Loma Linda Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Loma Linda, California.
- Location
- 25383 Cole Street, Loma Linda, California 92354
- CMS Provider Number
- 055299
- Inspections on file
- 28
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Loma Linda Post Acute during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including dish drying racks with black substance build-up, cracks, and corrosion, as well as scoops with dry food residue stored among clean utensils. Additionally, expired wheat tortillas were found in the refrigerator, and facility policies regarding sanitation and food storage were not followed, as confirmed by the kitchen director.
A resident was admitted with major depressive disorder, anxiety disorder, and PTSD, but the PASARR assessment did not reflect these mental health diagnoses and incorrectly indicated no serious mental illness. The MDS nurse, responsible for reviewing PASARR accuracy, acknowledged the oversight, and the facility did not identify or correct the discrepancy as required by policy.
A resident with a history of mental health conditions was newly diagnosed with Paranoid Schizophrenia, but the facility did not notify the State Mental Health or Intellectual Disability authorities or complete a required PASARR. Staff interviews confirmed that the MDS Coordinator was responsible for these actions, but they were not carried out, and facility policy was not followed.
A resident with complex medical needs did not receive the physician-ordered frequency of physical therapy sessions, missing one session in a week without any documentation or explanation in the clinical record. Facility staff failed to follow policy requiring documentation of missed or refused treatments.
A resident with chronic kidney disease and dependent on dialysis was not consistently provided with a sack lunch to take to dialysis appointments, as required by physician orders and facility policy. Facility records and interviews confirmed multiple missed meals, and the DON acknowledged that an order for sack lunches was never obtained at admission. The resident experienced notable weight loss during this period.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Staff did not assess or document the condition of a resident's dialysis access site or general condition after the resident returned from scheduled hemodialysis treatments, despite care plan and policy requirements. The required Hemodialysis Communication Observation/Assessment forms were left incomplete on two occasions, and the DON confirmed that these assessments should have been performed and documented.
Three expired over-the-counter medications—Simethicone, Vitamin A, and Vitamin B complex—were found stored in a medication cabinet. Both the RNS and DON confirmed these medications should have been discarded per facility policy, but the expired drugs remained accessible in the medication storage room.
The facility did not post its most recent recertification survey results, leaving residents and visitors unable to access this information. A binder intended to contain survey results for multiple years was missing the latest report, and the Administrator confirmed the results were not available elsewhere in the facility, contrary to facility policy requiring survey reports to be readily accessible.
A resident with multiple medical conditions and a high fall risk assessment experienced an unwitnessed fall after being left in a room located in a busy hallway rather than near the nurse station. Despite care plan directives and facility policies requiring targeted interventions for fall prevention, the supervision and measures provided were insufficient, resulting in the resident being found on the floor and sent to the hospital for evaluation.
A facility failed to complete and transmit a discharge MDS for a resident, as required by CMS guidelines. The resident was readmitted and later discharged, but the discharge MDS was not completed within the required timeframe. Interviews with the MDS Coordinator, DON, and Administrator confirmed the oversight and highlighted the expectation for timely and accurate MDS assessments.
A resident with a complex medical history was found unresponsive with an unprescribed bottle of pills at their bedside, leading to a suspected narcotic overdose. The facility failed to report the incident to the state agency within the required 24-hour timeframe, as confirmed by the DON. The resident was later diagnosed with cardiac arrest and opioid overdose at an acute hospital.
Unsanitary Kitchen Conditions and Expired Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during inspection. Dish drying racks used for air-drying sanitized dishes were found to have significant black-colored substance build-up, scratches, cracks, and corrosion on both the interior and exterior surfaces, as well as on supporting pillars. The Director of Kitchen confirmed these unsanitary conditions and acknowledged the risk of cross-contamination, noting delays in receiving replacement racks. Additionally, three scoops with dry food residue were discovered stored among other clean scoops in a drawer designated for clean utensils. The Director of Kitchen was unable to explain how these unsanitary scoops were placed with clean ones. Further inspection revealed four bags of wheat tortillas in the walk-in refrigerator that were past their expiration date, which the Director of Kitchen confirmed should have been discarded. Review of facility policies and procedures indicated that the Food and Nutrition Services Director is responsible for ensuring sanitation and that no food should be kept beyond its expiration date. The Director of Kitchen acknowledged that these policies were not followed. Reference to the FDA Federal Food Code highlighted the requirement for non-food-contact surfaces to be free of food residue and other debris.
Failure to Accurately Update PASARR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that the PASARR assessment used for admission did not include the resident's diagnoses of major depressive disorder and anxiety disorder, and incorrectly indicated that the resident did not have a serious mental illness. The resident's medical records showed ongoing treatment with buspirone for anxiety and fluoxetine for depression, and these conditions were documented in the admission and social history records. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for reviewing the completion and accuracy of PASARR assessments for all new admissions. The MDS nurse acknowledged that the PASARR assessment was inaccurate and should have been revised to reflect the resident's mental health diagnoses, but this was not done. The facility's policy required all new admissions to be screened for mental disorders per the PASARR process, but the discrepancy in the resident's assessment was not identified or corrected.
Failure to Notify State Authorities and Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State Mental Health authority or the State Intellectual Disability authority when a resident was newly diagnosed with Paranoid Schizophrenia. The resident, who had a history of bipolar disorder, unspecified dementia with behavioral disturbance, and post-traumatic stress disorder, was diagnosed with Paranoid Schizophrenia and Schizophreniform Disorder on December 3, 2024. A review of the clinical record showed there was no documentation that a Preadmission Screening and Resident Review (PASARR) was completed following the new diagnosis, nor was there evidence that the California Department of Health Services or the State Mental Health Department were notified as required. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that the responsibility for making such notifications and referrals lies with the MDS Coordinator. The MDS Coordinator acknowledged the requirement to notify the appropriate state authorities and complete a new PASARR when a resident is identified with a new mental disorder diagnosis or experiences a significant change in status. However, the MDS Coordinator could not explain why these actions were not taken for this resident. Review of the facility's policy and procedure confirmed the requirement for prompt notification and PASARR completion, which was not followed in this instance.
Failure to Provide Ordered Physical Therapy and Document Missed Sessions
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including end stage renal disease, encephalopathy, respiratory failure, wounds, and legal blindness, did not receive physical therapy services as ordered by the physician. The resident was supposed to receive physical therapy four times a week for four weeks, as documented in the care plan and physician's orders. However, during the week in question, the resident only received three physical therapy sessions instead of the prescribed four. There was no documentation in the clinical record explaining the missed session or the reason for the deviation from the physician's order. Interviews and record reviews confirmed that facility staff did not document the missed physical therapy visit or provide a reason for the absence, despite facility policy requiring such documentation. The lack of adherence to the prescribed therapy schedule and the absence of required documentation were confirmed by the Regional Rehab Resource during a review of the resident's clinical record. Facility policies and best practices reviewed also indicated that all missed or refused treatments should be documented, which was not done in this case.
Failure to Provide Required Sack Lunches for Dialysis Resident
Penalty
Summary
Staff failed to provide required nutritional services to a resident dependent on dialysis, as the resident was not consistently given a sack lunch to take to dialysis appointments on multiple occasions. The resident, who had chronic kidney disease, anemia, and sepsis, reported not receiving a sack lunch on several dialysis days and sometimes missing breakfast as well. Review of the facility's records confirmed that on several documented dates, the resident was not provided a sack meal for dialysis, despite physician orders specifying a renal diet and nutritional supplements. The facility's policy required notification of dietary staff for sack lunches on dialysis days and monitoring of special diets, but this was not followed. The DON acknowledged that a physician's order for a sack lunch should have been obtained at admission but was not. The resident experienced a 5.17% weight loss over a three-month period, as documented in the clinical record, during the time when sack lunches were not consistently provided.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this failure, nor does it include information about the resident's medical history or condition at the time.
Failure to Assess and Document Dialysis Access Site Post-Treatment
Penalty
Summary
Facility staff failed to provide required assessment and monitoring for a resident who was dependent on hemodialysis. The resident, admitted with chronic kidney disease, dependence on renal dialysis, anemia in chronic kidney disease, and sepsis, had physician orders for dialysis three times weekly at an outside facility. The resident's care plan specified that staff should monitor, document, and report any signs or symptoms of infection or complications at the dialysis access site, including redness, swelling, warmth, drainage, bleeding, or hemorrhage. However, on two separate occasions following the resident's return from dialysis, there was no documented evidence that staff assessed the dialysis access site or the resident's general condition, as required by both the care plan and facility policy. Review of the Hemodialysis Communication Observation/Assessment forms for the relevant dates showed that sections for access site assessment, general condition, and pain level were left blank. The DON confirmed that staff were expected to assess and document the resident's status and access site immediately upon return from dialysis, but this was not done. Facility policy also required such assessments to be completed and documented. The lack of assessment and documentation was confirmed through record review and staff interview.
Expired Medications Found in Storage
Penalty
Summary
During an inspection of the medication storage room, three over-the-counter bottles of medication—Simethicone, Vitamin A, and Vitamin B complex—were found stored past their expiration dates. The Simethicone had expired in January 2025, the Vitamin A in June 2024, and the Vitamin B complex in September 2024. These expired medications were discovered in a medication cabinet accessible within the facility. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nurses (DON) confirmed that the expired medications should have been discarded according to the facility's policies and procedures. The facility's policies, reviewed during the survey, clearly state that expired medications must be removed from active supply and destroyed, and that discontinued, expired, or deteriorated drugs and biologicals are not to be used. Both the RNS and DON acknowledged that these policies were not followed, resulting in the continued storage of expired medications.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to post the results of its most recent recertification survey, as required, resulting in residents and visitors being unable to view the survey results and assess the facility's compliance with regulations. During an observation, a binder labeled as containing survey results for 2022, 2023, and 2024 was found posted in a main hallway, but upon review, it did not contain the 2024 recertification survey results. The Administrator confirmed that the most recent survey results were supposed to be in the binder but were missing, and also stated that the survey results were not posted anywhere else in the facility. The facility's policy indicated that survey reports and plans of correction should be readily accessible to residents, family members, resident representatives, and the public, and that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' day room.
Failure to Provide Adequate Supervision for High-Risk Fall Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents for a resident who was identified as high risk for falls. The resident, who had multiple diagnoses including pulmonary edema, abnormalities of gait and mobility, hypertension, respiratory failure, and colon cancer, was assessed as a high fall risk upon admission. The care plan indicated the resident was at risk for falls due to altered balance, unsteady gait, and confusion, and required assistance with activities of daily living. Despite these identified risks, the resident experienced an unwitnessed fall during the night, after being last repositioned by a CNA and later found on the floor calling for help. The facility's fall risk management policies required staff to identify and implement interventions based on the resident's specific risks and causes for falling. However, the resident was not placed near the nurse station and was located in a busy hallway instead. The bed was in the lowest position, and staff reminded the resident to use the call light, but the resident was not ambulatory and required assistance. The fall resulted in the resident being sent to an acute hospital for evaluation. Documentation and interviews confirmed that the interventions in place were insufficient to prevent the fall, despite the resident's high-risk status and care plan directives.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) for a resident, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's policy, revised in March 2022, mandates that a comprehensive assessment of every resident's needs be conducted at intervals designated by OBRA and PPS requirements, including a discharge assessment. However, the discharge MDS for the resident, who was readmitted on September 10, 2022, and discharged on March 13, 2024, was not completed. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator revealed that the discharge MDS was overlooked. The MDS Coordinator acknowledged the oversight and stated that she had 14 days to complete and submit the discharge MDS after a resident's discharge. The DON confirmed that the discharge MDS was missed and emphasized the expectation for MDS assessments to be completed accurately and submitted timely. The Administrator also expressed the expectation for timely and accurate completion and submission of MDS assessments.
Failure to Timely Report Narcotic Overdose Incident
Penalty
Summary
The facility failed to report a possible overdose of narcotics for a resident within the required 24-hour timeframe to the state agency, as per their policy. The resident, who had a complex medical history including chronic respiratory failure, end-stage renal disease, and type 2 diabetes, was found unresponsive with shallow breathing and low oxygen levels. An unprescribed and unlabeled bottle of pills was discovered on the resident's bedside table, leading to the suspicion of a narcotic overdose. The resident was sent to an acute hospital where they were diagnosed with cardiac arrest and opioid overdose. The Director of Nursing (DON) acknowledged that the incident, which occurred on a specific date, was not reported to the California Department of Public Health (CDPH) until several days later, following a verbal report from a hospital social worker about the resident's death due to overdose. The facility's policy required unusual occurrences to be reported via telephone within 24 hours and a written report within 48 hours. The delay in reporting was confirmed by the DON, who stated that they were waiting for updates from the hospital and family before making the report.
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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