but the 19 tablets were not recovered. The DON confirmed that the medication had been accounted for on 11/29/25, was missing during RN B’s night shift, and that the torn label matched the missing Lorazepam, constituting misappropriation of the resident’s property in violation of the facility’s resident rights and misappropriation policies.
Failure to Account for and Provide Ordered Lorazepam Doses
Penalty
Summary
The facility failed to provide accurate accountability and timely availability of a controlled medication, lorazepam 0.5 mg, for one resident with an order for daily administration for anxiety. During a narcotic count on one shift, RN A and the night shift nurse (RN B) were unable to locate the resident’s lorazepam bubble pack in the Station 2 medication cart. RN A reported that three medication carts and 48 resident rooms were searched, but the medication could not be found. RN A contacted the pharmacy for a replacement, and the pharmacy indicated the refill was too early and would require DON authorization. As a result, the resident’s ordered lorazepam doses were not available for administration on two consecutive mornings. Review of the physician’s order dated 9/24/25 showed the resident was to receive lorazepam 0.5 mg by mouth once daily for anxiety, evidenced by repetitive questions and verbalizations. The MAR documented that lorazepam was not administered on two specified dates, and the DON confirmed that the medication had been missing since RN B’s night shift and that the resident missed those two morning doses. During an observation and interview, the DON also confirmed there was no lorazepam available in any of the five E-kits. The facility’s policy on controlled substances required compliance with all laws and regulations related to handling, storage, disposal, and documentation of controlled medications, but the missing lorazepam and resulting missed doses demonstrated a failure to meet this requirement for this resident.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Licensed vocational nurse A (LVN A) contaminated clean gauzes and Silver Alginate dressing by handling them with gloved hands that had touched a ring of keys and the treatment cart. Additionally, LVN A wore the same gloves while moving between residents' rooms, further risking cross-contamination. Certified nursing assistant H (CNA H) did not sanitize her hands before serving a lunch tray to a resident, and a restorative nurse assistant (RNA) failed to perform hand hygiene between assisting multiple residents during meal times. Licensed vocational nurse C (LVN C) also did not change gloves after touching a privacy curtain and continued to use the contaminated gloves for wound treatment. The facility also lacked a comprehensive water management program to prevent water-borne contaminants such as Legionella. The maintenance supervisor (MS) was unaware of the necessary steps to prevent the spread of water-borne contaminants and did not conduct a Legionella Risk Assessment for the current year. The outside water contractor confirmed that their monthly checks did not include testing for Legionella or potable water quality. These deficiencies were confirmed through interviews with the involved staff and the infection preventionist (IP G), as well as a review of the facility's policies. The facility's failure to adhere to proper infection control practices and maintain a water management program had the potential to spread infections within the facility.
Improper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed or side rails for five residents. There was no documentation indicating that the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the beds and side rails for all five residents. Additionally, there was no documentation that alternatives were offered or attempted prior to the use of bed or side rails for three of the residents. Furthermore, there was no entrapment risk assessment completed prior to the use of bed or side rails for two residents, and one resident did not have an updated bed or side rail assessment form completed. Lastly, one resident did not have a physician's order indicating the use of bed or side rails. During observations and interviews, it was confirmed that the bed rails were in the upright position for all five residents. The maintenance supervisor admitted that bed rails were installed without following the manufacturers' specifications and without proper documentation. The director of nursing confirmed that the facility's beds were old and lacked the manufacturer's handbook. The facility's policy and procedure indicated that manufacturer instructions should be adhered to and that residents should be periodically checked for safety relative to side rail use. The minimum data set coordinator and the director of nursing confirmed that there was no documentation indicating that alternatives were offered or attempted prior to the use of bed rails for three residents. Additionally, there was no entrapment risk assessment completed for two residents, and one resident's bed rail assessment was not updated quarterly. The director of nursing also confirmed that a physician's order should be obtained prior to the installation of bed rails, which was not done for one resident.
Hygiene and Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to maintain hygiene in the kitchen and ensure food was stored in accordance with professional standards for food safety. Observations revealed past use-by date food, rotten bananas, and dented cans in the freezer and on the shelves. Specifically, a container of Blue Bunny sherbet, frozen cookie dough, and cans of lemon pudding were found to be expired or damaged. Additionally, seven bananas had black spots. During interviews, the Dietary Director acknowledged these issues and stated that the food items would be discarded. The facility's policies on washing and handling produce and dented cans were not followed as required. Further observations in the kitchen showed that staff did not adhere to personal hygiene standards. Cook K and dietary aid L had hair out of their hair nets, and the maintenance director did not wash his hands before handling the ice machine. The dietary director also failed to sanitize thermometers before checking food temperatures. Additionally, a rusty screw in the ice storage bin caused rusty water to drip onto the ice, and the ice machine lacked an air gap, leading to potential contamination. These observations were confirmed through interviews with the staff involved, who acknowledged the lapses in following the facility's policies on personal hygiene and equipment maintenance.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily staffing information posted was current, which could result in nurse staffing misinformation to residents, families, and visitors. During facility rounds on 4/22/2024, it was observed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) forms posted on the first and second floors were outdated by 17 and 20 days, respectively. The Director of Staff Development (DSD) confirmed that she was responsible for updating the DHPPD postings but had been on vacation, leading to the outdated postings. The Administrator (ADM) also confirmed the outdated postings and acknowledged that the DHPPD should reflect the current date. The facility's policy, dated 7/2016, requires daily posting of the number of nursing personnel responsible for providing direct care to residents. Additionally, the Centers for Medicare and Medicaid Services Compliance Group document, dated 4/30/2021, mandates that the posted nurse staffing information must include the facility name and current date, and be placed in a prominent location accessible to residents and visitors. The failure to update the DHPPD postings as required was confirmed by both the DSD and ADM during interviews conducted on 4/24/2024.
Failure to Conduct and Act on Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that drug regimen reviews were conducted and acted upon for three residents. For Resident 11, an Interim Medication Regimen Review (iMRR) was not performed after multiple falls, despite the facility's policy requiring such reviews after significant changes. Additionally, the Consultant Pharmacist (CP) did not identify and report irregularities related to the lack of consistent monitoring of Resident 11's heart rate, which was necessary due to the resident's atrial fibrillation and use of Amiodarone. The heart rate was monitored inconsistently, with significant gaps in the monitoring schedule, which was verified by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The CP confirmed that the iMRR should have been done and that the heart rate monitoring was inadequate. For Resident 15, the CP also failed to identify and report irregularities related to the lack of blood pressure and heart rate monitoring. For Resident 31, the facility did not act on the CP's recommendation to administer Coreg with food to minimize the risk of orthostatic hypotension. The CP had recommended changing the administration time to align with the resident's breakfast time, but this recommendation was not implemented. The DON confirmed that the recommendation was not acted upon. These failures indicate a lack of adherence to the facility's policies and procedures for medication regimen reviews, potentially compromising the residents' health outcomes.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services as per their medical orders and preferences. For Resident 1, the facility did not have information on the resident's cardiologist and pacemaker, and did not schedule routine check-ups for the pacemaker. LVN A, who worked with Resident 1 for a year, was unaware of the resident's pacemaker, indicating a lack of proper documentation and communication within the facility. The Director of Nursing (DON) confirmed that the necessary information was missing from Resident 1's medical record and acknowledged the oversight in scheduling routine check-ups for the pacemaker. Resident 7 repeatedly refused her prescribed medications, including vitamin D3, cyanocobalamin, and levothyroxine, over several months. However, there was no documentation indicating that the physician was notified about these refusals. The DON confirmed that the licensed nurses should have informed the physician about Resident 7's medication refusals, as per the facility's policy. Similarly, Resident 27 also refused multiple routine medications, and the nurses failed to notify the physician about these refusals. The DON and other staff members acknowledged that the physician should have been informed about the refusals. For Resident 9, LVN A did not follow the physician's order for treating a suspected deep tissue injury on the resident's toes, applying povidone iodine instead of the prescribed skin prep. Additionally, LVN B administered Cyclosporine 0.05% eyedrops to Resident 145 without a physician's order indicating the strength of the medication. Lastly, LVN B administered Amlodipine to Resident 22 without adhering to the blood pressure parameters set by the physician, resulting in multiple instances where the medication was given despite the blood pressure being below the specified threshold. These actions and inactions highlight significant lapses in following physician orders and proper documentation, potentially jeopardizing the residents' health and well-being.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments. For Resident 34, two different MDS assessments did not reflect hospice care, a facility-acquired pressure injury, nutritional intervention, and the physician orders for life-sustaining treatment (POLST). The MDS coordinator confirmed these omissions during a review of the resident's records. Additionally, Resident 27's behavior of rejecting care was not accurately coded in the MDS, as confirmed by the social service director who did not review the medication administration record (MAR) before completing the assessment. Resident 17's left-sided weakness was not reflected in the MDS assessment, despite being observed by the MDS coordinator during a review. The coordinator acknowledged that the limitation of the resident's upper and lower extremities should have been coded. Similarly, Resident 7's behavior of rejecting care, such as refusing medications, was not accurately coded in the MDS. The social service director confirmed that the MDS should have indicated the resident's refusal of care during the observation period. These inaccuracies in the MDS assessments resulted in potential impacts on the residents' care. The Long-Term Care Facility Resident Assessment Instrument (RAI) manual emphasizes the importance of validating information for accuracy during the observation period. The facility's interdisciplinary team is responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete accurate assessments.
Failure to Accurately Complete PASARR Screenings
Penalty
Summary
The facility failed to ensure that the pre-admission screening and resident review (PASARR) was accurately completed for two residents, leading to potential inaccuracies in the care and services provided. Resident 27 was admitted with diagnoses including bipolar disorder, major depressive disorder, and other psychoactive substance abuse. However, the PASARR Level I Screening completed at the hospital indicated no mental illness. Despite exhibiting disruptive behaviors and refusing medications, the facility did not conduct a new PASARR screening. Both the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged the oversight and confirmed that a new PASARR should have been completed to reflect Resident 27's mental health diagnoses and behaviors. Similarly, Resident 21 was admitted with diagnoses of anxiety, depression, and bipolar disorder, but the PASARR Level I Screening did not mark these mental disorders. The DON confirmed that Resident 21 should have been marked for having diagnosed mental disorders. The facility's policy mandates that all new admissions and readmissions are screened for mental disorders and intellectual disabilities, and that a new PASARR should be completed promptly after a significant change in a resident's mental or physical condition. The failure to accurately complete the PASARR screenings for these residents indicates a lapse in adherence to this policy.
Failure to Accommodate Resident's Needs for Urinal Placement
Penalty
Summary
The facility failed to ensure that Resident 17's needs were accommodated when his urinal was not placed within reach. Resident 17, who has a history of urinary tract infection, major depressive disorder, hemiplegia affecting the nondominant side, and cerebral infarction, was observed multiple times struggling to reach his urinal. Despite being cognitively intact, as indicated by a BIMS score of 14, Resident 17 was unable to access the urinal due to its placement on the transfer pole, which was confirmed by both a CNA and an LVN. The resident repeatedly complained about the issue, but the staff's attempts to reposition the urinal were unsuccessful. The Director of Nursing (DON) acknowledged awareness of the problem but had not yet checked with Resident 17. The DON mentioned that the urinal should be placed on the bed frame within the resident's reach, but it was not done due to infection control concerns. The care plan for Resident 17 noted non-compliance with urinal use but did not address the contributing factors or provide interventions to resolve the issue. The facility's policy on accommodating needs emphasizes maintaining residents' independence and dignity, but this was not achieved in Resident 17's case.
Late Submission of MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) discharge assessment in a timely manner for one resident. Resident 12 was admitted to the facility and later discharged. The MDS coordinator confirmed that the discharge assessment for Resident 12 was completed and transmitted late, beyond the required 14-day period after discharge. The Director of Nursing (DON) also confirmed the delay, noting that the MDS coordinator requested her to sign the discharge assessment after the deadline had passed. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual specifies that discharge assessments must be completed and submitted within 14 days of the discharge date, which was not adhered to in this case.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure proper care and treatment services for oxygen use for a resident with chronic respiratory conditions. Resident 15, who was admitted with diagnoses including COPD, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and dependence on supplemental oxygen, had a physician's order for oxygen administration at 3 LPM via nasal cannula as needed for shortness of breath. However, during observations on two separate days, the resident was found to be receiving oxygen at levels lower than the prescribed 3 LPM. On one occasion, the oxygen was set at 2.5 LPM, and on another, it was set at 2 LPM. These observations were confirmed by a registered nurse who reviewed the resident's order summary report and acknowledged that the oxygen levels did not comply with the physician's order. The facility's policy and procedure for oxygen administration, which was last revised in October 2010, requires verification of a physician's order for the procedure and adherence to the specified oxygen levels. Despite this policy, the licensed nurses did not follow the physician's order for Resident 15's oxygen administration, leading to a deficiency in the resident's care. The registered nurse confirmed that the oxygen should have been administered at the prescribed 3 LPM, highlighting a failure in following the established guidelines for safe oxygen administration.
Insufficient Nursing Staff on Weekends
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends, as evidenced by the review of the Census and Direct Care Service Hours Per Patient Day (DHPPD) from January through March 2024. On specific dates, the actual Certified Nursing Assistant (CNA) DHPPD fell below the required 2.4 hours per patient day. Specifically, on January 6 and 7, the CNA DHPPD were 2.28 and 2.39, respectively. Additionally, on February 17, the overall DHPPD was 3.35, below the required 3.5, and the CNA DHPPD was 2.0. These deficiencies were confirmed by the Director of Staff Development (DSD) during an interview, who stated that CNAs who called off on those dates were not replaced, leading to short staffing. The DSD confirmed that the Director of Nursing (DON) was responsible for the licensed nurses' schedule, while CNA J handled the CNA schedule, including weekends. The DSD acknowledged that the actual DHPPD and CNA DHPPD on the specified dates were below the required staffing levels. The short staffing was attributed to a CNA scheduled to work 12 hours who got sick and was not replaced. The All Facilities Letter (AFL) 21-11 mandates a minimum of 3.5 DHPPD, with 2.4 hours performed by CNAs, and the facility failed to meet these requirements on the mentioned dates.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two out of five residents were free from unnecessary medications. For Resident 15, an order for Carvedilol did not include hold parameters relevant to blood pressure and heart rate, and these vital signs were last monitored a month prior. Both the Director of Nursing (DON) and the Consultant Pharmacist (CP) confirmed the absence of hold parameters and inconsistent monitoring of blood pressure and heart rate, which are necessary due to the potential adverse effects of Carvedilol, such as bradycardia and hypotension. The facility's policy requires vital signs to be checked prior to administering medications, which was not adhered to in this case. For Resident 11, an order for gabapentin had an incorrect indication of parkinsonism, and an order for amiodarone did not include heart rate monitoring. The DON and CP verified these discrepancies, noting that heart rate monitoring is essential due to the risk of bradycardia associated with amiodarone. The facility's policy mandates that the provider pharmacy screen new medication orders for key parameters, including appropriate indications, which was not followed. These failures had the potential for inadequate care and unrecognized side effects of the medications.
Failure to Ensure Resident Was Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications. Specifically, the facility did not consider a Gradual Dose Reduction (GDR) of psychotropic medications after the resident experienced multiple falls. The resident, diagnosed with insomnia, bipolar disorder, anxiety disorder, and major depressive disorder, had physician orders for paroxetine, trazodone, and aripiprazole. Despite the resident falling on several occasions, the Director of Nursing (DON) confirmed that no GDR was attempted, which was against the facility's policy and procedure for antipsychotic medication use. Additionally, the facility did not complete a baseline Abnormal Involuntary Movement Scale (AIMS) for the resident's use of aripiprazole, as verified by the DON and Social Services Director (SSD). The care plan for the resident's bipolar disorder also lacked specific target symptoms, interventions, and potential adverse effects. These deficiencies were confirmed during interviews and record reviews with the DON and SSD, and they were in violation of the facility's policies and procedures for psychotropic medication use.
Medication Administration Errors
Penalty
Summary
The facility had an 11.11% medication error rate when three medication errors out of 27 opportunities were observed during a medication pass for two residents. For Resident 145, Carvedilol was administered without food, and magnesium oxide and ferrous sulfate were given simultaneously, which could affect the absorption of the iron supplement. Observations and interviews confirmed that these medications were not administered according to the manufacturer's specifications, potentially compromising their therapeutic effects. For Resident 38, Metformin was administered without food, despite the manufacturer's instructions to give it with a meal to minimize gastrointestinal upset. The medication was scheduled at 4 p.m., but the resident's dinner was not until 5 p.m., and no snack was provided prior to the medication administration. These practices were not in line with the facility's policy to administer medications in a manner that enhances their therapeutic effect and prevents interactions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling of medications. During an observation and interview with an LVN, an opened multi-dose insulin vial and an insulin pre-filled pen were found without labeling for their open dates. The manufacturing labels indicated that the insulin vial should be discarded 31 days after opening and the insulin pen 56 days after first use. Additionally, an expired insulin pen and four expired over-the-counter medications were found during another observation and interview with an LVN. The expired medications included a pre-filled insulin pen, a bottle of Calcium + D3 tablets, a bottle of a vitamin and mineral supplement, a bottle of allergy medication, and a bottle of CoQ10 softgels. The facility's policy and procedure for the storage of medications indicated that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed. The observations and interviews revealed that the facility did not adhere to these policies, leading to the potential for residents to receive medications with reduced efficacy.
Failure to Handle Hazardous Medications and Prevent Drug-Drug Interactions
Penalty
Summary
The facility failed to ensure the correct handling of hazardous medications and the safe and effective use of medications for two residents. Two licensed nurses were observed preparing hazardous medications without gloves, despite the medications being clearly labeled as hazardous and requiring gloves for handling. The nurses admitted to not knowing the proper procedures for handling these medications, which could lead to harmful exposure through skin absorption. The facility's policy indicated that staff should be trained and competent in handling hazardous drugs, but this was not followed in practice. Additionally, the facility failed to administer medications in a manner that would prevent drug-drug interactions for two residents. Resident 145 received ferrous sulfate and magnesium oxide at the same time, which could lead to decreased absorption of iron. Similarly, Resident 10 received ferrous sulfate and Calcium-Vitamin D at the same time, which could also reduce iron absorption. Both interactions were noted to have significant risk ratings and required therapy modification according to a nationally recognized drug information resource. The facility's policy on administering medications emphasized the importance of preventing potential medication interactions, but this was not adhered to in these cases.
Failure to Properly Document Resident's Death
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for one resident when the pronouncement of death was not properly documented. Resident 41, who had multiple serious medical conditions including palliative care, atherosclerotic heart disease, hemiplegia, hemiparesis following a stroke, and dysphagia, passed away. The progress notes indicated the resident's death at 5:40 a.m., but detailed documentation about the resident's status before death and the pronouncement of death was lacking. The nurse's notes were inconsistent and did not include a detailed assessment, date, time, and the name of the nurse who pronounced the death. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the deficiencies in the documentation. The MDSC noted that the registered nurse should have documented a detailed assessment and the pronouncement of death, while the DON acknowledged that the nurse's documentation was confusing and not well-organized. The facility's policy on documenting the death of a resident was not followed, as it required appropriate documentation of all information pertaining to a resident's death, including the date, time, and the name and title of the individual pronouncing the resident dead.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, Resident 10 and Resident 35, were offered and/or received the pneumococcal conjugate vaccine 20 (PCV20). During an interview and record review, the infection preventionist (IP G) confirmed that Resident 10, who was admitted on an unspecified date, had a history of receiving the pneumococcal polysaccharide vaccine (PPSV23) on June 26, 2022. However, IP G missed offering the PCV20 to Resident 10 when reviewing her immunization record. Similarly, Resident 35, who was admitted on an unspecified date, had a history of receiving PPSV23 on March 19, 2019, but was not offered the PCV20 by IP G during the review of his immunization records. The facility's policy and procedure, revised in October 2019, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. The policy also required assessments of pneumococcal vaccination status within five working days of a resident's admission. According to the CDC's recommendations reviewed on February 13, 2023, adults aged 65 years or older who have only received PPSV23 should be given one dose of PCV15 or PCV20, administered at least one year after the most recent PPSV23 vaccination. The failure to follow these guidelines led to the deficiency identified in the report.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to implement their abuse policy for two residents, resulting in unreported allegations of abuse. Resident 19, who has multiple diagnoses including Type 2 Diabetes Mellitus, Dysarthria, Anarthria, Depression, Insomnia, and Schizophrenia, alleged verbal abuse by a Certified Nurse Assistant (CNA). The CNA reportedly made a joke about Resident 19 eating too much like a pig, which led to vomiting. Although the incident was documented and reported to the Medical Director, Responsible Party, Ombudsman, and Department of Health, it was not reported to Adult Protective Services (APS) as required by the facility's policy. The Administrator confirmed during an interview that the incident was not reported to APS. Resident 146, who reported financial abuse by a caregiver prior to admission, also had his allegation unreported to APS. The resident stated that the caregiver took his bank card and spent his money without consent. The Social Service Director (SSD) confirmed that the allegation should have been reported to APS according to the facility's abuse policy. The facility's policy, dated July 2017, mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to APS, but this was not followed in the cases of Resident 19 and Resident 146.
Deficiency in Room Square Footage
Penalty
Summary
The report identifies that several multi-resident rooms in the facility provided less than the required 80 square feet per resident. Specifically, Room 3 had 74.25 square feet per resident, Room 10 had 78.48 square feet per resident, and Room 23 had 76.30 square feet per resident. Despite these measurements, it was observed that the staff and residents were able to move freely within the rooms, and the residents received adequate care. Both staff and residents did not express concerns regarding the square footage of the rooms.
Failure to Report Abuse Incident
Penalty
Summary
The facility failed to follow its abuse reporting policy for one of the residents. The incident involved a resident with major depressive disorder and bipolar disorder, who was observed by a licensed nurse (LN A) yelling and cursing at another resident before pushing the other resident's wheelchair with such force that it rolled approximately 20 feet. Despite the severity of the incident, there was no documentation indicating that LN A reported the incident to the facility's abuse coordinator or any other relevant authorities as required by the facility's policy. During interviews, another licensed nurse (LN B) confirmed that the actions of the resident constituted abuse and should have been reported. LN B also confirmed that there was no documentation of the incident being reported to the abuse coordinator, the Ombudsman, the California Department of Public Health (CDPH), or the police. LN A, when contacted, vaguely remembered the incident but did not recall if she reported it. The facility's policy mandates that all alleged violations involving abuse must be reported to several authorities, including the state licensing agency, the Ombudsman, and law enforcement officials.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
