Lompoc Skilled Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lompoc, California.
- Location
- 1428 West North Avenue, Lompoc, California 93436
- CMS Provider Number
- 555830
- Inspections on file
- 25
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lompoc Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple health conditions, including malnutrition and pressure ulcers, experienced repeated significant weight loss. Facility staff did not follow policy to re-weigh after a 5% or greater loss and failed to notify the RD in writing, instead relying on verbal communication. This led to increased weight loss, worsening malnutrition, delayed treatment, and slower healing of pressure sores.
A urinary catheter bag was found lying on the floor next to a resident with multiple health issues, contrary to facility policy requiring catheter bags to be kept off the floor. Additionally, a CNA delivered lunch trays to two residents without providing hand hygiene before meals, in violation of the facility's infection control standards.
A facility failed to ensure a resident's self-administration of medication was approved by the IDT. A rescue inhaler was found in the resident's drawer, which the resident used as a backup when smoking outside. A nurse was unaware of the inhaler's presence and confirmed the resident lacked approval to self-administer medications. Facility policy requires IDT and physician approval for self-administration.
The facility did not keep the survey results binder up-to-date, with the most recent results missing from April 2024 to January 2025. This oversight was acknowledged by the Administrator during an interview, highlighting a lapse in ensuring residents and their families had access to the latest survey findings.
The facility failed to ensure call lights were within reach for two residents, as required by their care plans. Observations revealed that one resident's call light was on the floor, and another's was behind a radio, both out of reach. This oversight could lead to unmet needs and increased fall risk.
The facility failed to follow physician orders for three residents, leading to potential health risks. A resident did not have blood pressure documented before receiving Hydralazine, another was not weighed daily for heart failure monitoring, and a third had no blood pressure readings documented before withholding Lisinopril. The Director of Staff Development confirmed these documentation gaps.
The facility failed to ensure emergency drugs were available when ordered, as the Emergency Drug Supply Kit (E-Kit) was not reordered timely after being opened. An opened E-Kit with red locks was observed, indicating it had been accessed, but the last reorder was documented in August 2024. The facility's policy requires medications used from the E-Kit to be replaced upon the next routine drug order.
Two residents experienced significant medication administration errors. One resident with type 1 diabetes did not receive Insulin Aspart as per the sliding scale, and another resident with multiple conditions did not receive Diltiazem, Metoprolol Tartrate, and Clonidine according to prescribed parameters. The facility's staff failed to follow medication administration procedures, leading to these errors.
The facility failed to label nebulizer medications with opened dates for several residents and did not discard expired test strips, as observed during an interview with the DSD. Unlabeled and undated medication packets, including Albuterol, DuoNeb, and Budesonide, were found in medication carts. Additionally, expired Coaguchek XS PT test strips were not discarded, contrary to the facility's policy.
The facility failed to ensure accurate documentation of POLST in the EMR for three residents. A resident's POLST indicated DNR, but the EMR showed FULL CODE, acknowledged by an LPN. Another resident's POLST also indicated DNR, but the EMR showed FULL CODE, confirmed by the DSD. A third resident's POLST indicated DNR, but the EMR showed FULL CODE, confirmed by an LPN. These discrepancies could affect residents' end-of-life care preferences.
The facility failed to maintain infection control practices for respiratory equipment, as observed in several residents. A nebulizer for a resident was left uncovered, contrary to policy. Additionally, nasal cannula tubing for three residents was not labeled or dated, with some tubing touching the floor. These actions did not comply with the facility's policy requiring weekly changes and labeling, potentially leading to cross-contamination and healthcare-associated infections.
A resident's urine outputs via Foley catheter were not accurately documented, potentially contributing to their transfer to the ER. The resident experienced pain, and upon ER arrival, the catheter was removed, releasing urine and relieving pain. The task for documenting output was not initiated until days after intake was recorded, resulting in no outputs being documented. The facility's policy required documentation of input and output, which was not followed.
Failure to Follow Policy for Significant Weight Loss Notification
Penalty
Summary
The facility failed to follow its own policy regarding the management of significant weight loss in residents. Specifically, for one resident with multiple diagnoses including anemia, malnutrition, dysphagia, and multiple pressure ulcers, the facility did not re-weigh the resident after a weight loss of 5% or more, nor did they immediately notify the Registered Dietitian (RD) in writing as required by their policy. The resident experienced several instances of weight loss exceeding 5% within one-week intervals, but there was no documentation that the RD was notified in writing, and the process for re-weighing and written notification was not followed. Interviews with facility staff confirmed that the current practice was to notify the RD verbally rather than in writing, and that the policy for re-weighing and written notification was not being implemented. The DON acknowledged that the facility's actual process did not match the written policy. As a result, the resident experienced increased weight loss, worsening malnutrition, delayed medical treatment, and slower healing of pressure sores, as directly stated in the report.
Failure to Follow Infection Control Protocols for Catheter Care and Hand Hygiene
Penalty
Summary
A deficiency was identified when a urinary catheter bag belonging to a resident with multiple medical conditions, including a right femur fracture, acute kidney failure, and pressure ulcers, was observed lying on the floor beside the resident's bed. This was confirmed by a licensed nurse, who acknowledged that the catheter bag should not be on the floor, in accordance with the facility's catheter care policy, which requires that catheter tubing and drainage bags be kept off the floor. Additionally, a certified nursing assistant was observed delivering lunch trays to two residents and placing them on their bedside tables without offering hand hygiene before the residents began eating. The CNA acknowledged not providing hand hygiene, which was contrary to the facility's standard precautions policy that requires personnel to assist residents with hand hygiene before meals.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident's self-administration of medication was approved and determined as clinically safe and appropriate by the interdisciplinary team (IDT). During an observation and interview, a rescue inhaler labeled Atrovent HFA was found in the resident's bedside table drawer. The resident stated that the inhaler was brought from home to use as a backup when going outside the facility to smoke. A licensed nurse was unaware of the inhaler's presence and confirmed that the resident did not have approval from the physician and the IDT to self-administer medications. The facility's policy requires that residents may only self-administer medications if the attending physician and the IDT have determined it is safe for them to do so.
Failure to Maintain Current Survey Results Binder
Penalty
Summary
The facility failed to maintain an up-to-date survey results binder accessible to the public, as required by their policy. During an observation and interview with the Administrator at the facility's main entrance, it was found that the most current survey results available in the binder were from March 15, 2024. The binder was missing survey results from April 8, 2024, through January 30, 2025. The Administrator acknowledged that the survey results binder was not current and needed updating. This failure prevented residents, family members, and legal representatives from being informed of the most recent survey results.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to adhere to care plan interventions regarding the accessibility of call lights for two residents, Resident 44 and Resident 17. During an observation, Resident 44's call light was found on the floor, out of reach, which was confirmed by a Certified Nursing Assistant (CNA 2). The care plan for Resident 44 indicated that the call light should be within reach to prevent falls and encourage the resident to use it for assistance. Similarly, Resident 17's call light was observed behind a radio on the nightstand, also out of reach, as confirmed by CNA 1. The care plan for Resident 17 also specified that the call light should be within reach to mitigate fall risks. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timetables to meet residents' needs. However, the failure to ensure the call lights were accessible for these residents indicates a lapse in following these care plans. This oversight had the potential to leave the needs of Resident 44 and Resident 17 unmet by the staff, as the call lights are a critical tool for residents to request assistance and prevent falls.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to potential health risks. For Resident 93, the staff did not document blood pressure readings before administering Hydralazine, a medication for hypertension, on multiple occasions. This oversight occurred despite a clear physician order to withhold the medication if the systolic blood pressure was below 110. The Director of Staff Development (DSD) confirmed the absence of documentation for these readings, which were required to ensure safe medication administration. Resident 32 was not weighed daily as ordered by the physician for heart failure monitoring, with a specific instruction to notify the physician if there was a weight gain of more than three pounds. The Treatment Administration Record (TAR) lacked documentation of a weight measurement on a specific date, which the DSD acknowledged as a failure to follow the physician's order. Additionally, for Resident 12, the facility did not document blood pressure readings before withholding Lisinopril, another hypertension medication, on several occasions. The DSD noted that the electronic health record system did not require a blood pressure entry if the medication was not administered, leading to gaps in documentation and potential non-compliance with physician orders.
Failure to Reorder Emergency Drug Supply Kit
Penalty
Summary
The facility failed to ensure that emergency drugs were available to residents when ordered, as the Emergency Drug Supply Kit (E-Kit) was not reordered in a timely manner after being opened for use. During an observation and interview with the Director of Staff Development (DSD), it was noted that an opened E-Kit with red locks was present in the medication storage room, indicating it had been accessed by facility staff. The DSD confirmed that the nurse who opened the E-Kit should have reordered it the same day. However, the last documented reorder of the E-Kit was in August 2024, and there was no evidence of it being reordered from the time it was opened until February 2025. The facility's Policy and Procedure on Emergency Medications, dated April 2021, states that medications and supplies used from the emergency kit must be replaced upon the next routine drug order. This failure to reorder the E-Kit as per the policy had the potential to result in emergency drugs not being available during an emergency.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as directed and ordered for two residents, leading to significant medication errors. Resident 72, who was admitted with type 1 diabetes mellitus and other related conditions, did not receive the prescribed Insulin Aspart according to the sliding scale when their blood sugar levels were within the parameters set by the physician. On multiple occasions, the resident's blood sugar levels were recorded, but the insulin was not administered, and the reason was incorrectly coded as 'no med required - outside parameter.' Interviews with the licensed nurse and the Director of Staff Development confirmed that the insulin sliding scale was not followed, and there was no documentation to justify the non-administration of insulin. Resident 42, who had diagnoses including type 2 diabetes mellitus, COPD, and hypertension, also experienced medication administration errors. The resident was prescribed Diltiazem, Metoprolol Tartrate, and Clonidine, with specific parameters for administration based on blood pressure and heart rate. However, these medications were not administered on several occasions despite the resident's vital signs being within the parameters for administration. Conversely, there were instances where medications were given when they should have been held. The Director of Staff Development acknowledged that the staff did not adhere to the medication administration parameters for this resident. The facility's policy and procedure for administering medications, dated April 2019, stated that medications should be administered in accordance with prescriber orders, including any required time frames. The failure to follow these procedures for both residents resulted in significant medication errors, as confirmed by the review of the Medication Administration Records and interviews with facility staff.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that nebulizer medications were properly labeled with opened dates for two sampled residents and three unsampled residents. During an observation and interview with the Director of Staff Development (DSD), it was noted that several liquid inhalation medication solution packets, including Albuterol, DuoNeb, and Budesonide, were found unlabeled and undated in various medication carts. The facility's policy and procedure for administering medications, dated 2021, requires that the expiration or beyond-use date on the medication label be checked prior to administering and that the date opened be recorded on the container when opening a multi-dose container. Additionally, the facility failed to discard expired test strips, as observed during an interview with the DSD. Three vials of Coaguchek XS PT test strips were found with expired dates in a medication cart. According to the facility's policy and procedure for medication labeling and storage, outdated or deteriorated medications or biologicals should be returned or destroyed as per instructions from the dispensing pharmacy. These failures had the potential to result in residents receiving expired and ineffective medications.
Discrepancies in POLST Documentation in EMR
Penalty
Summary
The facility failed to ensure that the medical records for three residents accurately documented their Physician Orders for Life-Sustaining Treatment (POLST) in the electronic medical record (EMR). For Resident 94, the POLST indicated a Do Not Resuscitate (DNR) status, while the EMR showed a physician order for FULL CODE, indicating a preference for all possible life-saving measures. This discrepancy was acknowledged by a licensed nurse who stated that the EMR should have been updated to reflect the DNR status when the POLST was completed. Similarly, Resident 37's POLST indicated a DNR status, but the EMR contained a physician order for FULL CODE. The Director of Staff Development acknowledged the mismatch and noted that the EMR should have been updated when the POLST was signed. For Resident 17, the POLST indicated a DNR status, but the EMR showed a FULL CODE status. A licensed nurse confirmed that the order for the new DNR status was not updated in the EMR. These discrepancies had the potential to result in the residents not receiving their desired preferences for end-of-life care.
Infection Control Lapses in Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain proper infection control practices concerning respiratory care equipment for several residents. In the case of Resident 62, a nebulizer with an attached T-piece and tubing was observed uncovered on a nightstand, which was acknowledged by a licensed nurse who was unaware of the requirement to cover or enclose the equipment. The facility's policy indicated that nebulizer equipment should be stored in a plastic bag with the resident's name and date after use, which was not followed in this instance. Additionally, the facility did not label and date nasal cannula tubing for three residents, which is a critical step in preventing cross-contamination. Resident 12 was observed with oxygen tubing touching the floor and without a date label, a situation confirmed by a licensed nurse who acknowledged the tubing should not be on the floor and should be dated. Similarly, Resident 89's oxygen tubing was also found touching the floor and undated, and Resident 70's nasal cannula tubing lacked a label. The facility's policy requires oxygen tubing to be changed and labeled every seven days, which was not adhered to in these cases. The infection preventionist confirmed that oxygen nasal cannula tubing and nebulizers are to be changed weekly and labeled with the date and time, a practice that was not consistently implemented. These lapses in infection control practices had the potential to result in cross-contamination and healthcare-associated infections, posing a risk to residents' health and safety.
Failure to Document Catheter Output Leads to ER Transfer
Penalty
Summary
The facility failed to accurately document the urine outputs via Foley catheter for a resident, which may have contributed to the resident's transfer to the emergency room. The resident experienced pain related to the catheter, and upon arrival at the ER, the catheter was removed, releasing a significant amount of urine and relieving the pain. The resident reported a lack of consistent communication from the staff regarding catheter care, with conflicting advice being given. The Director of Staff Development confirmed that the task for documenting catheter output was not initiated until several days after the resident's intake was recorded, resulting in no urine outputs being documented until that time. The resident's physician orders indicated a need for evaluation due to excess hematuria, and the facility's policy required the documentation of input and output, which was not followed. The catheter care plan, created after the deficiency was identified, instructed staff to empty the catheter bag and record the urine amount at the end of each shift.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
