Knolls West Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Victorville, California.
- Location
- 16890 Green Tree Blvd, Victorville, California 92395
- CMS Provider Number
- 555251
- Inspections on file
- 36
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Knolls West Post Acute Llc during CMS and state inspections, most recent first.
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.
Kitchen staff did not consistently follow food safety and sanitation protocols, including wearing hairnets, labeling and covering food, and properly cleaning equipment. Unlabeled drink pitchers, uncovered ice containers, dented cans, and improperly thawed raw meat were found, along with dirty ovens, stove burners, and griddles. Staff also stored personal food items in resident-designated refrigerators, all in violation of facility policies.
Two kitchen ovens were found to be nonfunctional, unclean, and not labeled as out of order, despite being reported to maintenance and remaining accessible. Staff confirmed the ovens had been out of service for over a month, and facility policy requiring equipment to be kept clean and in good repair was not followed.
The facility did not ensure that physicians conducted required visits or signed physician orders in a timely manner for multiple residents. Several residents had unsigned physician orders for medications and treatments, and required physician visits were not documented as completed within the specified timeframes. Facility staff acknowledged that these actions did not follow established policies and procedures.
A resident with a Foley catheter was observed with an uncovered urine collection bag, exposing its contents to public view. Staff and the ADON confirmed that the bag should have been covered according to facility policy to maintain privacy and dignity. The resident's care plan and physician orders also included interventions to promote dignity, but these were not followed.
A resident with cellulitis and COPD was transferred to the hospital for a toe infection, but the facility did not send the required transfer notice to the Ombudsman. Staff interviews and record reviews confirmed there was no process or documentation for notifying the Ombudsman when residents are sent to the hospital.
Two residents' RAI-MDS assessments were inaccurately coded, with one resident's schizophrenia diagnosis and another's stage 1 pressure ulcer not documented as required. These omissions were confirmed by facility staff and contradicted information in the residents' admission records and physician orders.
A resident's MDS was inaccurately coded to show antibiotic administration, despite no supporting physician orders or documentation. The error was confirmed by the MDS nurse during a review of the resident's records and assessment documentation.
A resident was admitted with a diagnosis of schizophrenia, but the PASRR Level I screening used for admission did not reflect this diagnosis, resulting in an inaccurate assessment. Facility staff did not identify or correct the discrepancy upon admission, and there was no specific policy guiding the PASRR process. The omission was only discovered later, and the PASRR was subsequently updated to reflect the resident's actual condition.
A resident with multiple chronic conditions did not receive physical therapy five times per week as ordered by the physician, receiving only three sessions during one week due to a scheduling error and staff absence. This was confirmed through record review and staff interviews, and facility policy requires adherence to physician orders and care plans.
A resident with peripheral vascular disease and limited mobility, identified as high risk for pressure injuries, was not provided with physician-ordered heel protector boots while in bed. Staff left the heel protectors on the bedside table and did not notify a nurse or perform a skin assessment, leading to the development of a deep tissue injury. Facility policy required adherence to physician orders, which was not followed in this case.
Two residents admitted for short-term Medicare stays did not receive the required initial comprehensive physician visit within 30 days of admission. Both residents' charts lacked completed History and Physical documentation, despite multiple notifications to the attending physicians. The facility's policy for timely physician visits was not followed.
Staff did not consistently sign narcotic reconciliation logbooks when discrepancies were present in two of four logbooks. Multiple dates were missing required signatures at two nursing stations, as confirmed by a RN Supervisor and an LVN. Facility policy requires both on-coming and off-going nurses to count and reconcile controlled drugs at each shift change, but this procedure was not followed.
Medication storage rooms and medication refrigerators at two nursing stations were found unlocked and accessible without a key, containing various medications including injectables and insulin pens. Staff confirmed that these areas were routinely left unsecured, contrary to facility policy requiring locked storage accessible only to licensed nurses. The facility's policy and procedure for medication security was not followed.
A Registered Nurse Supervisor did not perform hand hygiene after a blood glucose check and before preparing medications for another resident, contrary to facility policy. Additionally, two empty IV medication bags and tubing remained at a resident's bedside for over 30 days after use, despite requirements for prompt removal. These actions did not comply with the facility's infection control procedures.
The facility did not submit the required quarterly PBJ Staffing Data report to CMS for a specified quarter. During review, it was confirmed that no data was submitted by the deadline, and the DON could not provide a related policy or procedure. An Administration Resource, responsible for timely submission, verified the omission and acknowledged the importance of this data for monitoring staffing and patient care.
A facility failed to develop a comprehensive nutritional care plan for a resident with dementia, cerebrovascular disease, and muscle weakness, despite the need for long-term artificial nutrition. Staff interviews confirmed that care plans are usually developed upon admission, but a review revealed the absence of a nutritional care plan, contrary to facility policy.
A resident with multiple medical conditions developed Stage 2 pressure ulcers on both buttocks despite being assessed as low risk and receiving treatment. The facility's policy requires prevention of pressure ulcers unless unavoidable, highlighting a deficiency in care.
A resident with a history of hypertension and other health conditions did not receive their prescribed Nifedipine on multiple occasions, as documented in the MAR. The medication was not administered on December 2 due to low blood pressure, and there was no documentation for administration on November 28 and 29. This failure to adhere to medication administration policy had the potential to compromise the resident's health.
A resident with multiple health conditions, including a wedge compression fracture and polyneuropathy, did not receive the prescribed physical therapy five times a week due to staff shortages. The facility's policy required adherence to physician orders, but therapy was only provided three to four times weekly, as confirmed by the Physical Therapy Director and the Administrator.
A resident with heart disease and hypertension was affected by a medication administration deficiency when an LVN pre-signed the MAR, failed to check medication expiration, and did not document the unavailability of Amlodipine. The LVN also considered borrowing medication from another resident, contrary to facility policy. The ADON confirmed these actions were against the facility's procedures.
A facility failed to report an alleged abuse incident involving a resident who claimed an LVN threw him to the ground. The resident, with a history of spinal stenosis and anxiety, was reportedly dependent on Ativan and had been asking for Norco. The administrator did not initially report the incident to authorities, citing a lack of evidence and the resident's son's eventual agreement with the LVN's account. The incident was only reported to the licensing board after a reminder of policy requirements.
A facility employed an LVN with a disciplinary action against her license, despite allegations of mistreatment of a dementia patient at a previous facility. The DON and Administrator were aware of the disciplinary action but did not review the details before hiring, violating the facility's abuse prevention policy.
A resident with multiple medical conditions did not receive their scheduled medication because an LVN failed to document the resident's refusal, as required by the facility's policy. The LVN admitted to forgetting to document the refusal, which was confirmed by the Administrator and RN Supervisor. This oversight had the potential to compromise the resident's health and safety.
The facility failed to properly store and date food items in nourishment refrigerators, as observed by surveyors. Several food items were found undated or past the three-day limit, contrary to facility policy. Interviews revealed confusion among staff regarding responsibilities for labeling, dating, and discarding food items, with discrepancies in understanding between nursing and housekeeping staff.
The facility failed to complete timely MDS assessments for three residents, as required by policy and CMS guidelines. The MDS assessments were not signed by the DON, resulting in overdue assessments. Interviews revealed that the MDS staff were responsible for completion, but the DON was responsible for signing. The DON acknowledged awareness of the issue, and the Administrator deferred responsibility to nursing.
The facility failed to complete timely MDS assessments for three residents, as required every 92 days. The assessments were not signed by the DON, indicating they were overdue. Interviews revealed confusion over responsibility, with the MDS Coordinator and DON acknowledging the oversight, and the Administrator deferring responsibility to nursing staff.
A resident with COPD and other conditions did not receive proper respiratory care as the facility failed to change oxygen tubing weekly and store respiratory equipment correctly. Observations showed the resident's CPAP mask and nasal cannula were left uncovered, contrary to facility policy. Staff interviews confirmed the non-compliance with established protocols.
A facility failed to specify the duration for an as-needed anti-anxiety medication for a resident, contrary to its policy requiring a written physician's order with a specified duration. The resident, with major depressive disorder and anxiety, had a care plan including Xanax, but the order lacked an end date. Interviews revealed the facility's policy and pharmacist's recommendation for a 14-day limit and re-evaluation were not followed, and the DON was unaware of the reason for the order.
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
Failure to Maintain Food Safety and Sanitation in Kitchen Operations
Penalty
Summary
The facility failed to maintain food safety practices in the kitchen as required by its own policies and procedures. Observations revealed that kitchen staff did not consistently wear hairnets in food preparation areas, and equipment such as the juice machine was found with visible grime, old stains, and residue. Multiple drink pitchers were left on counters without date labels, and a large ice container was left uncovered, exposing its contents to potential contamination. Additionally, dented cans were found in the ready-to-use section, and raw meat was improperly thawed in stacked containers under running water in the sanitizing compartment of the three-compartment sink, with temperatures exceeding safe limits and no thawing log maintained. Further inspection showed that food items such as desserts were stored uncovered in the refrigerator, and kitchen equipment including ovens, stove burners, and the flat top griddle were found with heavy grease, burnt food particles, and debris. Some ovens had loose screws inside, and the griddle had a dirty spatula resting on its edge. These conditions indicated a lack of regular cleaning and maintenance, as required by the facility's sanitation policies. Staff acknowledged that these practices did not align with established procedures for cleanliness and food safety. Personal food and beverage items belonging to staff were also found stored in the refrigerator designated for resident food, including opened bottles, canned drinks, and leftover food in condiment cups. This practice was confirmed by staff to be against facility policy, as it poses a risk of cross-contamination. Throughout the observations and interviews, staff and supervisors consistently acknowledged that the facility's policies and procedures were not followed in these instances, resulting in unsanitary conditions and potential food safety hazards for residents who rely on the kitchen for their meals.
Nonfunctional Kitchen Ovens Not Labeled or Maintained
Penalty
Summary
Two ovens in the facility's kitchen were found to be nonfunctional and not in use, yet they remained accessible and were not marked as out of order. Observations revealed that one oven had heavy blackened residue, grease buildup, burned-on food, and rust on the interior, indicating it was grimy and clearly nonoperational. The other oven was also nonfunctional, containing loose screws on the interior bottom surface. Both ovens had been reported to maintenance, but no repairs had been completed, and neither was labeled as out of service. Staff interviews confirmed that the equipment had been out of order for approximately 1.5 to 2 months and that maintenance had been notified, but no further action had been taken. Review of the facility's policy and procedure on sanitation indicated that all equipment should be kept clean, maintained in good repair, and free from breaks, corrosion, and buildup. The Dietary Services Supervisor acknowledged that the nonworking ovens should have been kept clean and labeled as out of order, even when not in use. Staff were expected to clean equipment daily, regardless of operational status, but this was not done for the nonfunctional ovens. The failure to maintain and properly label the ovens was confirmed through observation, staff interviews, and record review.
Failure to Ensure Timely Physician Visits and Signatures on Orders
Penalty
Summary
The facility failed to ensure that physicians conducted required visits and signed physician orders in a timely manner for several residents. Specifically, two residents admitted for short-term stays with Medicare Part A & B coverage did not have documented physician visits or signed physician orders for multiple months following their admission. Physician orders for these residents were received via phone, but there were no physician signatures for the relevant months, and all orders remained flagged for signature. The Assistant Director of Nursing (ADON) acknowledged that the facility's policy, which requires physician visits within specific timeframes and timely signatures, was not followed, despite repeated notifications to the physicians. Additionally, four other residents had unsigned physician orders in their charts. These orders included medication changes, discontinuations, and new prescriptions, all of which were not signed by the physician as required. The facility's policy states that telephone orders must be countersigned by the physician during their next visit, but this was not adhered to for these residents. The ADON confirmed that the policy was not followed in these cases as well. The deficiencies were identified through record reviews and interviews with facility staff, who confirmed the lack of timely physician visits and unsigned orders. The facility's own policies and procedures, which align with state and federal requirements, were reviewed and found not to have been implemented as required for the affected residents.
Failure to Provide Dignity Cover for Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed in bed with the urine collection bag visibly exposed and not covered by a dignity bag, as required by facility policy. The resident, who had a history of hemiplegia and hemiparesis following a stroke, acute and chronic respiratory failure, and congestive heart failure, was alert and oriented at the time of observation. The exposed urine bag was noted during a room observation, and both the Certified Nurse Assistant and the Assistant Director of Nursing confirmed that the bag should have been covered to protect the resident's privacy and dignity. Review of the resident's physician orders and care plan indicated the presence of a Foley catheter for a neurogenic bladder, with interventions specifically including the promotion of privacy and dignity. The facility's policy and procedure on dignity explicitly prohibited practices that compromise resident dignity, including the requirement to keep urinary catheter bags covered. The Assistant Director of Nursing acknowledged that staff did not follow the facility's policy in this instance.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer or discharge was sent to the Ombudsman when a resident was transferred to the hospital. The resident, who had a history of cellulitis and chronic obstructive pulmonary disease (COPD), was sent to the hospital for a left 4th toe infection as per physician's orders. Upon review of the resident's clinical and hospitalization records, there was no documentation indicating that the required notice was sent to the Ombudsman. Interviews with facility staff, including the DON, Social Services, Medical Records, and the Administrator, revealed that the facility did not have a process, policy, or procedure in place for notifying the Ombudsman when residents are transferred to the hospital. Staff indicated that notifications to the Ombudsman were only made for planned discharges to home or other care settings, not for hospital transfers. This lack of notification was confirmed through record reviews and staff statements.
Inaccurate Coding of RAI-MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for two residents, resulting in assessments that did not reflect their current medical status. For one resident, the RAI-MDS assessment did not indicate a diagnosis of schizophrenia, despite the admission record listing schizophrenia among the resident's diagnoses. Both the Assistant Director of Nursing and the MDS Nurse confirmed during interviews that the omission was an oversight and that the assessment should have included the schizophrenia diagnosis, as required by the RAI manual. For another resident, the RAI-MDS assessment failed to document the presence of a stage 1 pressure ulcer that was identified upon admission. The admission assessment and physician's orders confirmed the existence of the pressure ulcer, and the Assistant Director of Nursing acknowledged that the assessment was incorrectly coded. The RAI manual specifies that skin conditions, including pressure ulcers, must be accurately documented to ensure a complete assessment. These failures resulted in the MDS assessments not accurately reflecting the residents' current health conditions.
Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident when the MDS was incorrectly coded to indicate that the resident had received antibiotics, despite no physician's orders or documentation supporting antibiotic administration. The resident in question was admitted with diagnoses including peripheral vascular disease and stiffness in both ankles. A review of the resident's admission record and physician's orders revealed no evidence of antibiotic use during the assessment period. During interviews and record reviews, the MDS nurse confirmed that the resident's MDS Section N was inaccurately coded to reflect antibiotic use, acknowledging this as an oversight and a coding discrepancy. The nurse further recognized the importance of MDS accuracy for care planning. The error was identified during a review of the MDS and supporting documentation, which did not align with the information entered into the assessment tool.
Failure to Accurately Update PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASRR) for a resident who was admitted with a diagnosis of schizophrenia. Upon admission, the resident's medical record indicated diagnoses of schizophrenia, altered mental status, and dementia. However, the PASRR Level I screening completed at the hospital and used for admission did not include the schizophrenia diagnosis, marking the question regarding serious mental illness as 'NO.' This resulted in the PASRR resolution status being set to 'Level II not required,' which was inaccurate given the resident's actual condition. Interviews with facility staff, including the MDS Nurse and Assistant Directors of Nursing, revealed that the skilled nursing facility did not identify the discrepancy in the PASRR upon the resident's admission. The staff acknowledged that the PASRR should have been reviewed for accuracy and amended if necessary, but this process was not followed. The omission was only discovered later, and the PASRR was subsequently updated to reflect the correct diagnosis of schizophrenia. Further review of facility practices showed that there was no specific policy or procedure in place for the PASRR process. Staff relied on a general PASRR Level I Screening Assessment Guide, which outlined the need for accurate and current information and specified that major clinical errors required a new screening. The guide also indicated that certain PASRR resolutions, such as 'Categorical Review,' were not valid for admission to a Medicaid-certified skilled nursing facility, yet the resident's revised PASRR was marked as such, pending further review.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including polyneuropathy, generalized osteoarthritis, heart failure, obesity, and low back pain, did not receive physical therapy services as ordered by the physician. The physician's order specified that the resident should receive physical therapy five times a week for four weeks, with treatments including gait training, manual therapy, and wheelchair mobility training. However, documentation showed that during one week, the resident only received three physical therapy sessions instead of the prescribed five. The resident expressed awareness of not receiving therapy as frequently as expected and reported a desire to regain the ability to walk in order to leave the facility. The Rehab Director confirmed that the resident was scheduled to receive therapy five times a week, but missed sessions occurred due to a scheduling error and a staff absence, with no documentation of services provided on those days. The facility's policies require care and services to be provided in accordance with physician orders and for comprehensive care plans to be developed and implemented to meet residents' needs. The Assistant Director of Nursing acknowledged the importance of therapy in maintaining the resident's functional ability. The failure to provide therapy as ordered was confirmed through record review and staff interviews.
Failure to Follow Physician Orders for Heel Protectors Resulting in Deep Tissue Injury
Penalty
Summary
Facility staff failed to follow physician orders for a resident at high risk for pressure injuries, as evidenced by the resident not wearing ordered heel protector boots while in bed. Observations on two separate occasions found the heel protectors placed on the resident's nightstand or bedside table rather than on the resident, despite a physician order specifying their use for skin maintenance. Interviews with the Assistant Director of Nursing, a CNA, and an LVN confirmed that the heel protectors were not applied as ordered, and staff did not notify a nurse or assess the resident's skin as required. The CNA stated she did not apply the protectors because the resident did not have a dressing on her left ankle, and the LVN admitted to missing a skin assessment due to unfamiliarity with the resident. The resident had a history of peripheral vascular disease, limited ankle movement, and was assessed as high risk for pressure injuries with a Braden Scale score of 12. The care plan included interventions such as turning, repositioning, and use of pressure-reducing devices. Despite these documented risks and interventions, the resident developed a deep tissue injury (DTI) on the left lateral ankle, as noted in nursing progress notes. Facility policy required care to be provided in accordance with physician orders, which was not followed in this instance, as acknowledged by the Assistant Director of Nursing.
Failure to Complete Timely Initial Physician Visits for Two Residents
Penalty
Summary
The facility failed to ensure that the attending physician conducted an initial comprehensive visit within the first 30 days after admission for two residents admitted under Medicare Part A&B. Both residents, one with multiple diagnoses including arthritis, atrial fibrillation, hyperlipidemia, dementia, nutritional deficiency, and a femur fracture, and another with end stage renal disease, diabetes mellitus, morbid obesity, dependence on renal dialysis, hypertension, muscle weakness, major depressive disorder, and a history of falling, were admitted from the hospital for short-term stays. Upon review, both residents' charts contained blank History and Physical (H&P) pages, indicating that the required physician assessments had not been completed, signed, or dated as of the time of the survey. The Assistant Director of Nurses (ADON) acknowledged that the initial comprehensive physician visit must occur within 30 days of admission and that the facility's policy requires physician visits within 72 hours of admission, at least every 30 days for the first 90 days, and then at least every 60 days thereafter. Despite multiple notifications to the physicians via fax and phone calls regarding the overdue visits, the required documentation remained incomplete. The ADON confirmed that the facility's policy and procedure regarding physician visits was not followed for these two residents.
Failure to Sign Narcotic Reconciliation Logbooks
Penalty
Summary
Facility staff failed to ensure that narcotic reconciliation logbooks were properly signed when discrepancies were found in two of four logbooks. During observations and interviews, it was identified that multiple dates in the logbooks at two nursing stations were missing required signatures from staff responsible for the controlled drug count. Both a Registered Nurse Supervisor and a Licensed Vocational Nurse confirmed the missing signatures on the specified dates. Review of the facility's policy and procedure for controlled drug reconciliation indicated that both on-coming and off-going nurses are required to count and reconcile controlled drugs at the end of each shift, which was not followed in these instances. The Assistant Director of Nursing acknowledged that staff did not adhere to the established policy.
Failure to Secure Medication Storage Areas and Refrigerators
Penalty
Summary
The facility failed to ensure secure storage of medications in accordance with its policies and professional standards. During observations, one medication storage room and its medication refrigerator at one nursing station were found unlocked and accessible without a key. The refrigerator contained injectable medications such as Ativan and Haldol, insulin pens, and an emergency kit, all of which were not secured with a padlock. A nurse reported that both the medication room and refrigerator were always unlocked and that he had never seen a padlock on the refrigerator. The Assistant Director of Nursing (ADON) and RN Supervisor confirmed that the facility's policy requires these areas to be locked and accessible only to licensed nurses, but this was not being followed. A second medication storage room at another nursing station was also found unlocked, with the medication refrigerator inside unsecured and containing residents' refrigerated medications. The ADON acknowledged the security issue and attributed it in part to new nurses receiving only online training. Review of the facility's policy and procedure confirmed that all medication storage areas, including refrigerators, must be locked when not in use and accessible only to authorized personnel. The ADON stated that the facility's policy and procedure was not followed in these instances.
Failure to Follow Infection Control Protocols for Hand Hygiene and IV Equipment Removal
Penalty
Summary
A Registered Nurse Supervisor (RNS) failed to perform hand hygiene after conducting a blood glucose check on a resident. After using a lancet to obtain a blood sample and removing his gloves, the RNS proceeded to document in the Medication Administration Record and then prepared medications for another resident without using hand sanitizer or washing his hands. The RNS acknowledged during an interview that he forgot to perform hand hygiene and was aware of the requirement to do so after glove removal and before preparing medications. The facility's Infection Preventionist and Assistant Director of Nursing confirmed that staff are expected to perform hand hygiene after removing gloves and after using a glucometer, as outlined in the facility's hand hygiene policy. Additionally, two empty intravenous (IV) medication bags with attached tubing were found at a resident's bedside more than 30 days after their use. The bags were labeled with medication and expiration dates, and the Director of Nursing confirmed that the bags should have been removed immediately after administration was completed. The facility's policy on infection control and universal precautions requires staff to comply with guidelines during all IV therapy procedures, which was not followed in this instance.
Failure to Submit PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required quarterly Payroll Based Journal (PBJ) Staffing Data report to CMS for quarter 2 of 2024, covering January 1 through March 31. During a record review, it was found that no PBJ data had been submitted by the required deadline of May 15, 2024. When requested, the Director of Nursing (DON) was unable to provide a policy and procedure related to PBJ submission. In a subsequent interview, an Administration Resource confirmed that one of her responsibilities was to ensure timely submission of the PBJ Staffing Data report and verified that the report for the specified quarter was not submitted. The Administration Resource acknowledged the importance of timely PBJ data submission for monitoring staffing adequacy and patient care needs.
Failure to Develop Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 1, to address their nutritional needs. This deficiency was identified during a review of the resident's records, which revealed the absence of a nutritional care plan despite the resident's medical conditions, including dementia, cerebrovascular disease, and generalized muscle weakness. The resident's clinical record indicated the need for long-term artificial nutrition, including feeding tubes, yet no specific plan was documented to meet these nutritional requirements. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that care plans are typically developed upon admission and are followed by the nursing staff. However, during a review with the ADON, it was acknowledged that a nutritional care plan should have been in place for Resident 1. The facility's policy mandates the development of a comprehensive care plan for each resident to address their medical, nursing, and psychosocial needs, which was not adhered to in this case.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent the development of pressure ulcers for a resident who was admitted with multiple medical conditions, including metabolic encephalopathy, Down syndrome, sepsis, osteomyelitis, and cellulitis. Upon admission, the resident's skin assessment indicated that the coccyx area was clear, and the Braden Scale assessment categorized the resident as low risk for pressure ulcers. However, on November 8, 2024, nursing notes documented a change of condition with redness on the resident's left and right buttocks, and a doctor was notified with new treatment orders being carried out. Despite these measures, by November 11, 2024, the resident developed Stage 2 pressure ulcers on both buttocks. The right buttock ulcer resolved by November 18, 2024, but the left buttock ulcer worsened in size by November 25, 2024. The treatment nurse confirmed that a wound doctor was involved when the ulcer was at Stage 1, and a low air flow mattress was introduced after the ulcer developed. The facility's policy mandates that residents should not develop pressure ulcers unless their clinical conditions make it unavoidable, indicating a failure to adhere to this policy.
Failure to Administer and Document Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to its medication administration policy when a Licensed Vocational Nurse did not administer Nifedipine, a medication prescribed to lower blood pressure, to a resident. This resident, who had a history of cerebral infarction, hypertension, and other significant health conditions, did not receive their prescribed dose of Nifedipine on multiple occasions, as documented in the Medication Administration Record (MAR). Specifically, there was no documentation or signature indicating that the medication was administered on November 28 and 29, and it was confirmed that the medication was not given on December 2 due to the resident's blood pressure being below the threshold specified in the physician's orders. The deficiency was identified during interviews and record reviews conducted by the facility's administration. The Licensed Vocational Nurse involved stated that the medication was not administered on December 2 because the resident's systolic blood pressure was below 110, as per the physician's order to hold the medication under such conditions. However, the lack of documentation for the administration of the medication on the specified dates was a clear deviation from the facility's policy, which mandates that all medications and treatments be recorded in the clinical record. This oversight had the potential to compromise the resident's health and safety.
Failure to Follow Physician's Order for Physical Therapy
Penalty
Summary
The facility failed to adhere to a physician's order to provide physical therapy five times a week for a resident, which was necessary to maintain or improve the resident's range of motion and mobility. The resident, who was admitted with multiple diagnoses including a wedge compression fracture, polyneuropathy, hypertension, and major depressive disorder, was only receiving physical therapy three to four times a week due to staff shortages. This deviation from the prescribed therapy schedule was confirmed during an interview with the Physical Therapy Director, who acknowledged that the practice was not acceptable. The facility's policy and procedure documents, reviewed during the investigation, clearly stated that care and services should be provided in accordance with physician orders, including rehabilitation services. The administrator also confirmed that physical therapy should be performed as ordered by the physician. Despite these policies, the facility did not comply with the physician's order, potentially impacting the resident's physical health and well-being.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) adhered to the established policies and procedures for medication administration, which led to a deficiency in the care of a resident. During a medication pass, the surveyor observed that the LVN pre-signed the medication administration record (MAR) before actually administering the medication to the resident. Additionally, the LVN did not check the expiration date of the medication and failed to document the reason for the unavailability of Amlodipine, a medication used to treat high blood pressure, on the MAR. The LVN also mentioned the possibility of borrowing medication from another resident, which is against the facility's policy. The resident involved in this incident was admitted with diagnoses including atherosclerotic heart disease, acute myocardial infarction, and hypertension, making them clinically compromised. The Assistant Director of Nursing (ADON) confirmed that the LVN's actions were not in compliance with the facility's expectations, which include performing the 7 rights check, ensuring medications are not expired, and only initialing the MAR after medication administration. The facility's policy explicitly states that medications should not be used for any resident other than the one for whom they were prescribed.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the appropriate local, state, and federal agencies as required by their policy. The incident involved a resident who claimed that a Licensed Vocational Nurse (LVN) threw him to the ground after he attempted to leave the facility. The resident's son, who was upset about the situation, initially believed the LVN was at fault but later agreed with the administrator that his father might have been confused. Despite this, the facility's policy mandates reporting any allegations or suspicions of abuse, which the administrator did not initially do, citing a lack of evidence and the son's eventual agreement with the LVN's account. The administrator only reported the incident to the licensing board after being reminded of the policy requirements. The resident involved had a medical history that included spinal stenosis, muscle weakness, difficulty walking, major depressive disorder, and anxiety disorder. At the time of the incident, the resident was reportedly dependent on Ativan and had been asking for Norco for pain relief. The LVN involved stated that the resident was aggressive and required assistance from multiple staff members to return to his wheelchair after he threw himself on the floor. The resident was later moved to another part of the facility to avoid contact with the LVN, and he expressed feeling safe in the facility as long as the LVN was not near him.
Failure to Screen LVN with Disciplinary Action
Penalty
Summary
The facility failed to protect residents from potential abuse and mistreatment by employing a Licensed Vocational Nurse (LVN) with a disciplinary action against her professional license. The LVN was hired despite a formal statement of charges filed against her, which included allegations of verbal and physical mistreatment of a patient with dementia at a previous facility. The disciplinary action was publicly posted, yet the Director of Nursing (DON) and the Administrator admitted to knowing about the disciplinary action but did not review the details of the accusations before hiring the LVN. The facility's policy on patient abuse and prevention mandates thorough screening of potential employees for any history of abuse, neglect, or mistreatment. However, this policy was not adhered to, as the LVN was hired without proper consideration of her disciplinary record. The Director of Staff Development (DSD) stated that the disciplinary action should have been a hard stop in the hiring process, but the facility proceeded with the employment due to staffing shortages, overlooking the potential risk to residents' safety.
Failure to Document Medication Refusal
Penalty
Summary
The facility failed to adhere to its Policy and Procedure when a licensed nurse did not document a resident's refusal of medication. This incident involved a resident who was admitted with multiple medical conditions, including polyneuropathy, gastroenteritis, bipolar disorder, muscle weakness, dysphagia, type II diabetes mellitus, anxiety, psychotic disorder, and hepatomegaly. The resident reported that on a specific date, the Licensed Vocational Nurse (LVN) did not administer the scheduled 9:00 pm medications, despite the resident's request. The LVN claimed that the resident refused the medication but admitted to forgetting to document this refusal, which is against the facility's policy. The facility's policy requires that any refusal of medication by a resident be documented, including the reasons for refusal and the risks and benefits of such refusal. During interviews, both the Administrator and the Registered Nurse Supervisor confirmed that there was no documentation of the medication refusal in the resident's records. The Registered Nurse Supervisor emphasized that if a medication refusal is not documented, it is considered as not given. This lack of documentation had the potential to place the resident's health and safety at risk, as the necessary medication was not administered as prescribed by the physician.
Improper Food Storage and Labeling in Facility Refrigerators
Penalty
Summary
The facility failed to properly store and date food items in the nourishment refrigerators on Unit 1 and Unit 2, as observed by surveyors. The facility policy, revised in January 2022, required that perishable foods brought by family or visitors be consumed, discarded, or taken home on the same day, with intact family-prepared meals allowed to be stored for three days. During an observation, the surveyor found several food items in the refrigerators that were either undated or past the three-day limit, including cold pizza dated 05/09/2024, an undated container of prunes, an undated bag of pears, and an unlabeled container of sprouts. A sign on the refrigerator indicated that resident food items must be discarded within three days. Interviews with facility staff revealed a lack of clarity and consistency in the process of labeling, dating, and discarding food items. LVN #4 stated that food items were labeled and dated by whoever placed them in the refrigerator, and were supposed to be kept for only two to three days. Housekeeper #5 confirmed the presence of outdated and undated food items and stated that the housekeeping staff checked the refrigerators daily and cleaned them weekly. The Housekeeping Supervisor and the Director of Nursing both indicated that the nursing staff was responsible for labeling and dating, while housekeeping was responsible for discarding items after 72 hours. However, the Administrator was unaware of who maintained the refrigerators or the procedures for labeling and discarding food items.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of comprehensive Minimum Data Set (MDS) assessments for three residents. The facility's policy, revised in January 2022, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. The CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that the annual assessment must be completed no later than 14 days after the assessment reference date (ARD). However, the MDS assessments for Residents #16, #69, and #79 were not signed as completed by the Director of Nursing (DON) and were overdue. Interviews with facility staff revealed that the MDS Coordinator acknowledged the responsibility of the MDS staff to ensure assessments were completed, but the DON was responsible for signing them. The DON admitted awareness of some late MDS assessments, and the Administrator deferred questions related to MDS assessments to nursing, indicating that the DON was ultimately responsible. MDS Coordinator #3 confirmed the late assessments, stating they had not been signed by the DON, but was unsure of the reason for the oversight.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of quarterly Minimum Data Set (MDS) assessments for three residents. According to the facility's policy, MDS assessments must be conducted and submitted in accordance with federal and state timeframes, specifically every 92 days following the previous assessment. However, the assessments for Residents #58, #96, and #109 were not signed as completed by the Director of Nursing (DON), indicating they were overdue. The MDS Coordinator acknowledged the oversight, confirming that the assessments were not completed within the required timeframe. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and signing of MDS assessments. The MDS Coordinator stated that it was the responsibility of the MDS staff to complete the assessments, while the DON was responsible for signing them to indicate completion. The DON admitted awareness of the late assessments, and the Administrator deferred responsibility to the nursing staff, ultimately holding the DON accountable for signing the assessments. This lack of coordination and oversight led to the deficiency in timely MDS assessment completion.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to adhere to its policy on respiratory care for a resident with chronic obstructive pulmonary disease (COPD), heart failure, and pleural effusion. The resident, who was readmitted to the facility and had moderate cognitive impairment, was observed using oxygen therapy. The facility's policy required that nasal cannulas be placed in a clean plastic bag when not in use to prevent contamination. However, observations revealed that the resident's CPAP mask was left uncovered on the floor and later hung on the side of the bed, while the nasal cannula was found uncovered on the bed, exposing it to potential contamination. Additionally, the facility did not comply with the physician's order to change the oxygen tubing weekly. The resident's oxygen tubing was dated several days prior to the observation, indicating it had not been changed as required. Interviews with staff, including a CNA, LVN, Infection Preventionist, and the Director of Nursing, confirmed that the facility's policy and physician's orders were not followed. The staff acknowledged that the nasal cannula and CPAP mask should be stored in a bag when not in use and that the tubing should be changed weekly, highlighting a lapse in the facility's adherence to its respiratory care protocols.
Failure to Specify Duration for As-Needed Anti-Anxiety Medication
Penalty
Summary
The facility failed to specify the duration of an as-needed anti-anxiety medication for a resident, which is a requirement according to their policy on psychotropic medications. The policy mandates that any psychotropic drug or chemical restraint must be used only as part of a plan to address specific symptoms, with a written physician's order detailing the duration and circumstances for use. However, the order for Xanax for the resident did not include an end date, which is necessary for re-evaluation by the physician. The resident, who was admitted with diagnoses of major depressive disorder and anxiety, had a care plan that included Xanax for anxiety. Despite the facility's policy and the pharmacist's recommendation to limit as-needed psychotropic medications to 14 days, the order for Xanax lacked a specified duration. Interviews with the pharmacist and the Director of Nursing confirmed the requirement for a 14-day limit and re-evaluation, but the Director of Nursing was unaware of the reason for the as-needed Xanax order. The Administrator deferred to nursing staff regarding the use of as-needed psychotropic medications.
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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