Kern Valley Healthcare District Dp Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Isabella, California.
- Location
- 6412 Laurel Ave, Lake Isabella, California 93240
- CMS Provider Number
- 555517
- Inspections on file
- 35
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Kern Valley Healthcare District Dp Snf during CMS and state inspections, most recent first.
A cognitively intact resident with a history of pneumonia had physician orders for a NAS pureed diet with nectar‑thick liquids following a video swallow evaluation that recommended minced & moist texture and thin liquids by cup in a chin‑tuck position or nectar‑thick liquids. The care plan noted non‑compliance with diet recommendations and directed staff to educate on risks and benefits, monitor for aspiration, and respect the resident’s right to refuse. IDT documentation showed the NP explained that non‑compliance with the ordered diet could lead to aspiration and that the resident stated she did not care if this was what killed her. Despite the resident’s clear refusal of pureed foods and thickened liquids, staff continued to enforce the ordered diet, including restricting participation in an activity to items that met texture requirements, while the resident left pureed meals untouched and reported only eating desserts. The DON stated the facility had no waivers for refusal of therapeutic diets and did not offer a minced & moist texture, even though facility policy affirmed patients’ rights to make decisions about care and to refuse treatment.
A resident with severely impaired cognition experienced a fall and was found on the bathroom floor, with documentation showing that the NP and DON were notified. Review of nursing notes and the facility’s fall TRIPS form showed no documentation that the resident’s family was notified, and the family notification section was marked “NA,” which the DON could not explain. This failure occurred despite a facility policy requiring licensed staff to promptly notify the resident’s physician and family/representative of any accident involving the resident.
A resident with moderately impaired cognition, extremity impairments, and total dependence for transfers was found sitting naked on the floor by staff, yet the Charge Nurse did not treat the event as a fall, did not perform or document timely vital signs or neuro checks, and did not immediately report the incident to a supervisor. Multiple CNAs reported that the resident could not have gotten to the floor independently, that they assisted in lifting the resident into a Geri-chair, and that the Charge Nurse did not assess the resident and told them not to say anything about the incident. A later assessment by an LVN, prompted by reports to social services, identified a new bruise on the resident’s forearm and led to completion of unwitnessed fall documentation hours after the event, while the Charge Nurse’s own late entry note, written days later, acknowledged that she chose not to report or document the incident as a fall at the time.
A resident with a documented history of a fall had a care plan intervention requiring fall mats on both sides of the bed when in bed. During observation and concurrent interview and record review, the resident was found in bed with only one fall mat in place. An LVN confirmed that the care plan called for fall mats on both sides but that only one was provided, despite a facility fall prevention policy stating that residents at risk for falls must have care plans incorporating appropriate safety interventions.
A resident was found unclothed and sitting on the floor next to the bed, confused and hallucinating, and was placed in a Geri-chair near the nurses’ station without documented vital signs, neuro checks, or a full assessment at the time of the incident. CNAs later reported seeing the charge nurse lifting the resident from the floor and being told not to say anything, and the event was not initially reported as a fall or documented on a fall form. An LVN learned of the incident hours later, completed unwitnessed fall documentation, vitals, and skin assessment, and noted a new bruise on the resident’s forearm; the first neuro checks were not started until several hours after the fall. The charge nurse acknowledged in interview that she did not complete neuro checks, vital signs, or a full assessment at the time and documented her nursing note as a late entry days later, contrary to the facility’s Neurological Evaluation policy requiring immediate assessment and scheduled neuro evaluations after witnessed or unwitnessed falls.
A resident with a history of stroke and intact cognition experienced sudden right-sided weakness and slurred speech, indicating a possible stroke. Despite reporting these symptoms and requesting help, staff only contacted the NP, who instructed them to monitor the resident and did not assess her in person, citing her DNR status. No escalation to the MD occurred, and the resident's POLST allowed for selective treatment. The resident was eventually transferred to the hospital after significant decline and was diagnosed with an intracranial hemorrhage, resulting in a marked loss of functional abilities.
The facility did not ensure that residents were seen face-to-face by an MD or NP at the required intervals, as confirmed by interviews and record reviews. Multiple residents reported not seeing their MD or NP for extended periods, and staff acknowledged ongoing complaints about missed visits. Documentation showed delays and inconsistencies in assessment records, failing to meet the facility's policy for regular physician visits and timely progress note entries.
The facility did not report an allegation of sexual abuse involving two residents to CDPH, the Ombudsman, and LLE within the required 24-hour period, and failed to complete a follow-up investigative report within five working days, as confirmed by the DON and facility records.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not ensure an RN was on duty for at least eight hours each day, as required, with multiple days showing insufficient or no RN coverage according to staffing records. The Staffing Coordinator confirmed ongoing challenges in recruiting qualified RNs and reliance on registries when applications were lacking.
Surveyors found that food items in the dry storage room were not properly sealed or labeled with received by dates, including an open bag of powdered cocoa and multiple bottles of chocolate syrup and cans of tuna. Staff confirmed that these practices did not follow facility policy for food storage and labeling.
Two residents were found to have tab alarms in use without proper physician orders, informed consent, or care plan documentation. Staff confirmed the absence of required documentation and stated there was no facility policy or process for alarm use.
The facility did not document an unwitnessed fall or update the care plan for a resident with a history of falls and multiple health conditions, and failed to include blood sugar monitoring indicators in the care plan for another resident receiving insulin for diabetes. These actions did not follow facility policy for care planning and monitoring.
A resident with depression and intact cognition did not receive timely follow-up for dentures after admission, resulting in embarrassment, difficulty speaking, and withdrawal from social activities. Despite dental appointments and x-rays, staff failed to ensure consistent follow-up or documentation, and the resident remained without dentures, affecting her participation and well-being.
A resident reported distressing interactions with an Activities Supervisor, including exclusion from activities and uncomfortable comments. The facility did not investigate or resolve the grievance within the required timeframe, failing to follow its own grievance policy.
Two residents who were cognitively intact and had no upper extremity impairments were not allowed to fully participate in activities, such as rolling dice during games, due to the actions of the Activities Supervisor. This restriction limited their ability to make choices and discouraged their involvement in the activity program, contrary to facility policy.
A resident with a history of anxiety and bipolar disorder, and moderately impaired cognition, repeatedly attempted to leave the facility. Despite these attempts, the facility failed to complete an elopement risk evaluation or notify the physician, as required by policy. The resident eventually eloped, sustaining a hip fracture that required surgery. Interviews revealed staff did not follow the facility's elopement policy, leading to the resident's injury.
The facility failed to provide sufficient CNAs and RNAs to meet the needs of 20 residents, leading to long wait times for call lights and missed restorative nursing exercises. Interviews and records confirmed that staffing shortages, particularly during the night shift, resulted in inadequate care and unmet physician orders for RNA services.
The facility failed to monitor the temperatures of a refrigerator and freezer in the Day room, which contained drinks and ice cream, potentially leading to foodborne illnesses. The absence of thermometers was confirmed by the DON and AD, and a work order for temperature monitoring had not been addressed until the day of the survey.
The facility failed to update a resident's PASRR after a new diagnosis of Schizophrenia was made, resulting in the resident not receiving recommendations for specialized services. The Social Worker confirmed that a new PASRR Level 1 screening should have been completed.
The facility failed to communicate a resident's weightbearing status to the interdisciplinary team, resulting in a delay of rehabilitative and restorative care. The resident, who had a brace on her right leg, had not received therapy since breaking her leg six weeks prior. The PT discontinued services due to unknown weightbearing status, and the LVN confirmed no follow-up documentation was received from the orthopedic doctor. A letter from the clinic indicated weightbearing was allowed with specific conditions, but this was not communicated to the staff.
The facility failed to provide proper care for a Foley catheter for a resident, leading to potential risks of infection and injury. The catheter tubing was found on the floor under the wheelchair, despite the resident being treated for a urinary tract infection. Both the LVN and Infection Preventionist confirmed that the tubing should not have been on the floor, as per the facility's policy.
The facility failed to update and communicate a change in dietary orders for a resident, resulting in the resident receiving thickened liquids instead of the preferred thin liquids. The CNA, LVN, RD, and DON all acknowledged lapses in updating the physician's order and notifying the kitchen.
The facility failed to store oxygen tubing per policy for two residents. Observations revealed that the oxygen tubing was laying on the handrail of the bed instead of being placed in a plastic bag, as required by the facility's policy to avoid contamination and decrease the risk of infection.
Failure to Honor Cognitively Intact Resident’s Refusal of Therapeutic Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident could exercise the right to refuse a physician‑ordered therapeutic diet and meal consistency. The resident had an order for a NAS pureed diet with nectar/mildly thick liquids and no straws, based on a video swallow evaluation that recommended minced & moist food texture and thin liquids by cup in a chin‑tuck position or nectar‑thick liquids. The resident’s care plan for non‑compliance with diet and fluid recommendations included interventions to educate on risks and benefits, observe for signs and symptoms of aspiration, and respect the resident’s right to refuse recommendations. The MDS showed a BIMS score of 15, indicating the resident was cognitively intact. IDT notes documented that the NP discussed the risks of non‑compliance with the ordered pureed diet and thickened liquids, including that the resident’s pneumonia was likely caused by aspiration and that continued non‑compliance made aspiration very probable. The NP documented that the resident stated, “I don’t care if this is what kills me.” Despite this, the facility continued to enforce the ordered pureed/nectar‑thick diet without honoring the resident’s expressed refusal of the prescribed meal consistency. Nursing notes described that when the resident wanted to participate in a Christmas hot chocolate bar and treats, the DON confirmed with the provider that participation was allowed only if items met the ordered texture requirements; when this was explained, the resident declined and returned to her room. Observation showed an untouched lunch tray with multiple pureed items at the bedside, and the resident reported she did not eat the pureed foods, only desserts, and that she had told the NP she frequently had pneumonia but the diet was not changed. She stated she wanted food “the way I want it,” acknowledged she was “stubborn,” and said the facility must bring the food but knew she would not eat it. The DON stated the facility did not have waivers for residents who refuse therapeutic diets and did not offer a minced & moist texture, despite the VSE recommendation. The facility’s own Patient Rights and Responsibilities policy stated that patients have the right to make decisions regarding medical care, receive information needed to give informed consent or refuse treatment, and are responsible for their actions if they refuse treatment or do not follow physician instructions.
Failure to Notify Family of Resident Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member after the resident experienced a fall. The resident’s admission record listed the daughter as the first emergency contact and the son as the second emergency contact. The resident’s MDS dated 10/21/25 documented a BIMS score of 4, indicating severely impaired cognition. A nursing note dated 12/1/25 at 6:04 a.m. recorded that the resident was found on the bathroom floor and that the nurse practitioner and DON were notified. However, there was no documentation in the progress notes that the resident’s family was notified of the fall. During review of the facility’s TRIPS form for the fall dated 12/1/25, the section for family notification was marked “NA,” and the DON stated she did not know what “NA” meant in that context. The facility’s policy titled “Change in a Resident’s Condition or Status,” approved 9/2/15, requires licensed staff to promptly notify the resident, attending physician, and family/representative of changes in the resident’s condition or status, including when the resident is involved in any accident. Despite this policy, there was no evidence that the resident’s family or representative was notified following the fall incident, resulting in the cited deficiency.
Failure to Report and Assess Unwitnessed Fall Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect when a Charge Nurse intentionally did not report, document, or properly assess an unwitnessed fall. The resident had moderately impaired cognition with a BIMS score of 11 and was documented as having upper and lower extremity impairments, requiring total assistance for bed-to-chair transfers. On the day of the incident, a behavior note documented that the Charge Nurse found the resident attempting to get out of bed, talking about playing a game with her boys and getting a dog, and then later documented that the resident was found sitting naked on the floor, confused, hallucinating, and talking about playing a game with her boys and eating toes. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation, but the contemporaneous documentation did not show that a fall assessment, vital signs, or neuro checks were completed at that time. A later nursing note by another LVN, entered that evening as a late entry, indicated that CNAs had informed her that the resident had been found on the floor naked and hallucinating earlier in the day, and that she then notified the DON, the physician, and the resident’s son, completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. Neuro/vital sign flow sheets showed that the first neuro checks were not initiated until the early evening, several hours after the initial fall event. Another late entry nursing note, authored by the Charge Nurse days later, stated that the Charge Nurse had found the resident calmly sitting on the floor next to the bed, unclothed and playing a game with her boys, that the resident denied falling twice, was assessed with no injury noted, denied pain or discomfort, and was lifted into a Geri-chair and placed by the nursing station. This late entry note also stated that the Charge Nurse did not report the event as a fall to a supervisor and did not complete a fall form at the time because she did not believe the resident had actually fallen. Multiple CNAs reported that they observed the resident on the floor and assisted in moving the resident without seeing the Charge Nurse perform an assessment or ask the resident questions. One CNA stated that the Charge Nurse instructed them to help lift the resident into the Geri-chair and did not assess the resident before or after moving her, and that the resident was totally dependent for care and could not have gotten to the floor and sat there on her own. This CNA reported that the Charge Nurse told the CNAs not to say anything, and she felt this was neglect. Another CNA stated that the Charge Nurse said this was the second time the resident had been found on the ground, did not perform an assessment or take vital signs, and told the CNAs not to say a word about the incident; this CNA had given the resident a shower earlier and noted no skin issues at that time. A third CNA, who initially found the resident on the floor without a gown, reported the fall to the Charge Nurse, helped dress the resident and transfer her to the Geri-chair, and also stated that the Charge Nurse did not ask questions or take vital signs and told the CNAs not to say anything about the fall. The Charge Nurse later acknowledged that she did not complete vital signs or neuro checks at the time of the incident, did not document the late entry note until a couple of days later, and stated that she told the CNAs she was not reporting it as a fall. The facility’s abuse prevention policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and the resident’s care plan later identified a focus on potential for neglect related to unwitnessed falls, including interventions that all necessary documents would be completed and staff would report any unwitnessed falls.
Failure to Implement Ordered Fall Mat Interventions per Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of an actual fall. The resident’s comprehensive care plan, initiated on 12/13/25 with a focus on a prior fall, specified the intervention of placing fall mats on both sides of the bed when the resident was in bed. During an observation and concurrent interview and record review on 12/17/25 at 1:52 p.m., the resident was observed in bed with only one fall mat at the bedside. The LVN present confirmed that the care plan required fall mats on both sides of the bed but acknowledged that only one mat was in place. Review of the facility’s Fall Prevention policy, approved 11/4/09, indicated that all residents are considered at risk for falls and that the care plan should incorporate goals and interventions to provide an optimal safe environment, but the specific fall mat intervention in this resident’s care plan was not fully implemented. This failure to follow the resident’s individualized fall prevention care plan constituted the deficiency identified by the surveyors.
Failure to Perform Timely Neuro Checks and Assessment After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Neurological Evaluation policy after an unwitnessed fall for one resident. A behavior note documented that on 12/2/25 at 3:11 p.m., the charge nurse found the resident sitting naked on the floor next to the bed, described as playing a game with "my boys," very confused, hallucinating people and objects, and making unusual statements. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation. The behavior note did not document that a neurological assessment, vital signs, or a full assessment were completed at that time. A later nursing note, entered at 7:08 p.m. as a late entry, stated that CNAs had informed an LVN that the resident had been found on the floor earlier in the day, naked and hallucinating, and that the resident was dressed and assisted into a Geri-chair. The LVN documented that she then completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. The Neuro/Vital Sign Flow Sheet showed that the first set of neuro checks was not completed until 6:30 p.m., approximately 3 hours and 15 minutes after the initial unwitnessed fall. In an interview, the LVN stated she was informed of the fall around 5:30 p.m. and that she was instructed to treat the fall as if it had just occurred. Additional documentation and interviews showed that the charge nurse did not initially report the incident as a fall, did not notify a supervisor, and did not complete a fall form at the time of the event because she did not believe the resident had actually fallen, based on the resident twice denying a fall. CNAs reported seeing the charge nurse picking the resident up from the floor and helping to put the resident back in bed, and reported that the charge nurse told them not to say anything and that it was the second time it had happened. The charge nurse confirmed in interview that she did not complete vital signs, neurological checks, or a full assessment at the time of the incident, and that her late-entry nursing note describing the fall was written a couple of days after the event. These actions and omissions did not comply with the facility’s Neurological Evaluation policy, which required immediate safety assessment, full assessment, vital signs, timely neuro checks, and documentation after any witnessed or unwitnessed fall where a head bump was suspected or the fall was unwitnessed.
Failure to Respond to Resident's Acute Change in Condition Due to Misinterpretation of DNR Status
Penalty
Summary
The facility failed to assess, recognize, escalate, and properly respond to a significant change in condition for a resident who experienced symptoms consistent with a stroke. The resident, who had a history of stroke and was cognitively intact, reported new onset slurred speech and right-sided weakness to staff, explicitly stating she believed she was having a stroke. Despite these acute symptoms and her direct communication, staff only contacted the Nurse Practitioner (NP), who instructed them to place the resident back in bed and monitor her, citing her DNR status as a reason for not pursuing further intervention. The NP did not assess the resident in person, and no further escalation to the Medical Doctor (MD) occurred, even though the resident was not in need of resuscitation but required a higher level of care. Staff interviews revealed that both the LVN and CNA observed clear signs of neurological decline, including facial droop, drooling, and loss of mobility, which were significant changes from the resident's baseline. The CNA noted that the resident, previously able to move independently, now required assistance from three staff members to return to bed. Documentation in the resident's records confirmed these changes, and progress notes indicated low oxygen saturation and elevated blood pressure. Despite these findings, the only action taken was to monitor the resident, and the NP did not visit or reassess the resident during the night. The MD later stated he was not contacted and would have reviewed the resident's POLST and wishes had he been notified. The resident's POLST indicated she did not want resuscitation but did want selective treatment for medical conditions, including IV antibiotics, fluids, and non-invasive airway support. Facility policy required prompt notification of the physician and family for significant changes in condition, but this did not occur. The resident was eventually transferred to the hospital after further decline, where she was diagnosed with a left thalamic intracranial hemorrhage and experienced a marked decline in functional abilities. The failure to escalate care and provide timely intervention resulted in a delay in treatment for a critical medical emergency.
Failure to Ensure Timely Physician and NP Assessments
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a Medical Doctor (MD) or Nurse Practitioner (NP) at all required intervals, as outlined in the facility's policy and procedure. Record reviews and resident interviews revealed that seven residents had not consistently received timely assessments by an MD or NP. Several residents reported not having seen their MD or NP for extended periods, ranging from several months to over a year. Documentation in progress notes showed that while NPs had entered assessments, there were significant delays between the actual assessment dates and the dates the notes were electronically signed, and residents' recollections did not align with the documented visits. Interviews with staff, including the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN), confirmed that there had been ongoing complaints from both residents and staff regarding the lack of regular visits by the MD or NP. Some residents stated they had never met their MD or NP, while others recalled only sporadic visits since their admission. The Director of Nursing (DON) stated she was not aware of these concerns but expected residents to be seen for their assessments as required. A review of the facility's policy indicated that residents should be visited by their physician at least every 30 days, with each visit documented in a progress note. The failure to adhere to this policy resulted in incomplete and potentially outdated medical records, as events were not always recorded in chronological order or within the required timeframes. This deficiency was identified for all seven residents reviewed, indicating a systemic issue with compliance to required physician and NP visits and documentation.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Program - Reporting policy for two residents when an allegation of sexual abuse was not reported to the California Department of Public Health (CDPH), the Ombudsman, and local law enforcement (LLE) within 24 hours as required. Documentation showed that the initial report (SOC-341) was submitted to CDPH two days after the incident, and there was no evidence that the report was sent to the Ombudsman or LLE. The Director of Nursing (DON) confirmed the lack of timely reporting and missing documentation for the required agencies. Additionally, the facility did not complete and submit a follow-up investigative report (FIR) within five working days of the allegation, as mandated by facility policy. The DON acknowledged that the FIR had not been completed or sent to CDPH within the required timeframe. These actions were in direct violation of the facility's written procedures for reporting and investigating allegations of abuse.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process and indicates that the required pharmaceutical oversight and services were not in place for residents at the time of the survey. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day, seven days a week, as required. Review of the Payroll Staffing Data Report (PBJ) and the facility's Staffing Log from September to December 2024 revealed multiple days where no RN hours were recorded or the hours worked were less than the required eight hours. Specific dates were identified where either no RN was present or the RN coverage was insufficient, as documented in both the PBJ and staffing logs. During an interview and record review with the Staffing Coordinator, it was confirmed that the facility experienced ongoing difficulties in securing adequate RN staffing. The Staffing Coordinator stated that the facility was not receiving enough applications and that a requirement for previous skilled nursing facility experience further limited the applicant pool. When applications were lacking, the facility attempted to reach out to registries to fill the RN shifts, but gaps in coverage persisted.
Improper Food Storage and Labeling in Dry Storage Room
Penalty
Summary
Surveyors observed that food items in the facility's dry storage room were not stored and labeled according to professional standards and facility policy. Specifically, a bag of powdered cocoa was found open and not properly sealed, exposing it to room air. Additionally, five bottles of chocolate syrup and eleven cans of tuna did not have received by date labels. During interviews, staff confirmed that all food items should be closed, sealed, and labeled with a received by date, as required by the facility's policy and procedure for food storage, labeling, and dating. These actions and inactions resulted in a failure to maintain food in a sanitary manner.
Failure to Obtain Orders and Informed Consent for Tab Alarms
Penalty
Summary
The facility failed to ensure that tab alarm orders and informed consents were obtained for two residents. For one resident, a tab alarm was observed attached to the resident's wheelchair and T-shirt, but there was no physician order for the alarm, and the informed consent form was unsigned by the resident's representative. The resident's care plan referenced the use of a bed alarm and tab alarm, but the Minimum Data Set (MDS) did not indicate the use of a chair alarm. The Assistant Director of Nursing (ADON) confirmed the absence of both the required order and signed consent. For another resident, a tab alarm was also observed in use while the resident was in a wheelchair. The MDS indicated daily use of a chair alarm, and the medical orders included a tab alarm while in the chair. However, there was no informed consent for the tab alarm in the medical record, and no care plan had been initiated for its use. The ADON and a Licensed Vocational Nurse (LVN) confirmed the lack of consent and care plan documentation. Additionally, the ADON stated that there was no alarm policy or process in place at the facility.
Failure to Document Fall and Monitor Diabetes Management in Two Residents
Penalty
Summary
The facility failed to document and monitor changes in condition for two residents. For one resident with Alzheimer's disease, a history of falls, and multiple comorbidities including a left femur fracture and impaired mobility, an unwitnessed fall occurred. The nursing note indicated the fall, but the nurse did not initiate the fall protocol or update the care plan as required. The facility's policy states that all falls, including those prior to or during admission, must be documented in the care plan, but this was not done for this resident. For another resident with diabetes who was receiving insulin therapy, the comprehensive care plan did not include indicators for identifying or preventing hypo- or hyperglycemia, despite physician orders for insulin administration and specific blood sugar monitoring protocols. The Assistant Director of Nursing confirmed that the care plan should have included these indicators. The facility's policy requires that acute or temporary problems be incorporated into the comprehensive plan of care, but this was not followed in this case.
Failure to Provide Timely Dental Care and Denture Follow-Up
Penalty
Summary
The facility failed to ensure that a resident's dental needs were met and that appropriate follow-up was conducted regarding the provision of dentures. The resident, who was admitted with a diagnosis of depression and had intact cognitive function, reported having dentures prior to admission but did not have them upon arrival. The resident expressed that her dentures were uncomfortable and did not fit properly, and she was interested in obtaining new ones. Despite an initial dental appointment being scheduled and rescheduled due to pain, and x-rays being completed for dentures, there was a significant delay in follow-up regarding the status of the dentures. Observations and interviews revealed that the resident was without teeth, had difficulty speaking, and felt embarrassed, leading her to avoid social activities. The Activities Assistant confirmed that the resident refused to participate in group activities due to the lack of dentures, resulting in increased isolation and potential worsening of her depression. Documentation showed repeated statements from the resident about her desire to obtain dentures before rejoining activities, and staff noted her ongoing discomfort and social withdrawal. The Social Services Designee acknowledged that follow-up with the dental office was infrequent and not consistently documented in the medical record. The delay was attributed to waiting for insurance authorization, but no proactive steps, such as contacting the ombudsman as done for another resident, were taken for this resident. The facility's policy required annual and as-needed dental care, but the lack of timely follow-up and documentation resulted in the resident not receiving necessary dental services, impacting her quality of life.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
A resident submitted a Concern/Comment Form (CCF) detailing upsetting interactions with the Activities Supervisor, including being told to leave an activity if they did not want to participate, feeling unwelcome, and being prevented from fully participating in a game. The resident also reported feeling uncomfortable after the Activities Supervisor referenced buying them food in a manner that made the resident feel awkward. These concerns were formally documented on the CCF. Upon review, it was found that the facility failed to investigate or resolve the resident's grievance in accordance with its own policy and procedure. The policy required that concerns be routed to Social Services within 24 hours and that the appropriate department manager respond within 48 hours. However, ten days after the CCF was filed, the Social Worker confirmed that the grievance had not been investigated or resolved, and acknowledged that this was not acceptable and did not follow the facility's established procedures.
Failure to Promote Resident Choice and Participation in Activities
Penalty
Summary
The facility failed to promote the physical and emotional well-being of two residents by not allowing them to fully participate in activities and make their own choices. Both residents were assessed as cognitively intact with no upper extremity impairments, as indicated by their MDS assessments and BIMS scores of 15. Despite this, one resident reported that the Activities Supervisor did not allow him or other residents to roll dice during Yahtzee, treating them as if they were handicapped. This led the resident to avoid participating in activities when the Activities Supervisor was present. Another resident confirmed that some activities staff, particularly the Activities Supervisor, did not allow residents to handle dice, attributing this to staff being overly cautious. An Activity Assistant stated that she allowed residents to play games and respected their wishes, but noted that the Activities Supervisor tended to make decisions for the residents, which discouraged participation. The facility's policy on activity programs requires that activities promote physical, cognitive, and emotional well-being, encourage self-expression and choice, and reflect individual resident evaluations. The actions of the Activities Supervisor were inconsistent with these policy requirements, resulting in residents not being able to fully engage in activities or exercise their autonomy.
Failure to Implement Elopement Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement its policy and procedure on elopement and wandering for a resident who expressed and attempted to leave the facility. The resident, who was admitted with diagnoses including muscle weakness, anxiety, and bipolar disorder, had a moderately impaired cognition score. Despite multiple documented attempts to leave the facility, the resident's elopement risk evaluation was not completed, and no care plan was initiated. The staff did not notify the physician after the resident's initial elopement attempt, which was a requirement according to the facility's policy. The resident made several attempts to leave the facility, expressing a desire to go home and displaying aggressive behavior towards staff. On one occasion, the resident managed to elope and was found outside the facility, having sustained a fall that resulted in a left hip fracture. The resident required surgical intervention for the fracture. The facility's failure to reassess the resident's risk for elopement and implement appropriate interventions, such as a wander guard, contributed to the resident's successful elopement and subsequent injury. Interviews with the Director of Nursing and Assistant Director of Nursing revealed that the staff did not follow the facility's policy, which required an elopement risk assessment upon admission, quarterly, and after any elopement attempts. The policy also mandated that care plan interventions be initiated based on the results of the Wandering Risk Scale. The lack of adherence to these procedures resulted in the resident's elopement and injury, highlighting a significant deficiency in the facility's supervision and safety measures.
Insufficient Staffing and Inconsistent RNA Services
Penalty
Summary
The facility failed to provide sufficient Certified Nursing Assistants (CNA) and Restorative Nursing Assistants (RNA) to meet the needs of 20 out of 31 sampled residents. Interviews with residents and staff revealed that the facility was consistently short-staffed, particularly during the night shift. Residents reported long wait times for call lights to be answered, with one resident stating it took up to 45 minutes, and another reporting a wait time of five hours. Additionally, several residents indicated they had not received their prescribed restorative nursing exercises for several days or weeks, which are crucial for maintaining their range of motion and mobility. The staffing coordinator confirmed that on a specific night, only one CNA was available to cover a census of 43 residents, as two CNAs from the Emergency Department who were supposed to assist left after a few minutes. This left the lone CNA to handle all responsibilities, including answering call lights and changing residents. The facility's staffing schedule typically included four CNAs for the day shift and three for the night shift, but they were not always able to meet the required Direct Care Service Hours per Patient Day (DHPPD). Record reviews showed that multiple residents had physician orders for RNA services, such as range of motion exercises and ambulation, which were not provided for an entire week. Interviews with CNAs and residents confirmed that RNA services were inconsistent, with CNAs often being pulled to cover other duties due to staffing shortages. The facility's policy on Activities of Daily Living (ADLs) emphasized the importance of following daily work assignments and providing necessary care, including answering call lights promptly and performing daily range of motion exercises, which were not adhered to due to the staffing issues.
Failure to Monitor Refrigerator and Freezer Temperatures
Penalty
Summary
The facility failed to ensure that one refrigerator and one freezer in the Day room were monitored for temperature control, which had the potential for foodborne illnesses to be spread to residents. During an observation and interview, it was noted that the Day room refrigerator and freezer did not have thermometers inside, despite containing drinks and ice cream. The Director of Nursing (DON) and Activities Director (AD) confirmed the absence of thermometers. Further review with the Plant Operations Manager (POM) revealed that the temperature sensor had only been installed on the same day, and food should not have been placed in the units until the sensor was in place. Additionally, a work order dated two months prior indicated the need for temperature monitoring in the Day room fridge/freezer, which had not been addressed until the day of the survey.
Failure to Update PASRR After Change in Psychological Status
Penalty
Summary
The facility failed to ensure that a resident was referred for a Preadmission and Resident Review (PASRR) after a change in psychological status. During an interview and record review, it was found that the resident's PASRR, dated 11/26/19, indicated a diagnosis of Generalized Anxiety Disorder. However, a Psychiatric Mental Health Progress Note dated 8/22/23 indicated a new diagnosis of Schizophrenia. The Social Worker confirmed that the PASRR did not include the new diagnosis and acknowledged that a new PASRR Level 1 screening should have been completed at the time of the new diagnosis in August 2023. This oversight resulted in the resident not receiving recommendations for specialized services to best meet her needs.
Failure to Communicate Weightbearing Status Delays Resident's Care
Penalty
Summary
The facility failed to communicate the weightbearing status of a resident to the interdisciplinary team, resulting in a delay of rehabilitative and restorative care. The resident, who had a brace on her right leg after breaking it six weeks prior, expressed a desire for therapy but had not received any. The Physical Therapist discontinued the resident's Restorative Nursing Assistant services because the weightbearing status was unknown. The Licensed Vocational Nurse confirmed that no orders or follow-up documentation were received from the orthopedic doctor after the resident's visit. A letter from the orthopedic clinic, dated the day after the visit, indicated that weightbearing was allowed with specific conditions, but this information was not communicated to the staff. The Director of Nursing acknowledged that the weightbearing status should have been documented and communicated to all involved staff.
Failure to Maintain Foley Catheter Care
Penalty
Summary
The facility failed to provide proper care for a Foley catheter for one resident, leading to potential risks of infection and injury. During an observation, the resident's Foley catheter tubing was found on the floor under the wheelchair. The Licensed Vocational Nurse confirmed that the resident was being treated for a urinary tract infection and acknowledged that the catheter tubing should not have been on the floor due to the risk of infection or it being pulled out. The Infection Preventionist also confirmed that the catheter tubing should not have been touching the floor, especially since the resident was already at high risk for infection. The facility's policy and procedure for Indwelling Foley Catheter Care indicated that drainage bags should be kept off the floor, which was not adhered to in this case.
Failure to Update and Communicate Dietary Orders
Penalty
Summary
The facility failed to change a physician order and communicate the change in the dietary order for one resident. During an observation, it was noted that the resident's meal tray contained both thickened and non-thickened milk, contrary to the resident's preference for thin liquids. The CNA acknowledged that the resident's preference for whole milk was not honored. The LVN admitted that the physician's order for thin liquids was not updated, despite being informed of the change during a report. The PA confirmed that the order for thin liquids was made based on the resident's request during a discussion about comfort care options. The RD stated that the kitchen was not notified of the change in the dietary order, resulting in the continued provision of thickened liquids. The RD received an email about the resident's preference for whole food but noted that the nursing staff failed to submit a dietary service request to update the kitchen. The DON confirmed that the change in the resident's diet order was neither entered into the computer system nor communicated to the dietary staff, leading to the deficiency.
Failure to Properly Store Oxygen Tubing
Penalty
Summary
The facility failed to store oxygen tubing per policy for two residents, Resident 13 and Resident 31. During an observation and interview with a Certified Nursing Assistant (CNA) in Resident 13's room, it was noted that Resident 13's oxygen tubing was laying on the handrail of the bed instead of being placed in a plastic bag as required by the facility's policy. Similarly, during an observation and interview with a Registered Nurse (RN) in Resident 31's room, Resident 31's oxygen tubing was also found on the handrail of the bed. The RN confirmed that the tubing should have been placed in a plastic bag to avoid contamination. The facility's policy, dated 12/1/10, indicated that all oxygen tubing should be placed in a plastic bag to ensure clean equipment and decrease the risk of infection.
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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