Maywood Acres Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxnard, California.
- Location
- 2641 South C Street, Oxnard, California 93033
- CMS Provider Number
- 055597
- Inspections on file
- 27
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Maywood Acres Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain the walk-in refrigerator door in the kitchen, leading to potential temperature abuse, as the door would not remain closed, causing internal temperatures to rise. Additionally, there was no appropriate air gap between the dish machine drain and the floor sink drain, risking backflow contamination. The maintenance supervisor was unaware of the required air gap specifications, and the facility's policy for interior maintenance was not adequately followed.
The facility failed to follow its policy on checking room temperatures, affecting three residents who reported discomfort due to heat. Observations revealed that a resident was lying in bed without clothes, another had two fans blowing warm air, and a third used a fan attached to the bed. The Maintenance Supervisor was unaware of the policy's requirement to check temperatures between noon and 4 p.m., leading to incomplete temperature logs.
A facility failed to complete a CMS-required discharged MDS assessment for a resident who was discharged with orthopedic aftercare of surgical amputation. The MDS discharge assessment was 137 days overdue. The MDS Coordinator acknowledged responsibility for the missed assessment and admitted it could have been completed on time.
A facility failed to conduct accurate assessments for a resident with an AV shunt undergoing dialysis. Observations revealed missing vital signs in the Dialysis Communication Records on multiple occasions, contrary to the facility's Hemodialysis Care policy. Staff confirmed the oversight, acknowledging the absence of required pre and post-dialysis assessments.
The facility failed to develop care plans for two residents using pad alarms as restraints and another resident with Hepatitis C. Observations and record reviews confirmed the absence of care plans, which was acknowledged as an oversight by staff. Facility policy mandates care plans upon admission and updates as needed, but this was not adhered to.
A facility failed to ensure nursing staff competency in medication administration, leading to errors and documentation failures. An LVN administered the wrong medication to a resident, believing it was correct despite discrepancies. Another resident's vital signs were not documented before administering Carvedilol, and a third resident on Apixaban lacked monitoring for side effects. The DON confirmed these deficiencies.
A facility failed to monitor side effects and behaviors for a resident prescribed Mirtazapine for depression. The resident's care plan required monitoring depressive behaviors and documenting side effects every shift, but records show this was only initiated months after the prescription. An LVN confirmed the lack of monitoring, which was against the facility's policy on psychotropic medications.
Two residents on mechanical soft, chopped diets were served meals that did not meet their dietary requirements, with one resident receiving improperly sized food and another receiving unchopped food. The facility's diet manual was not properly implemented, increasing the risk of choking.
The facility failed to serve lunch in an attractive manner, with food items of similar brown color and mushy noodles due to prolonged hot holding. Three residents expressed dissatisfaction, noting mushy vegetables and lack of freshness. The kitchen staff prepared food too early and held it at a cooking temperature, contrary to facility policies. The RD and CDM acknowledged the lack of color and inappropriate preparation timing.
A resident experienced hypoxia and diaphoresis during PT, with oxygen levels fluctuating between 88%-95% RA. The PT assistant informed the charge nurse, who returned the resident to bed and administered oxygen without a physician's order. The physician was notified later, leading to a delay in emergency care. The facility's policy requires immediate reporting of such changes, which was not followed.
The facility failed to follow its policy for residents going out on a leave of absence. For two residents, multiple instances were found where the required documentation, including return time and signatures by a licensed nurse or facility representative, was incomplete or missing.
Refrigerator Door and Dish Machine Air Gap Deficiencies
Penalty
Summary
The facility failed to maintain the door of a walk-in refrigerator in the kitchen in a safe, operating condition. During observations and interviews, it was noted that the door would not remain closed after being pushed shut, leading to potential temperature abuse. The internal thermometer of the refrigerator read 50 degrees Fahrenheit, and a milk carton inside measured 53 degrees Fahrenheit, indicating a failure to maintain appropriate food storage temperatures. The external thermometer used by dietary staff showed compliance, but the door was observed not to be completely shut, with a visible gap allowing warm air to enter. The maintenance supervisor acknowledged the issue and mentioned previous attempts to fix the door, but no follow-up was conducted to ensure the problem was resolved. Additionally, the facility did not ensure an appropriate air gap between the dish machine drain and the floor sink drain, which is necessary to prevent contaminated water from backing up into the dish machine. Observations revealed that the black plastic pipe draining wastewater from the dish machine was near the floor of the floor sink drain, lacking the required air gap. The maintenance supervisor was unaware of the appropriate air gap specifications according to plumbing codes or the FDA food code, and the registered dietitian confirmed the absence of an appropriate air gap, highlighting the potential for backflow contamination. The facility's policy and procedure for interior maintenance, which includes checking major kitchen equipment and plumbing connections, was not adequately followed. The FDA Food Code specifies the need for proper maintenance of equipment to prevent health risks, such as ensuring refrigeration units are capable of maintaining safe temperatures and providing an air gap to prevent backflow contamination. The facility's failure to adhere to these guidelines resulted in deficiencies that could compromise resident safety.
Failure to Implement Room Temperature Policy
Penalty
Summary
The facility failed to implement its policy on checking resident room temperatures, affecting three of nine sampled residents. During observations and interviews, it was noted that Resident 50 was lying in bed without clothes, covered only by a sheet, and expressed discomfort due to the heat. Resident 78 had two fans blowing towards her but still felt hot, indicating that the fans were only circulating warm air. Resident 45 was using a fan attached to the bed's siderail and also reported that the room was too hot. The Maintenance Supervisor (MS) was interviewed and revealed that room temperatures were checked and recorded daily at 10:00 a.m., but the logs did not indicate the time of the temperature checks. Upon reviewing the facility's policy, it was found that room temperatures should be checked between 12 noon and 4 p.m., when temperatures typically peak. The MS was unaware of this requirement and had been using a form provided to him since he started in January 2023, which did not include a section to record the time of temperature checks.
Failure to Complete Timely MDS Discharge Assessment
Penalty
Summary
The facility failed to complete a CMS-required discharged Minimum Data Set (MDS) assessment for a resident who was discharged. The facility's policy and procedure, dated May 2016, mandates adherence to the Resident Assessment Instrument (RAI) Manual Assessment schedules as required by federal and state agencies. The Resident Assessment Coordinator (RAC), who is a Registered Nurse, is responsible for the effective and efficient interdisciplinary care coordination and completion of a comprehensive plan of care from admission to discharge. The resident in question was admitted to the facility with diagnoses including orthopedic aftercare of surgical amputation. The resident was discharged home, as indicated in the Nursing Progress Notes, but the MDS discharge assessment was not completed in a timely manner, being 137 days overdue. The MDS Coordinator acknowledged the responsibility for the missed discharged assessment and admitted that the assessment could have been opened and completed prior to the resident's discharge.
Inaccurate Assessment of Dialysis Care
Penalty
Summary
The facility failed to ensure an accurate assessment reflective of a resident's status at the time of the assessment. This deficiency was identified for one resident who had an AV shunt for dialysis access. During an observation, the resident was noted to have a clean and well-maintained AV shunt and reported attending dialysis sessions three times a week. However, discrepancies were found in the documentation of the resident's dialysis schedule and vital signs assessments. The Dialysis Communication Records for the resident were missing vital signs for several dates, indicating a lack of pre and post-dialysis assessments as required by the facility's policy. Both a registered nurse and the Medical Records Director confirmed the absence of these vital signs, acknowledging that the assessments were not conducted. The facility's policy on Hemodialysis Care mandates conducting pre and post-dialysis assessments, which were not adhered to in this case.
Failure to Develop Care Plans for Restraints and Hepatitis C
Penalty
Summary
The facility failed to develop care plans for three residents, which led to deficiencies in their care. For two residents, pad alarms were used as restraints, but there were no care plans in place to address this. During observations, one resident was seen in bed with a pad alarm, and another was in a wheelchair with a similar device. Upon reviewing the medical records, it was confirmed by the RN and Medical Records Director that care plans for these restraints were missing, which they attributed to oversight. Additionally, a third resident with a diagnosis of Hepatitis C did not have a care plan addressing this condition. The absence of a care plan was confirmed during a review of the resident's clinical records and an interview with an LVN. The facility's policy requires care plans to be initiated upon admission and updated as needed, but this was not followed, resulting in the lack of appropriate care planning for the residents involved.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in medication administration, leading to several deficiencies. One incident involved a Licensed Vocational Nurse (LVN) administering the wrong medication to a resident. The resident was prescribed Senna 8.6 mg, but the LVN administered Senna Plus, which contains both Senna and Docusate sodium. The LVN mistakenly believed that Senna Plus was the correct medication, despite the discrepancy in the medication order. This error was acknowledged by the Director of Nursing (DON) after being informed of the situation. Another deficiency was identified when staff failed to accurately document blood pressure and heart rate readings for a resident before administering Carvedilol, a medication used to treat high blood pressure. The resident's Medication Administration Record (MAR) showed only four blood pressure readings and no heart rate readings, contrary to the requirement to check these vital signs before administering the medication. The LVN and DON confirmed the lack of documentation, acknowledging the oversight in monitoring the resident's condition prior to medication administration. Additionally, the facility did not implement monitoring for medication side effects and bleeding complications for a resident receiving Apixaban, a medication that prevents blood clots. The MAR for this resident did not include any monitoring orders for potential side effects or complications associated with the medication. Both the LVN and DON confirmed the absence of necessary monitoring orders, recognizing the failure to adhere to the facility's policy and procedures for medication administration.
Failure to Monitor Side Effects and Behaviors for Antidepressant Use
Penalty
Summary
The facility failed to ensure proper monitoring for side effects and manifestations of behaviors for a resident prescribed Mirtazapine, a medication used to treat depression. The resident, diagnosed with Major Depressive Disorder, was prescribed Mirtazapine on April 24, 2024, due to depression manifested by a lack of interest in food. The care plan for the resident, dated May 2, 2024, included interventions to monitor depressive behaviors and document side effects and effectiveness every shift. However, the Medication Administration Record (MAR) for August 2024 showed that monitoring for depressive episodes and side effects was only initiated on August 20, 2024, indicating a lack of documentation and monitoring from April 24, 2024, to August 19, 2024. During an interview on August 20, 2024, a Licensed Vocational Nurse confirmed the absence of monitoring for behavior occurrences or side effects related to Mirtazapine. The facility's policy on Psychotropic Medications and Behavior Management required documentation of behaviors for which psychotropic medications are used, to be recorded on the Monthly Behavior Monitoring Sheet and/or MAR every shift. This lack of adherence to the policy resulted in the potential for unrecognized side effects and manifestations of behaviors in the resident.
Failure to Adhere to Prescribed Diets for Residents
Penalty
Summary
The facility failed to ensure that the dietary needs of two residents on a mechanical soft, chopped diet were met according to their physician's orders and the facility's diet manual. During an observation, Resident 19's lunch was found to have pieces of baked chicken larger than the specified 1/2 inch size for a chopped diet. Despite the Registered Dietitian initially stating the meal was acceptable, a review of the diet manual confirmed that the pieces were too large, and the mechanical soft, chopped diet was not followed. Additionally, Resident 19's meal tray card did not provide instructions for the double portions required by the physician's order. In another instance, Resident 1 was served a meal that did not adhere to the prescribed mechanical soft, chopped consistency. The meal included chicken chow mein and other items that were not chopped as required. A licensed nurse confirmed that the meal did not match the prescribed diet after inspecting the tray. Resident 1's records indicated a need for a mechanically altered diet due to swallowing and nutritional status requirements. The facility's policies and procedures, including the diet manual and tray service protocol, were reviewed and found to lack proper implementation. The diet manual was not signed by the Registered Dietitian, indicating a lack of formal approval. The facility's failure to adhere to the prescribed dietary requirements increased the risk of choking for the residents involved.
Deficiency in Food Presentation and Preparation
Penalty
Summary
The facility failed to ensure that residents' lunch was served in an attractive and appetizing manner, as observed during a survey. The food items on the plate were of similar brown color, and the noodles were mushy due to being hot held for a prolonged period before the lunch meal service. Three residents expressed dissatisfaction with the facility's food, noting that the vegetables were mushy and lacked freshness, primarily using frozen vegetables. The facility's menu planning did not adhere to the standard practice of including a variety of colors to present food attractively, which could lead to reduced food intake and potential weight loss. During the survey, it was observed that the kitchen staff prepared the chicken chow mein and vegetables early in the morning and hot held them at 350 degrees Fahrenheit, which is a cooking temperature rather than a holding temperature. This resulted in the noodles becoming mushy and the vegetables losing their color and texture. The pureed food served to residents also lacked color, with two brown scoops of food on the plate that were indistinguishable without a menu. The facility's recipe and policy indicated that food should be prepared close to serving time to maintain its nutritive value and appearance, which was not followed in this instance. The facility's policies and procedures, as well as the recipe for chicken chow mein, were reviewed and found to emphasize the importance of preparing food close to serving time and maintaining its attractiveness and nutritive value. However, these guidelines were not adhered to, resulting in the deficiency. The Registered Dietitian (RD) acknowledged the lack of color and the mushy appearance of the food, which did not meet the standards of practice in menu planning. The Certified Dietary Manager (CDM) also confirmed that the food was prepared too early and held at an inappropriate temperature.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident, which could have delayed emergency medical care. The resident experienced hypoxia and diaphoresis during a physical therapy session, with oxygen saturation levels fluctuating between 88% and 95% on room air. The physical therapy assistant noticed the resident's condition and informed the charge nurse, who returned the resident to bed and administered two liters of oxygen without a physician's order, citing it as an emergency. The incident occurred between 10:30 a.m. and 11:00 a.m., but the physician was not notified until 12:00 p.m., when orders were given to transfer the resident to the emergency room. The facility's policy requires immediate reporting of changes in condition to the physician, which was not followed in this case. The delay in notification and the administration of oxygen without a physician's order were key factors in the deficiency.
Failure to Follow Leave of Absence Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding residents going out on a leave of absence for two sampled residents. According to the facility's policy, residents must fill out a Release of Responsibility for Leave of Absence Form, which includes the name and signature of the person accompanying the resident, the time the resident left, and the destination. Upon return, a licensed nurse or facility representative must document the return time and sign the form. However, for Resident 1, out of 14 instances of leaving the facility, 13 times lacked documentation of the return time and signature by a licensed nurse or facility representative. Similarly, for Resident 2, out of 22 instances, 21 times lacked the destination information, and on four occasions, the return time and signature were missing. During a concurrent record review and interview with the Director of Nursing (DON) and the Director of Staff Development (DSD), it was acknowledged that the forms for both residents were incomplete and did not comply with the facility's policy. The DON and DSD confirmed that the forms were filled out incorrectly on the specified dates, indicating a failure to follow the established procedures for residents going out on a leave of absence. This deficiency highlights the facility's lapse in ensuring proper documentation and supervision of residents when they leave and return to the facility.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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