Lake Merritt Healthcare Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 309 Macarthur Boulevard, Oakland, California 94610
- CMS Provider Number
- 056350
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Lake Merritt Healthcare Center Llc during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, morbid obesity, paroxysmal atrial fibrillation, and on a blood thinner bit his tongue, resulting in oral bleeding. An LVN identified the bleeding and documented on an SBAR that the resident refused hospital transfer and that the MD ordered continued monitoring. Although the LVN reported checking the resident every 15 minutes and the night-shift RN reported ongoing bleeding and applying pressure, neither could recall specific findings or confirm documentation of assessments and interventions. Review of progress notes showed no evidence of monitoring or treatment from the time of the initial event through the early morning, despite facility policy requiring monitoring and documentation of acute condition changes. The resident was later sent to the hospital, where a tongue laceration with significant bleeding was treated with pressure, special glue, and stitches.
The facility failed to prevent physical abuse when one cognitively impaired resident with a history of agitation around others in his room struck another cognitively impaired, nonverbal, wandering resident on the forehead with a wooden hanger. Staff reported hearing commotion and, upon entering the room with the door closed, found the victim on the floor bleeding from a laceration above the eyebrow and the aggressor on the bed holding a wooden hanger and using profanity. ED documentation described an assault with a wooden hanger causing a 3 cm forehead laceration that required irrigation and closure with steri-strips, despite facility policy prohibiting physical abuse.
The facility failed to prevent two separate incidents of resident‑to‑resident physical abuse, resulting in injuries. In one case, a resident with moderate cognitive impairment was involved in an escalating confrontation with another cognitively impaired resident; both held chairs defensively before one pushed the other from a wheelchair, causing a fall and lacerations to the shin and knee. In another case, a cognitively intact resident with a known history of punching others, who was assigned a 1:1 sitter, abruptly charged and punched his severely cognitively impaired roommate in the face after mistakenly believing the roommate was wearing his shirt, causing facial swelling. These events occurred despite a facility policy guaranteeing residents’ rights to be treated with respect, kindness, and dignity.
A resident with severe cognitive impairment, dementia with agitation, a language barrier, and documented suicidal ideation was care planned for close monitoring and suicide precautions. An LVN later found the resident with a light‑string tightly around the neck, removed it, and the resident was subsequently transported to an acute care hospital by ambulance after police involvement. When the hospital MSW determined the resident was ready to return, the DON refused readmission, citing high self‑harm risk and lack of trained staff to meet the resident’s needs, despite these issues having been identified in the care plan months earlier. This refusal led to an extended hospital stay and placed the resident at risk for an unsafe, unplanned transition.
A resident with severe cognitive impairment and multiple neurologic conditions sustained a forehead laceration requiring stitches after being struck in the head with a chair by another resident. The aggressive resident, who had metabolic encephalopathy, anxiety, and an adjustment disorder, admitted hitting the other resident because he was angry about being awakened. An RN found the injured resident bleeding in the doorway of the aggressor's room while the aggressor stood inside holding a chair and screaming. The aggressor's care plan documented a pattern of physical and verbal aggression, including hitting, pushing, threatening, and throwing objects, while facility policy stated residents have the right to be free from abuse and neglect.
A facility failed to implement a psychiatry recommendation to increase the Olanzapine dosage for a resident with schizophrenia, leading to potential emotional distress. The resident exhibited paranoid delusions and agitation, but the recommended dosage increase from 10 mg to 15 mg was not followed. Staff interviews revealed a lack of awareness and follow-up on the recommendation, highlighting a communication breakdown in the facility's process.
Two residents reported missing personal items during a resident council meeting, but the facility failed to follow its grievance policy to address these complaints. The Activity Director informed staff, but the Social Worker did not receive the referral, and the Administrator was unaware of the grievances. The facility's policy requires prompt resolution of grievances, which was not adhered to in this case.
The facility failed to maintain a safe environment, with broken floor tiles, damaged baseboards, and chipped overbed tables posing risks to residents. A screen door was off track, electrical cords were unsafely taped, and a wall clock displayed incorrect time, causing confusion. A shared bathroom lacked soap for over two days, and the smoking patio had rusty furniture with sharp edges. Maintenance issues were not properly reported or addressed, violating the facility's maintenance policy.
The facility failed to ensure accurate PASRR assessments for two residents, leading to potential inappropriate placement and lack of necessary mental health services. One resident's PASRR Level 1 Screening was not resubmitted after 30 days, despite multiple mental health diagnoses. Another resident's assessment inaccurately marked 'No' for serious mental disorders and psychotropic medication use. The DON and MDSC acknowledged the inaccuracies, which could have led to appropriate mental health referrals.
The facility failed to enforce smoking safety policies, leading to potential hazards for residents. A resident with limited mobility kept smoking materials despite being unable to safely use them. Another resident was not properly assessed for smoking safety and smoked unsupervised. A third resident did not receive required safety items. Additionally, a janitor smoked near open resident rooms, and cigarette butts were improperly disposed of, posing fire risks.
The facility failed to conduct performance reviews and maintain competency records for three licensed nurses, placing residents at risk of receiving care from potentially incompetent staff. The DSD and DON acknowledged the absence of evaluations, and the facility's policy requires such evaluations upon hire and annually. This issue was previously identified in an annual recertification survey.
The facility failed to conduct required competency evaluations for CNAs, risking resident care quality. The DSD did not complete evaluations for CNAs 4, 6, and 7, and the ADM acknowledged non-compliance with policy requirements for CNA assessments.
The facility failed to maintain sanitary conditions in food storage and preparation areas, potentially exposing residents to foodborne illness. An unlabeled and undated bag of sliced ham was found in the refrigerator, and kitchen vents, fans, and window screens were dusty. The Maintenance Supervisor lacked documentation of cleaning activities, contrary to the facility's policies requiring labeled food storage and maintenance records.
A facility failed to maintain infection control practices as a nurse did not perform hand hygiene during medication administration, handling medication cups, eye drop bottles, and inhalers without sanitizing hands before and after glove use. Additionally, an IV pole used for nutritional feeding was found with dried stains, indicating lapses in cleaning protocols. These deficiencies were confirmed by staff interviews and a lack of cleaning documentation.
A facility failed to ensure effective communication with a non-English speaking resident who required an interpreter. Despite having a communication binder, staff were unaware of its existence and relied on gestures. The Director of Staff Development admitted no training was provided on using communication tools, and the facility lacked an interpreter phone line, contrary to their language access policy.
A resident with a documented interest in drawing and painting was not provided with sufficient materials or engagement opportunities, leading to inactivity and feelings of worthlessness. The activity logs lacked documentation of one-on-one participation, and the facility's policy on supporting residents' well-being was not followed.
A resident with a left hip contracture was not provided with an appropriate wheelchair for seven months, leading to physical discomfort and emotional distress. The resident was mostly bedbound due to the unsuitable Geri-chair and manual wheelchair, which affected their goal of returning to the community. Facility staff were unaware of the Geri-chair's limitations, and there was no documentation of a wheelchair evaluation since admission.
A resident with glaucoma did not receive their prescribed Brinzolamide eye drops because an RN mistakenly believed the medication was unavailable. The RN administered only Artificial Tears, not realizing that the Brinzolamide was part of the Simbrinza eye drop bottle already in the medication cart.
The facility failed to control access to the medication room, allowing unauthorized staff to enter, and left an unlabeled medication cup with a white substance unattended in a resident's room for over 24 hours. The CSS had access to the medication room despite not being authorized to handle medications, and a nurse could not confirm the contents of the medication cup, posing a risk to residents.
The facility did not ensure that the director of food and nutrition services met the required educational qualifications when a full-time registered dietitian was not hired. The Dietary Manager, who was not certified and still in school, worked full-time, while a Registered Dietician visited weekly for resident assessments. The Administrator was aware of the DM's lack of qualifications, placing residents at risk for foodborne illness and decreased nutrient intake.
A facility failed to accurately complete a discharge planning assessment for a resident, leading to an inaccurate reflection of the resident's clinical condition. The resident was assessed as independent in certain activities, despite being bedbound and dependent on staff for daily living activities. The Social Worker admitted to using assumptions rather than direct observations or consultations with care staff, contrary to facility policy requiring objective and accurate documentation.
A facility failed to follow a hospice agreement requiring a coordinated plan of care (POC) for a resident with dementia on hospice care. The resident and family were not included in a care plan conference, and staff interviews confirmed the lack of coordination. The facility's agreement required participation from hospice, facility, and family, which was not met.
The facility had seven rooms with multiple beds that did not meet the required 80 square feet per resident, providing only 79.33 square feet per bed. Despite this, observations showed adequate space for care, no interference from equipment, and no resident complaints or safety concerns.
Failure to Monitor and Document Care After Resident Tongue Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation of care for a resident who sustained a tongue injury. The resident was admitted with metabolic encephalopathy, morbid obesity, and paroxysmal atrial fibrillation, and was taking a blood thinner. An MDS dated 10/29/25 showed the resident had an intact BIMS score of 15/15. On 12/3/25 at 9:40 p.m., an LVN noted blood in the resident’s mouth, and the resident reported he had bitten his tongue. An SBAR form documented that the resident refused transfer to the hospital and that the MD’s recommendation was to continue monitoring. The facility’s Acute Condition Changes – Clinical Protocol required staff to monitor and document the resident’s progress and responses to treatment so the physician could adjust treatment accordingly. During interview, the LVN stated the resident was monitored every 15 minutes after the bleeding was noted but could not recall the resident’s condition at each check and did not remember documenting these assessments. The night-shift RN reported that the resident’s tongue continued to bleed through the night, but the RN did not know how much bleeding occurred, and although pressure was applied to the tongue, the RN was unsure whether monitoring and interventions were documented. Review of the resident’s progress notes from the evening of 12/3/25 through the early morning of 12/4/25 showed no documentation that the LVN or RN monitored the resident or provided interventions during that period. A subsequent SBAR form on 12/4/25 indicated the resident continued to bleed through the night, and the RN notified the MD of prolonged bleeding at 6:21 a.m., at which time EMS was called and the resident was sent to the hospital, where the tongue laceration required multiple methods to control significant bleeding related to blood thinner use.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, resulting in a head laceration and transfer to an acute care hospital. Resident 1, who had metabolic encephalopathy, unspecified dementia, and daily wandering behavior, was rarely or never understood and could not make himself understood, and a CNA reported that this resident often wandered the hallways and did not have the ability to defend himself. On the day of the incident, Resident 1 was later found in Resident 2’s room, sitting on the floor near the door with active bleeding from a laceration above the left eyebrow. Resident 2 had metabolic encephalopathy, unspecified dementia, and undifferentiated schizophrenia, with a BIMS score of 7/15 indicating severe cognitive impairment. Staff interviews indicated that Resident 2 tended to become agitated when people walked around his room. On the day of the incident, the charge nurse heard commotion and a low voice from Resident 2’s room, which had a closed door. Upon entering, the nurse found Resident 1 bleeding from the forehead and Resident 2 sitting on his bed holding a wooden hanger while using profanity. Although the nurse did not directly witness the strike, he stated it was evident that Resident 2 had hit Resident 1 with the hanger. Progress notes documented that the charge nurse immediately separated the residents and assessed Resident 1, noting bleeding on the left forehead above the eyebrow. Emergency Department provider notes described that Resident 1 had been assaulted with a wooden hanger to the head, resulting in a 3 cm horizontal laceration of the left forehead, which was irrigated and closed with steri-strips. The facility’s abuse prevention/prohibition policy stated that the facility does not condone any form of resident abuse and defined physical abuse as hitting, slapping, pinching, or kicking, but staff acknowledged that although Resident 1’s wandering had been monitored before the incident, they should have been more cautious about his whereabouts.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect residents from abuse when two separate resident‑to‑resident altercations occurred, resulting in injuries. In the first incident, a resident with moderate cognitive impairment (BIMS score 10/15) reported that another resident, also with moderate cognitive impairment (BIMS score 9/15), became angry, yelled, and pushed him from his wheelchair to the floor. A nurse later documented that both residents had been holding chairs and positioned defensively in an escalating altercation, and that attempts to de‑escalate were unsuccessful before the aggressor pushed the other resident, causing him to fall forward out of his wheelchair. The injured resident sustained lacerations to the left shin and right knee. The facility’s abuse and residents’ rights policy stated that residents are guaranteed rights to a dignified existence and to be treated with respect, kindness, and dignity. In the second incident, the facility did not prevent an assault by one resident on his roommate, who had severe cognitive impairment (BIMS score 4/15). The aggressor, who had intact cognition (BIMS score 14/15) and a known history of punching others that necessitated a 1:1 sitter, punched his roommate in the face after mistakenly believing the roommate was wearing his shirt. A CNA assigned as a 1:1 sitter stated she did not expect the resident to charge and punch the roommate while he was being escorted, and another CNA described the aggressor abruptly getting up, charging, and punching the roommate in the face while she was at the bedside setting up a meal tray. The injured resident sustained swelling below the right eye, for which pain medication and an ice pack were provided. These events occurred despite the facility’s written policy on abuse reporting, investigation, and residents’ rights to be treated with respect and dignity.
Failure to Provide Resident‑Centered Discharge Planning and Readmission for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an appropriate, resident‑centered discharge planning process and safe transition for a resident with known suicidal ideation and dementia. The resident had diagnoses including cognitive communication deficit and unspecified dementia with agitation, and an MDS BIMS score of 4/15 indicating severe cognitive impairment. The care plan documented a language barrier due to the resident’s primary language being Russian and identified suicidal ideation related to dementia, with interventions for close monitoring and suicide precautions. On one date, an LVN documented that the resident was found around 9:30 a.m. with a string used to turn the room light on/off wrapped tightly around her neck; the nurse intervened, removed the string, and notified the MD and responsible party. Later that day, progress notes indicated that police arrived around 4:00 p.m., attempted to calm the resident, and then called an ambulance, which transported the resident to an acute care hospital at approximately 4:20 p.m. At the acute care hospital, the MSW reported that the resident was considered ready for transport back to the facility the following day, but when the MSW contacted the facility’s DON, the DON declined to accept the resident back, citing the resident’s high risk for self‑harm and the facility’s lack of trained staff to meet the resident’s needs. The MSW also stated this was not the first time the facility had refused to readmit its residents. Hospital progress notes documented that the DON stated the facility would not accept the resident back due to high risk of self‑harm. In a later interview, the DON stated the facility did not accept the resident back because staff could not adequately communicate with the resident due to the language barrier and that the resident had not shown self‑harm behaviors prior to the incident, despite the care plan having identified both the language barrier and suicidal ideation months earlier. This refusal to readmit resulted in an extended acute care hospital stay and placed the resident at risk for an unsafe and unplanned transition.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the head with a chair. One resident, with Alzheimer's disease, Parkinson's disease, agitation, and severe cognitive impairment (BIMS score 4/15), was found by an RN sitting on the floor in the doorway of another resident's room with blood coming from the left side of his forehead. The injured resident could not recall going to the emergency department or how his head was injured. Progress notes documented a laceration on the left side of his forehead, and an acute care hospital encounter summary indicated a 4-centimeter laceration requiring stitches. The other resident involved had diagnoses of metabolic encephalopathy, anxiety, and adjustment disorder with mixed disturbance of emotions and conduct, and his MDS indicated he sometimes made himself understood and sometimes understood others. This resident's care plan, dated the same day as the incident, documented a history of physical and verbal aggression, including hitting, pushing, threatening, and throwing objects, with observed aggressive behavior toward staff and residents. During an interview, this resident stated he hit the other resident in the head with a chair because he was angry about being awakened. At the time of the incident, the RN observed this resident standing in his room holding a chair and screaming, while the injured resident was bleeding in the doorway. The facility had a policy stating residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.
Failure to Implement Psychiatry Recommendation for Resident with Schizophrenia
Penalty
Summary
The facility failed to provide appropriate treatment for a resident diagnosed with schizophrenia, as the recommended increase in Olanzapine dosage was not implemented. The resident, who had a history of paranoid delusions, was observed to become easily agitated and aggressive. Despite a psychiatry recommendation to increase the Olanzapine dosage from 10 mg to 15 mg daily, this adjustment was not made, potentially leading to increased emotional distress and a decline in the resident's mental and psychosocial well-being. The deficiency was identified through a review of the resident's records, which showed a positive Level I PASRR screening for mental illness, indicating the need for a Level II evaluation that was not conducted. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), revealed a lack of awareness and follow-up on the psychiatry recommendation. The DON, who was responsible for follow-ups, was unaware of the recommendation due to a failure in the facility's process of communicating psychiatry consult reports to the appropriate personnel.
Failure to Address Resident Grievances on Missing Personal Items
Penalty
Summary
The facility failed to adhere to its Grievance/Complaints, Filing policy and procedure by not promptly responding to and resolving grievances for two residents, identified as Resident 5 and Resident 26. Both residents reported missing personal items during a resident council meeting, with Resident 5 missing a purple brassiere with star symbols and Resident 26 missing two sport shirts. Despite these complaints being documented in the Resident Council Minutes, there was no follow-up action taken by the facility staff to address these grievances. Interviews revealed that the Activity Director informed the staff by leaving a referral for response in the social services mailbox, but the Social Worker stated she did not receive any such referral. The Administrator was also unaware of these grievances and acknowledged that the expectation was for complaints from resident council meetings to be addressed within a week. The facility's policy, revised in April 2017, mandates that the Administrator and staff make prompt efforts to resolve grievances, which was not followed in this instance.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several maintenance issues observed in different areas. In the resident care hallway, floor tiles were broken and coming off, posing a potential hazard. The Maintenance Supervisor (MS) acknowledged the issue but had not addressed it, despite conducting regular room rounds. Additionally, the baseboards in Rooms A and B were missing and broken, with drywall and plaster pieces sticking out, which MS also failed to notice during his rounds. In Rooms A and B, overbed tables for two residents were chipped and unfurnished, with rough edges that could cause injury. The screen door for Room A was broken and off the track, and MS admitted awareness of the issue but had not yet replaced it. Electrical cords for a television and a call light in Room B were taped to the wall, which MS recognized as unsafe but had not corrected due to a lack of staples. Furthermore, the wall clock in Room B displayed an incorrect time, causing confusion for a resident, and the shared bathroom between Rooms A and B lacked soap for over two days, despite being reported to the janitorial staff. The smoking patio contained broken and rusty furniture with sharp edges, which posed a risk of injury to residents. The Director of Staff Development (DSD) and MS acknowledged the condition of the furniture, but it had not been removed or replaced. The facility's maintenance logbook did not reflect these issues, indicating a lack of proper reporting and follow-up on maintenance needs. The facility's policy and procedure for maintenance services, which requires maintaining the building and equipment in a safe and operable manner, was not adhered to, leading to these deficiencies.
Inaccurate PASRR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for two residents, leading to potential inappropriate placement and lack of necessary mental health services. Resident 44's PASRR Level 1 Screening was not resubmitted after the resident remained in the facility for more than 30 days, despite having multiple mental health diagnoses including Unspecified Dementia with Psychotic Disturbance, Anxiety Disorder, Paranoid Personality Disorder, Depression, and Auditory Hallucinations. The facility's policy required a new Level 1 Screening within 40 days of admission if the stay exceeded 30 days, but this was not done, and the Director of Nursing (DON) incorrectly stated that the screening did not need to be repeated. Resident 37's PASRR Level 1 Screening was completed inaccurately, failing to identify the resident's serious mental disorders, including Depression and Schizophrenia, and the use of psychotropic medication, Trazadone, for Depression. The assessment incorrectly marked 'No' for questions regarding serious diagnosed mental disorders and the use of psychotropic medications. The DON mistakenly believed that Trazadone was not a psychotropic medication and that the assessment was accurate despite the resident's schizophrenia diagnosis. The MDS Coordinator (MDSC) acknowledged the inaccuracies and noted that the facility was responsible for reviewing the assessment for accuracy, which could have led to appropriate mental health referrals. The deficiencies in the PASRR process for both residents were identified through interviews and record reviews. The facility's failure to adhere to its own policy and accurately complete the PASRR assessments placed the residents at risk of not receiving the necessary mental health services. The MDSC confirmed the lack of records for psychiatric referrals or consults for Resident 37, highlighting the oversight in addressing the residents' mental health needs.
Failure to Enforce Smoking Safety Policies
Penalty
Summary
The facility failed to adhere to its smoking policy and procedures, leading to potential accident hazards for three residents. Resident 19, who has amputated fingers and limited range of motion, was found to be non-compliant with the smoking policy, keeping cigarettes and a lighter in her possession despite being assessed as unable to safely light, hold, and extinguish tobacco. The facility staff, including the Activity Assistant and Licensed Vocational Nurse, were aware of her non-compliance but did not enforce the necessary supervision or safety measures. Resident 41 was not properly assessed for smoking safety, and his care plan did not reflect his smoking habits. Despite being a known smoker, the charge nurses were unaware of his smoking status, and he was allowed to smoke unsupervised. The smoking evaluation conducted was incomplete, and the staff failed to communicate his smoking status to the attending physician or other direct care staff. This lack of oversight and communication resulted in Resident 41 smoking without the necessary supervision or safety precautions. Resident 37, who was assessed to require a smoking apron and cigarette holder due to balance issues, did not receive these safety items. The facility did not have smoking aprons available, and staff were unaware of their location or existence. Additionally, a janitor was observed smoking in the smoking patio with doors to adjacent rooms open, exposing residents to secondhand smoke. Cigarette butts were improperly disposed of in flower planters, posing a fire risk. These actions and inactions by the facility staff contributed to an unsafe environment for residents who smoke.
Failure to Conduct Competency Evaluations for Licensed Nurses
Penalty
Summary
The facility failed to complete performance reviews and maintain competency/skills records for three licensed nurses, identified as LVN 1, RN 2, and RN 4. This deficiency was discovered through interviews and record reviews conducted with the Director of Staff Development (DSD) and the Director of Nursing (DON). LVN 1, who was hired on June 17, 2024, reported not receiving any orientation, training, or competency evaluation upon or after hire. Similarly, RN 2 and RN 4, hired on May 5, 2023, and August 23, 2023, respectively, had no documentation of competency evaluations in their personnel files. The DSD acknowledged the absence of these evaluations and expressed uncertainty about how to anticipate staff training needs. The facility's policy and procedure, revised in May 2019, mandates that competency evaluations be conducted upon hire, annually, and as necessary based on facility assessments. However, the DON admitted to not having completed any competency evaluations since starting at the facility. The Administrator confirmed that the DON was responsible for these evaluations and noted that this issue had been identified in a previous annual recertification survey. The lack of competency evaluations for the licensed nurses placed residents at risk of receiving care from potentially incompetent staff, as the facility was unable to identify and address training needs effectively.
Failure to Conduct CNA Competency Evaluations
Penalty
Summary
The facility failed to complete annual performance reviews and competency checks for its Certified Nursing Assistants (CNAs), which are essential for ensuring the provision of competent care to residents. Specifically, the facility did not conduct or maintain records of competency checks for CNA 7, who has been employed since November 2020, and did not complete orientation competency checks for CNAs 4 and 6, who have been employed since May 2024 and January 2024, respectively. The Director of Staff Development (DSD) admitted to not having completed any competency checks in the past two months since starting the role, and the facility's policy requires these evaluations upon hire, after 90 days, and annually. The Administrator acknowledged that the facility's policy mandates standard orientation and competency assessments for CNAs, but these were not being conducted as required. The facility had been non-compliant with this requirement during a previous annual recertification survey as well. The lack of completed evaluations and documentation placed residents at risk of receiving care from potentially incompetent CNAs, as the facility did not ensure that CNAs were adequately trained and evaluated in necessary skills and techniques.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store and prepare foods in a sanitary manner, which could potentially expose residents to foodborne illness. During an initial tour of the kitchen, an opened bag of sliced ham was found in the refrigerator without a label or use-by date. This was observed by the Dietary Aide and Dietary Manager. Additionally, during a subsequent observation and interview, the kitchen's vents, fans, and window screens were found to be dusty. The Maintenance Supervisor, who was responsible for cleaning these areas monthly, admitted to not having any records or documentation of the cleaning. The facility's policy and procedure for food receiving and storage, revised in July 2014, requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Furthermore, the facility's sanitation policy from 2023 indicates that the Maintenance Department should assist Food & Nutrition Services in maintaining equipment and performing janitorial duties, with maintenance records kept on all equipment.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration by a registered nurse (RN). On multiple occasions, RN 2 did not perform hand hygiene before and after glove use while administering medications to residents. Specifically, RN 2 was observed preparing and administering medications to three different residents without sanitizing hands before donning gloves or after removing them. This included handling medication cups, eye drop bottles, and inhalers, as well as touching the medication cart and keys with contaminated gloves. During an interview, RN 2 acknowledged the importance of hand hygiene to prevent the transfer of bacteria and viruses. Additionally, the facility did not ensure the cleanliness of medical equipment, as evidenced by the condition of an IV pole in a resident's room. The IV pole, which was used for nutritional feeding, was observed with multiple dried light brown stains. Both a licensed vocational nurse (LVN) and the infection preventionist (IP) confirmed that the IV pole appeared unclean and acknowledged that there was no documentation of its cleaning schedule. The facility's policy required regular cleaning and disinfection of environmental surfaces, including IV poles, to prevent infection. The facility's failure to adhere to its own policies and procedures regarding hand hygiene and environmental cleaning posed a risk of cross-contamination and the spread of infections among residents. The infection preventionist confirmed that hand hygiene should be performed before and after glove use, and that environmental surfaces should be cleaned according to CDC recommendations. However, the observations and interviews indicated lapses in these practices, highlighting deficiencies in the facility's infection control program.
Failure to Utilize Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a non-English speaking resident, identified as Resident 43, who preferred to communicate in Chinese and required an interpreter for interactions with healthcare staff. Despite having a communication binder available, the staff, specifically CNA 5, was unaware of its existence and relied on gestures and pointing to communicate with the resident. This lack of awareness and utilization of the communication tool led to a communication barrier, as observed during an interaction where the resident was unable to effectively communicate her needs. The Director of Staff Development acknowledged that CNAs were expected to use communication binders for non-English speaking residents but admitted that no in-service training had been provided on this matter. Additionally, the facility lacked an interpreter access phone line, and the administrator mentioned that staff could use Google Translate as an alternative. The facility's policy on language access, revised in November 2020, stated that individuals with limited English proficiency should have meaningful access to information and services, a standard that was not met in this instance.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing and effective activity program to meet the preferences and goals of a resident, identified as Resident 37. The resident was admitted to the facility with a documented interest in activities such as drawing and painting, as noted in the Admission Minimum Data Set and discharge planning review. Despite these documented preferences, the resident was observed lying in bed without engagement in activities and expressed feelings of worthlessness due to inactivity. The resident reported a lack of adequate art supplies and insufficient visits from the activity staff to support his interests. The activity assistant confirmed that Resident 37 received only three visits per week for art and games at bedside and attended the activity room twice a month. However, the activity participation logs lacked documentation of one-on-one activity participation since July 2024. The facility's policy on activity programs, revised in 2018, states that activities should support the physical, mental, and psychological well-being of each resident, which was not adhered to in this case, leading to a risk of mental and psychosocial decline for the resident.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate wheelchair for a resident with a left hip contracture, who was admitted seven months prior. The resident's care plan indicated the use of assistive devices as ordered, but there was no documentation of a wheelchair evaluation in the therapy treatment records since admission. The resident expressed the need for a larger wheelchair, as the current Geri-chair was too small and uncomfortable, causing physical discomfort and limiting mobility. The facility had only one Geri-chair, which residents shared, and the manual wheelchair available was unsuitable in size and had non-functional brakes. The resident's goal was to return to the community with home health services, but the lack of appropriate mobility support left the resident mostly bedbound, contributing to feelings of worthlessness and hopelessness about achieving personal goals. The resident expressed sadness about missing significant family events and felt separated from family due to being confined to bed. Interviews with facility staff revealed a lack of awareness regarding the Geri-chair's weight limit and the responsibility for evaluating medical equipment needs, highlighting a gap in the facility's care provision and assessment processes.
Medication Administration Error Due to Misunderstanding of Eye Drop Contents
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident diagnosed with glaucoma. During a medication administration, a registered nurse (RN) was unable to locate the prescribed Brinzolamide eye drops in the medication cart and mistakenly believed they were unavailable. The RN proceeded to administer only the Artificial Tears eye drops, which were also prescribed for the resident's dry eyes. The RN was unaware of how long the Brinzolamide eye drops had been unavailable and planned to reorder them from the pharmacy. Upon further review, it was discovered that the Brinzolamide eye drops were in the medication cart all along, as they were part of the Simbrinza eye drop bottle, which contains both Brinzolamide and Brimonidine. The RN had mistakenly thought Simbrinza and Brinzolamide were two different medications. This oversight was documented in the resident's progress notes, and the facility's policy on administering medication clearly states that medications should be administered as prescribed.
Unauthorized Access and Improper Medication Storage
Penalty
Summary
The facility failed to ensure proper medication storage and access control, leading to two significant deficiencies. Firstly, an unauthorized staff member, the Central Supply Staff (CSS), had access to the medication room. The CSS was able to unlock the medication room door using a key provided to him when he started working at the facility. The Director of Nursing (DON) confirmed that the CSS was not authorized to prepare and administer medications, yet he was allowed to access the medication room to obtain over-the-counter medications. This was in direct violation of the facility's policy, which states that only authorized personnel should have access to the medication room. Secondly, an unlabeled and undated medication cup filled with a white creamy substance was found unattended on top of a resident's overhead light fixture for over 24 hours. The resident, identified as Resident 31, was lying in bed during the observation. The substance was suspected to be Eucerin cream by Registered Nurse 2 (RN 2), but this could not be confirmed due to the lack of labeling. RN 2 acknowledged that medication cups should be discarded after use and expressed concern that confused and ambulatory residents could easily access and ingest the unknown substance. This oversight posed a risk of accidental access to the substance by residents.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the person designated to serve as the director of food and nutrition services met the required federal and/or state educational qualifications when a full-time registered dietitian was not hired. The Dietary Manager (DM), who worked full-time, admitted during an interview that she was not a certified director of food and nutrition and was still in school. The facility had a Registered Dietician (RD) who visited weekly to complete new admission assessments of residents. The Administrator acknowledged awareness of the DM's lack of educational qualifications for the position. This lack of full-time, competent oversight of food and nutrition staff placed residents at risk for foodborne illness and/or decreased nutrient intake, which could potentially result in death and/or nutritional-related medical complications.
Inaccurate Discharge Planning Assessment
Penalty
Summary
The facility failed to accurately complete the functional status in the discharge planning assessment for one of the residents, leading to an inaccurate reflection of the resident's clinical condition. The resident, identified as Resident 37, was admitted to the facility and was assessed as being dependent on staff for various activities of daily living, including toilet hygiene, showering, lower body dressing, personal hygiene, and wheelchair mobility. However, during an observation, it was noted that the resident was bedbound and unable to fully extend both legs, contradicting the assessment that indicated independence in using a wheelchair and performing other activities. The Social Worker (SW) responsible for completing the discharge planning assessments admitted to using assumptions rather than direct observations or consultations with the resident's direct care staff. The SW had never observed the resident using a wheelchair or performing activities independently, yet the discharge planning review inaccurately reflected these capabilities. The Regional Social Services Director (RSS) acknowledged that the SW was trained to gather input from all disciplines working with residents, but this was not done in this case. The facility's policy on documentation emphasized the need for objective, complete, and accurate records, which was not adhered to in this instance.
Failure to Coordinate Hospice Care Plan
Penalty
Summary
The facility failed to adhere to a written hospice agreement that required joint responsibilities to develop and implement a coordinated plan of care (POC) for a resident admitted into a hospice program. The deficiency was identified when the resident's hospice POC did not reflect the participation of facility staff, the resident, and the resident's representative. The resident, who was on hospice care due to senile degeneration of the brain and had a diagnosis of non-Alzheimer's dementia, was not included in a care plan conference with the facility and hospice agency. The resident's family also reported not being invited to participate in the hospice POC. Interviews with facility staff, including the Director of Nursing, Registered Nurse/Hospice Nurse, and MDS coordinator, confirmed that a care planning conference involving the resident, family, and hospice agency had not taken place. The Regional Social Services Director acknowledged that the social services department was responsible for coordinating the care plan conference but had not invited the resident and family to participate. The facility's Nursing Facility Services Agreement stipulated that the POC should reflect the participation of hospice, facility, and the hospice patient and family, which was not adhered to in this case.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility was found to have seven resident rooms with multiple beds that did not meet the required space of at least 80 square feet per resident. Each of these rooms had three beds with a total area of 238 square feet, resulting in only 79.33 square feet per bed. This deficiency was identified through observation, interview, and record review. Despite the insufficient space, observations from 10/21/24 through 10/24/24 indicated that there was adequate space for the provision of care, no heavy equipment was present that could interfere with care, and residents had sufficient personal space and privacy. There were no complaints from residents about space for their belongings, and no negative consequences or safety concerns were noted due to the decreased space in these rooms.
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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