Menifee Lakes Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sun City, California.
- Location
- 27600 Encanto Drive, Sun City, California 92586
- CMS Provider Number
- 056185
- Inspections on file
- 53
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Menifee Lakes Post Acute during CMS and state inspections, most recent first.
The facility did not complete required annual performance evaluations for three CNAs, leaving their personnel records without current assessments of job performance, goals, attendance, and policy adherence. The DSD, who is responsible for CNA evaluations, confirmed that no annual evaluations had been done and acknowledged their importance for ensuring staff competency in providing resident care. The DON also confirmed that these evaluations had not been completed and should have been, noting they are necessary to ensure staff can provide appropriate care and meet residents’ needs. This failure was not consistent with the facility’s written evaluation policy, which requires formal written annual evaluations for employees.
A resident with contractures of the left arm, documented as having decision-making capacity, reported to a family member and later to an RN supervisor that a CNA handled her roughly during perineal care, including slamming her left arm onto the bed. The resident expressed feeling unsafe and wanting to leave. Despite facility policy requiring physician consultation for significant physical, mental, or psychosocial changes, and staff acknowledgment that such an allegation constitutes a change in condition, there was no documentation that the physician was notified of the incident.
A resident with contractures and intact decision-making capacity reported to a family member and later to the RNS that a CNA was rough during perineal care and slammed the resident’s arm on the bed, causing the resident to feel unsafe and want to leave. Despite facility policy and expectations requiring all abuse allegations to be reported to the DON, administrator, and State Agency within two hours, the RNS did not report the allegation, and there was no documentation of timely notification to required authorities.
A resident with contractures of the left arm, who was capable of making decisions, reported that a CNA slammed her arm on the bed during nighttime incontinence care. Facility records showed no assessment for injury, pain, or emotional distress and no monitoring or interventions initiated after the allegation. An RN supervisor and the DON both acknowledged that this should have been treated as a change of condition under facility policy, with assessment and physician notification, but confirmed that no such assessment or monitoring was completed.
A resident admitted with CHF and angina, who had documented decision-making capacity, did not receive a written summary of the baseline care plan as required by facility policy. Record review showed no evidence that the baseline care plan summary was provided, and staff interviews revealed confusion and lack of awareness about required timeframes and the obligation to give a copy to the resident or responsible party. The MDS nurse described a practice of completing baseline care plans within 72 hours and providing copies, while an LVN reported unfamiliarity with baseline care plans and the RN supervisor was unaware of the 48–72 hour requirement or the need to share the plan. The DON stated that the admission nurse and department heads are responsible for initiating and completing the baseline care plan within 48 hours and that a copy should be given to the resident or representative, but confirmed there was no documentation that this occurred for the resident.
A resident with a traumatic subdural hematoma, history of falls, and abnormal gait, care planned as a fall risk with an intervention to keep the call light within reach, was observed with the call light hanging out of reach on the side of the bed. The resident reported normally using the call light for assistance but could not locate it. A CNA acknowledged missing the call light and confirmed it should have been secured in front of the resident. Facility policies on call light accessibility and the fall prevention program require staff to keep call lights within reach, which was not done in this case.
A resident with Parkinson’s disease and mild cognitive impairment, previously assessed as having bed mobility and balance difficulties and whose representative had requested grab bars, was observed without bed rails/grab bars in place. After a hospital transfer and subsequent readmission, the facility did not complete a required reassessment for bed rail/grab bar use, despite facility policy and prior recommendations, and the DON confirmed that this reassessment should have occurred but did not.
A resident with recurrent UTIs caused by multidrug-resistant Pseudomonas aeruginosa did not have required infection precautions implemented despite multiple positive urine C&S results. The IPN and DON stated that facility practice and policy required EBP or CIP, physician orders, PPE use, and precaution signage when an MDRO such as Pseudomonas is identified, yet there was no documentation of orders or initiation of EBP or CIP after the initial symptomatic MDRO UTI or after the resident’s readmission from the hospital with continued MDRO Pseudomonas. Surveyors observed the resident on antibiotics without any precaution signage posted, and record review confirmed that the facility’s own policies on EBP and transmission-based precautions for MDROs were not followed.
A resident with diabetes and other complex medical conditions was admitted without documentation of baseline blood glucose or meal intake. Insulin was administered before confirming food intake, and staff failed to communicate essential information about the resident's status. This led to a hypoglycemic event requiring emergency intervention, in violation of facility policy for diabetic care.
The facility did not ensure that several residents had copies of their advance directives (ADs) in their medical records or that residents and their representatives were provided with information and education about formulating ADs. In multiple cases, documentation was missing to show that ADs or DPOAs were obtained or discussed, despite residents being cognitively intact and assessments indicating these steps should have been taken.
Nursing staff failed to properly document the administration and wasting of controlled substances for two residents. In both cases, CS medications were signed out on the count sheet but not recorded on the MAR, and one instance of medication waste lacked a second nurse's witness signature, resulting in unaccounted doses and incomplete records as confirmed by the DON and an LVN.
A resident with type 2 diabetes was not provided a controlled carbohydrate diet after being discharged from hospice and remaining in LTC. Despite fluctuating blood sugar levels and an elevated Hgb A1c, the resident continued on a regular diet without physician review or dietary adjustment, contrary to facility policy and care plan directives.
Nursing staff did not properly disinfect shared equipment such as BP cuffs, stethoscopes, and glucometers according to manufacturer instructions, and a neurotherapy nurse failed to wear required PPE while providing care to a resident on enhanced barrier precautions. These actions were not consistent with facility policy or infection control protocols.
A resident with a history of chronic subdural hemorrhage and nasal septal deviation experienced ongoing shortness of breath and difficulty breathing, but staff did not assess the condition, update the care plan, or document the change as required by facility policy.
A resident with ESRD did not receive required post-hemodialysis weight assessments on two occasions, as the responsible nurse failed to document or perform these checks after dialysis treatments. This was confirmed by both LVN and RN staff during interviews and record reviews, and was not in accordance with the facility's policy for ongoing assessment after dialysis.
The facility did not ensure timely medically-related social service referrals for two residents. One resident with a history of stroke and blood thinners experienced gross hematuria and had a physician order for a CT scan, but the referral was not completed due to unresolved authorization issues. Another resident with a deviated nasal septum and chronic subdural hemorrhage had a physician order for an ENT evaluation for shortness of breath, but no referral was made, and staff were unaware of the order.
A resident with multiple diagnoses and prescribed several sedating medications experienced two falls after changes in their medication regimen. Facility staff did not request an intermediate medication regimen review (MRR) following these falls, and the consultant pharmacist was not notified or able to make recommendations regarding the potential contribution of polypharmacy to the falls. The facility's policies requiring additional MRRs after significant changes in condition were not followed, and the monthly MRRs did not address the risk of medication-related adverse effects.
A surveyor found an opened multi-dose vial of Tuberculin PPD stored unrefrigerated in a medication cart, contrary to manufacturer instructions and facility policy requiring refrigeration. The LVN present could not confirm how long the vial had been unrefrigerated, and the DON acknowledged the storage error.
A resident with multiple health conditions reported an abuse allegation involving a staff member, which was not reported to the CDPH within the required two-hour timeframe. Despite staff awareness of the reporting policy, the incident was reported approximately 10 hours later, violating the facility's policy.
The facility failed to conduct annual fit testing for N-95 respirators for a PT treating COVID-19 residents, contrary to its Respiratory Protection Plan. The PT had not been fit tested for approximately two years, despite the policy requiring annual testing. This oversight could contribute to the spread of COVID-19 among vulnerable residents.
The facility failed to accommodate the needs of two residents. One resident was not provided with bedrails for repositioning despite a documented need, and another resident's call light was not within reach, contrary to her care plan and facility policy. These oversights could lead to unmet needs and lack of timely assistance.
A resident's room in the facility was found to have missing slats in the curtain blinds, which were not documented in the maintenance repair log. The resident, with a history of palliative care and various medical conditions, was aware of the issue but could not recall reporting it. Interviews with staff revealed inconsistencies in the process of reporting and documenting maintenance issues, with some staff unaware of the maintenance log's existence.
A resident's legal representative requested access to medical records, but the facility failed to provide them within the required timeframe. The Medical Records Director delayed forwarding the request to the legal team, resulting in a breach of the facility's policy and potentially impacting the resident's care.
Failure to Complete Required Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to maintain current personnel records by not completing required annual performance evaluations for three CNAs, resulting in an inability to assess staff performance, identify areas needing improvement, and ensure competency in providing resident care. Review of personnel files on March 13, 2026, showed no documented annual performance evaluations for CNA 1, hired August 16, 2022, CNA 2, hired August 30, 2023, and CNA 3, hired February 28, 2024. During a concurrent interview and record review, the Director of Staff Development (DSD) acknowledged responsibility for completing CNA performance evaluations and confirmed there was no documentation of annual evaluations for these three CNAs, stating that such evaluations are important to ensure staff competency in resident care. In a separate interview, the Director of Nursing (DON) confirmed that the DSD is responsible for CNA evaluations, acknowledged that annual evaluations for these CNAs had not been completed and should have been, and stated that annual evaluations are necessary to ensure staff are competent in providing appropriate care and meeting residents’ needs. A review of the facility’s policy titled “Evaluation Process,” dated December 19, 2022, indicated that the facility is to review employee work performance with a formal written evaluation annually, considering factors such as job performance, achievement of preset goals, attendance records, and adherence to workplace policies. The absence of annual performance evaluations for the three CNAs was therefore not in accordance with the facility’s own written policy and represented a failure to follow established procedures for monitoring and documenting staff performance and competency.
Failure to Notify Physician After Resident’s Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition after a resident alleged rough handling by staff. On the night of February 25, 2026, the resident told a family member that a CNA slammed her left arm onto the bed while attempting to wake her for a brief change. The family member reported that the resident subsequently stated she did not feel safe and wanted to leave the facility. The resident’s admission record showed she was admitted on September 17, 2025, with contractures of the left elbow, wrist, and hand, and her history and physical dated September 18, 2025, documented that she had the capacity to understand and make decisions. The RN supervisor reported that on the morning of February 25, 2026, she became aware of the incident when the resident reported that the CNA was rough with her during perineal care. The RN supervisor stated this alleged incident was considered a change of condition and that the physician should have been notified. The DON stated that staff are expected to notify the physician of significant changes in condition, including allegations of abuse, and that the licensed nurse should have reported the change in condition to the resident’s physician. A review of the medical record showed no documentation that the physician was notified following the allegation of abuse, despite the facility’s “Notification of Changes” policy requiring consultation with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
Failure to Timely Report Allegation of Abuse to DON and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a resident with contractures of the left elbow, wrist, and hand. The resident, who had documented capacity to understand and make decisions, told a family member that during the night a CNA slammed her left arm on the bed while attempting to wake her for a brief change. The resident reported feeling unsafe and wanting to leave the facility following the incident. There was no documented evidence in the electronic medical record that this allegation was reported to the DON, the administrator, or the State Agency within two hours of the allegation being made, as required. On the morning of the same date, the RNS became aware of an incident when the resident reported that the CNA had been rough with her during perineal care. The RNS acknowledged that this was considered an allegation of abuse that should have been reported immediately to the DON and to the State Agency, in accordance with facility expectations and policy. The RNS stated she did not report the incident to the DON or the State Agency. The DON confirmed that staff were expected to report any allegations of abuse to the DON and administrator within two hours and that such allegations should be reported to the State Agency. The facility’s Abuse, Neglect, and Exploitation policy required reporting all alleged violations to the administrator, state agency, and other required agencies immediately, but not later than two hours after the allegation is made.
Failure to Assess and Monitor Resident After Alleged Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a resident after the resident alleged that a staff member handled her roughly during care. The resident, who was admitted with contractures of the left elbow, wrist, and hand and had documented capacity to understand and make decisions, reported that during the night a CNA slammed her left arm on the bed while attempting to wake her for a brief change. Record review showed no documented evidence that the resident was assessed following this incident for injury, pain, or emotional distress, and no evidence that any monitoring or interventions were initiated in response to the allegation. The RN Supervisor stated she became aware the morning after the incident that the resident reported the CNA was rough during care and acknowledged this should have been treated as a change of condition. She stated the resident should have been assessed and monitored, but no assessment or monitoring was completed. The DON similarly stated that licensed nurses were expected to complete a change of condition assessment, notify the physician, and perform assessment and monitoring when a concern is identified, and confirmed that this was not done for this resident after the alleged incident. The facility’s “Notification of Changes” policy required informing the resident and consulting with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
Failure to Provide Written Baseline Care Plan Summary to Newly Admitted Resident
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a newly admitted resident, identified as Resident C. Resident C was admitted with diagnoses including congestive heart failure and angina pectoris, and a History and Physical documented that the resident had the capacity to understand and make decisions. During an unannounced survey, record review showed no evidence that a written summary of the baseline care plan had been provided to the resident or the resident’s representative, despite the facility’s policy requiring development of a baseline care plan within 48 hours of admission and provision of a written summary to the resident and representative. Interviews with staff revealed inconsistent understanding and implementation of the baseline care plan process. The MDS nurse reported that baseline care plans are completed within 72 hours and that nurses are to give a copy to the resident or responsible party. An LVN stated she was not familiar with the baseline care plan because she was not involved in admissions. The RN Supervisor stated she was not aware that the baseline care plan was supposed to be completed within 48 to 72 hours or that residents or responsible parties were to receive a copy. The DON stated that the admission nurse initiates the baseline care plan and department heads complete it within 48 hours, and that a copy should be provided to the resident or representative, but acknowledged there was no proof that any care plan meeting occurred with Resident C or that a copy of the baseline care plan summary was provided.
Call Light Not Kept Within Reach for Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when a resident at risk for falls did not have their call light within reach. During an observation and interview on January 30, 2026, at 8:17 a.m., the resident’s call light button was seen hanging on the left side of the bed, out of the resident’s reach. The resident reported that she normally used the call light when she needed staff assistance but could not locate it at that time. The resident’s admission record showed diagnoses including traumatic subdural hematoma, history of fall, and abnormality of gait. Her care plan documented that she was at risk for falls related to a history of falls prior to admission and unsteady gait/balance, with an intervention specifying that the call light should be placed within reach. At 8:30 a.m. the same day, a CNA assigned to the resident acknowledged during an interview in the resident’s room that she had missed the call light button and that it had been left hanging on the left side of the bed, not within the resident’s reach. The CNA stated the call light should have been positioned and secured in front of the resident. The DON later stated that fall-risk residents are discussed during the morning huddle and acknowledged that a call light not within reach may present a potential risk for falls. Review of facility policies titled “Call Light Accessibility and Timely Response” and “Fall Prevention Program,” both dated December 19, 2022, showed that staff are required to ensure call lights are within reach and secured, and that fall prevention measures include ensuring call lights are within reach, which was not followed in this instance.
Failure to Reassess Bed Rail/Grab Bar Need After Resident Readmission
Penalty
Summary
The deficiency involves the facility’s failure to reassess a resident for the use of bed rails/grab bars upon readmission, as required by its own policy. During an unannounced Quality-of-Care complaint investigation, a resident with Parkinson’s disease and mild cognitive impairment was observed sitting in a wheelchair at bedside with no side rails or grab bars attached to the bed. Review of the resident’s prior bed rail assessment from June 11, 2025, showed documented bed mobility issues, including difficulty moving in bed, moving to a sitting position, and maintaining standing/sitting balance. That assessment also recorded that the resident’s representative reported the resident had fallen at home and requested grab bars, with recommendations for left and right grab bar assistance. Record review showed the resident had been transferred to a general acute care hospital on November 12, 2025, and readmitted on November 16, 2025. There was no documented evidence that the resident was reassessed for the use of bed rails or grab bars following this readmission, and the resident did not currently have grab bars on the bed. In interviews, the DON stated that facility policy requires assessment for bed rails upon admission, readmission, and at the request of the resident/representative or nursing staff, and acknowledged that the resident was not reassessed for grab bar use after readmission despite this policy. The facility’s written policy on proper use of bed rails requires reassessments at least quarterly and upon a significant change in status, but this was not carried out for the resident after returning from the hospital.
Failure to Implement MDRO Infection Precautions for Recurrent Pseudomonas UTI
Penalty
Summary
The deficiency involves the facility’s failure to initiate and maintain appropriate infection prevention precautions for a resident with repeated UTIs caused by multidrug-resistant Pseudomonas aeruginosa. During an unannounced visit, surveyors observed that the resident, who reported being on antibiotics for a UTI and feeling better, had no signage outside the room indicating any infection prevention precautions. The Infection Prevention Nurse (IPN) explained that the facility’s process was to monitor residents on antibiotics during weekday clinical review meetings and that when a urine culture and sensitivity (C&S) showed an MDRO such as Pseudomonas, infection control interventions such as Enhanced Barrier Precautions (EBP) or Contact Isolation Precautions (CIP) should be initiated, with corresponding signage and PPE requirements posted outside the resident’s room. Record review for the cognitively intact resident showed a series of UTIs and positive C&S results for MDRO Pseudomonas. Progress notes documented that on one date in October, the resident complained of painful urination, a C&S was ordered, and antibiotics were started for a UTI. The C&S result reported on a later October date confirmed MDRO Pseudomonas, and the physician changed the antibiotic to one susceptible to the organism. However, there was no documentation that physician orders were obtained or implemented for CIP at that time, despite the IPN’s statement that CIP should have been initiated for this symptomatic MDRO UTI. The DON later confirmed that on that October date, the resident was diagnosed with a symptomatic UTI caused by Pseudomonas and that CIP was not implemented and no physician order was obtained. Further review showed that in early November the resident was transferred to an acute hospital for evaluation of recurrent UTI, where a urine C&S again showed Pseudomonas. The resident was readmitted to the facility with new antibiotic orders for UTI, but there was no documented evidence that EBP or CIP were initiated upon readmission, despite the hospital C&S indicating MDRO Pseudomonas. The IPN stated that EBP should have been started when the resident was readmitted, and the DON stated that an EBP should have been initiated upon admission for the asymptomatic MDRO UTI but was not, and that if a physician’s order is not received, it cannot be verified that precautions were initiated. Facility policies on Enhanced Barrier Precautions and Transmission-Based (Isolation) Precautions identified multidrug-resistant Pseudomonas aeruginosa as an important MDRO and required EBP for the duration of the resident’s stay and transmission-based precautions for residents known or suspected to be infected or colonized with such organisms, but these were not implemented for this resident as required.
Failure to Monitor Blood Glucose and Meal Intake for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to monitor blood glucose levels, assess meal intake, and ensure proper communication among staff for a newly admitted resident with diabetes. The resident, who had a history of type 2 diabetes mellitus with ketoacidosis, chronic kidney disease stage 3, and a below-knee amputation, was admitted without documentation of baseline blood glucose or oral intake. The clinical admission form lacked this essential information, and the physician's order specified insulin administration before breakfast. On the morning following admission, the resident received insulin at 7:00 a.m. with a recorded blood glucose of 99. Shortly after, the resident was found unresponsive with a critically low blood sugar of 25. Emergency interventions included administration of glucagon and orange juice, which gradually improved the resident's condition. Interviews with nursing staff revealed that there was no communication regarding the resident's last meal or baseline blood glucose, and the assigned nurse was unaware of whether the resident had eaten prior to insulin administration. Facility policy required documentation of blood glucose levels and meal intake for diabetic residents, as well as communication of this information among staff. Multiple staff members, including the DON, confirmed that these steps were not followed. The lack of documentation and communication led to the administration of insulin without confirming food intake, resulting in a hypoglycemic event for the resident.
Failure to Provide and Document Advance Directive Information and Accessibility
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were properly managed for six of nine residents reviewed. Specifically, there was no copy of the AD available in the medical record for one resident, and five other residents or their representatives were not provided with information or education regarding the formulation of an AD. In several cases, documentation was missing to show that the facility had followed up on whether residents had an AD or Durable Power of Attorney (DPOA), and copies of these documents were not placed in the residents' records as required. For example, one resident was noted in the social service assessment to have a DPOA, but there was no evidence that a copy was obtained or that the resident or their representative was given information about ADs. Another resident was indicated to have an AD and POLST available, but no copy of the AD was found in the medical record. Multiple residents were cognitively intact, as indicated by their BIMS scores, yet there was no documentation that they or their representatives received education or resources about ADs, nor was there evidence of follow-up regarding their wishes. Interviews with the Social Services Assistant confirmed that assessments should include notations about AD discussions and that copies of ADs and DPOAs should be placed in the medical record. However, the records reviewed did not consistently reflect these practices. The facility's own policy required determining if a resident had executed an AD, providing information and education, and ensuring copies were accessible to staff and physicians, but these steps were not documented for the affected residents.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substance (CS) medications for two residents. For one resident with an order for Ativan 1 mg as needed for anxiety, nursing staff signed out a tablet on the controlled drug count sheet but did not document its administration on the Medication Administration Record (MAR). Additionally, a tablet of Ativan was wasted without a second nurse's witness signature on the count sheet, contrary to facility policy. For another resident with an order for hydrocodone-acetaminophen 5/325 mg as needed for pain, a tablet was signed out on the count sheet but not documented as administered on the MAR. Interviews with the DON and an LVN confirmed that the facility's process requires documentation of CS administration on both the count sheet and MAR, and that two licensed nurses must witness and document any waste of CS medications. The discrepancies resulted in unaccounted doses and incomplete records for both residents, as acknowledged by facility staff during the review of records and interviews.
Failure to Adjust Diabetic Resident's Diet After Change in Health Status
Penalty
Summary
The facility failed to provide a recommended diet for a resident with type 2 diabetes mellitus following a change in health status. After being discharged from hospice services and remaining in long-term care, the resident continued to receive a regular diet despite having diabetes and experiencing fluctuating blood sugar levels. The care plan indicated the need for a dietary consult and ongoing monitoring, but there was no documentation that the resident's diet was reviewed or clarified with the physician after the change in status. The resident expressed a desire for meals with fewer carbohydrates, and laboratory results showed an elevated Hgb A1c of 8.8%. Interviews with facility staff, including a Licensed Vocational Nurse, the Minimum Data Set Nurse, and the Registered Dietitian, confirmed that the resident remained on a regular diet without a controlled carbohydrate intervention. Staff acknowledged that the resident's diet should have been reassessed and clarified with the physician after the significant change in condition. Facility policies required that therapeutic diets be provided as prescribed and that changes in a resident's condition prompt notification and consultation with the physician, but these procedures were not followed in this case.
Failure to Follow Infection Control Practices for Equipment Disinfection and PPE Use
Penalty
Summary
Nursing staff failed to implement proper infection control practices when cleaning and disinfecting shared resident care equipment, including blood pressure cuffs, stethoscopes, and glucometers. During medication pass observations, staff were seen using Sani-Cloth Prime disposable wipes but did not adhere to the manufacturer's specified contact time, which requires the equipment to remain visibly wet for one minute. Both the Infection Preventionist and Director of Nursing confirmed that staff were expected to follow these instructions, but interviews revealed a misunderstanding of the correct procedure, with staff believing that simply wiping and allowing the equipment to air dry was sufficient. Additionally, a neurotherapy nurse did not wear the required personal protective equipment (PPE), specifically an isolation gown, while providing care to a resident on enhanced barrier precautions due to a gastrostomy tube. The nurse entered the resident's room and performed contact care without donning the appropriate PPE, later stating she forgot to check the signage and wear the gown. The Assistant Director of Nursing and Infection Preventionist both confirmed that the expectation was for staff to follow designated precaution protocols and wear PPE as indicated for residents on enhanced barrier precautions. The facility's policies and procedures, as well as the manufacturer's instructions for disinfectant wipes, were reviewed and clearly outlined the requirements for cleaning and disinfecting reusable equipment and the use of PPE for residents on enhanced barrier precautions. Despite these established protocols, staff actions did not align with the documented procedures, resulting in lapses in infection prevention and control.
Failure to Assess and Care Plan for Resident's Respiratory Change
Penalty
Summary
A resident with a history of chronic subdural hemorrhage and nasal septal deviation reported experiencing shortness of breath and difficulty breathing for about a month, with a visibly deviated nasal bridge and nasal-sounding speech. Despite these ongoing symptoms, there was no documentation that the resident had been assessed for shortness of breath, and the issue was not addressed by the nursing staff. Interviews with facility staff revealed that the Minimum Data Set Nurse acknowledged a care plan should have been initiated for the resident's change in condition, but this was not done. Additionally, a Licensed Vocational Nurse was unaware of the resident's nasal septal deviation or respiratory symptoms and confirmed that an assessment, care plan update, and documentation should have occurred. Review of facility policy indicated that changes in resident status require notification, assessment, care plan revision, and communication among staff, none of which were completed in this case.
Failure to Complete Post-Hemodialysis Assessments
Penalty
Summary
The facility failed to complete post-hemodialysis assessments for a resident with End Stage Renal Disease (ESRD) on two separate occasions. Specifically, the licensed nurse did not assess or record the resident's weight after dialysis treatments on January 10, 2025, and January 27, 2025, as documented in the Dialysis Communication Form. This omission was confirmed during interviews and record reviews with both a Licensed Vocational Nurse and a Registered Nurse Supervisor, who acknowledged that the required post-dialysis assessments were not performed on those dates. The facility's policy on hemodialysis care requires ongoing assessment and monitoring of residents before and after dialysis treatments, including the assessment of weight to detect potential complications. The failure to follow this policy resulted in missed opportunities to identify and manage possible complications related to fluid balance for the resident receiving dialysis.
Failure to Obtain Timely Medically-Related Social Service Referrals
Penalty
Summary
The facility failed to ensure that medically-related social service referrals were obtained for two residents. For one resident with a history of stroke, hemiplegia, and hemiparesis, who was on blood thinners due to DVT and had experienced gross hematuria, a physician order was written to schedule a CT scan of the abdomen and pelvis. Although a follow-up call was made to the imaging center and an issue with the authorization address was noted, there was no documentation that the incorrect address was corrected or that the referral process was completed. The social services assistant confirmed that no further follow-up was documented and the CT scan referral remained incomplete. For another resident with chronic subdural hemorrhage and a deviated nasal septum, who reported ongoing shortness of breath and nasal obstruction, a physician order was written for an ENT evaluation. However, there was no documentation that a referral to an ENT specialist was made. The LVN interviewed was unaware of the order, and the social services assistant stated that the department did not receive the referral order until much later, despite the order being dated previously. The facility's policy indicated that the social services department is responsible for identifying and ensuring the provision of medically-related social services, but this process was not followed in these cases.
Failure to Request Medication Review and Address Polypharmacy After Resident Falls
Penalty
Summary
The facility failed to request a medication regimen review (MRR) by a licensed pharmacist following significant changes in a resident's condition, specifically after two falls, and did not ensure that the consultant pharmacist identified or made recommendations regarding potentially sedating medications that could have contributed to these falls. The resident involved was elderly, had multiple complex diagnoses including metabolic encephalopathy, schizoaffective disorder, anxiety, depression, and mobility issues, and was prescribed several medications with sedating effects such as oxycodone-acetaminophen, quetiapine, trazodone, gabapentin, Remeron, Ativan, and Depakote. Despite the addition of new medications and the occurrence of falls, the facility did not initiate an intermediate MRR as outlined in their policies and procedures. Interviews with facility staff, including the ADON, DON, and consultant pharmacist, revealed that the process for requesting an additional MRR after a change in condition, such as a fall, was not followed. The nursing staff did not notify the pharmacy or request a review after the resident's falls, and the consultant pharmacist was not made aware of these incidents. The consultant pharmacist confirmed that if notified, he would have recommended additional monitoring for increased risk of falls, dizziness, and sedation due to the combination of medications. The monthly MRRs conducted in the months surrounding the incidents did not include any recommendations to address the potential for medication-related falls or suggest changes to the resident's medication regimen. The facility's policies required ongoing evaluation of psychotropic medications and specified that an MRR should be conducted during significant changes in a resident's condition. Documentation showed that these procedures were not followed, as no additional MRR was requested after the resident's falls, and the consultant pharmacist did not identify or report the potential for medication-related adverse effects. Interviews with the medical director and psychiatric nurse practitioner further confirmed that the combination of medications could have contributed to the resident's falls, but no action was taken to review or adjust the medication regimen in response to these events.
Improper Storage of Refrigerated Medication
Penalty
Summary
A surveyor inspection of the 300 Hall medication cart, conducted in the presence of an LVN, found an opened and used multi-dose vial of Tuberculin PPD stored unrefrigerated in the top drawer of the medication cart. The LVN was unable to specify how long the vial had been stored outside of refrigeration and acknowledged that the PPD vial should have been kept refrigerated, not in the cart. The Director of Nursing later confirmed that the manufacturer's instructions require the PPD vial to be stored between 2 and 8 degrees Celsius (36 and 46 degrees Fahrenheit). A review of the facility's own medication storage policy, dated December 19, 2022, indicated that all medications requiring refrigeration must be stored in refrigerators. The failure to store the PPD vial according to both manufacturer instructions and facility policy resulted in a deficiency related to improper medication storage.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe to the California Department of Public Health (CDPH). The incident involved a resident who was admitted with multiple diagnoses, including atrial fibrillation, diabetes mellitus with diabetic neuropathy, and anxiety disorder. On February 8, 2025, the resident, who had the capacity to make decisions, reported being abused by a staff member. The resident called the police, claiming that a Registered Nurse (RN) had abused him by squeezing his leg. The police were called around 3 a.m., and the allegation was reported to the facility administrator at approximately 1 p.m., which was about 10 hours after the incident. Interviews with facility staff, including a Registered Nurse, Licensed Vocational Nurse, and the Director of Nursing, revealed that the staff was aware of the requirement to report allegations of abuse within two hours. However, the report to the state agency was delayed. The facility's policy, revised in December 2022, clearly stated that allegations involving abuse should be reported immediately, but not later than two hours after the allegation is made. Despite this policy, the administrator reported the incident to CDPH and the local state agency only after a significant delay, which constituted a failure to comply with the reporting requirements.
Failure to Conduct Annual N-95 Fit Testing
Penalty
Summary
The facility failed to implement its Respiratory Protection Plan by not conducting annual fit testing for N-95 filtering facepiece respirators (FFR) for one of four staff members. During an unannounced visit, it was revealed that the Physical Therapist (PT), who was treating residents with COVID-19, had not been fit tested for his N-95 mask for approximately two years. This was contrary to the facility's policy, which mandates fit testing upon hire and annually thereafter. The Infection Preventionist (IP) confirmed that the facility had two models of N-95 FFRs available and that staff were supposed to be fit tested annually. However, a review of the facility's Fit Test Record indicated that the PT's last fit test was conducted on August 17, 2023, which was not within the required annual timeframe. This oversight had the potential to contribute to the spread of COVID-19 among residents and staff, particularly affecting vulnerable residents with compromised health conditions.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs of Resident A by not providing bedrails for repositioning as requested. Resident A was admitted with a diagnosis that included aftercare following joint replacement surgery and had the capacity to understand and make decisions. The Bedrail Assessment indicated that bedrails were necessary for mobility and transfer purposes. However, the Maintenance Director did not install the bedrail because there was no request made by the nurse for its installation. The facility's policy on the proper use of bedrails emphasized a person-centered approach, but this was not followed in Resident A's case. Resident B's call light was not within reach, which could prevent her from calling for assistance. Resident B was admitted with diagnoses including dementia and legal blindness. During an observation, it was noted that her call light was clipped to the top portion of her bed, far from her reach. The CNA confirmed that the call light should be clipped to her clothes for accessibility. The care plan for Resident B indicated that the call light should be within reach due to her risk of falls. The facility's policy required staff to ensure call lights are accessible, but this was not adhered to for Resident B.
Failure to Maintain Homelike Environment Due to Missing Curtain Slats
Penalty
Summary
The facility failed to ensure a comfortable homelike environment for one of its residents, identified as Resident 2, due to missing slats in the curtain blinds covering the resident's sliding door. This issue was not documented in the maintenance repair log, which is a critical step in ensuring timely repairs. During an unannounced visit, it was observed that four slats were missing from the blinds, and Resident 2 was aware of the issue but could not recall when or to whom it was reported. The resident's medical records indicate a history of palliative care, peripheral vascular disease, vascular dementia, anxiety disorder, and major depressive disorder. Interviews with facility staff, including CNAs, an LVN, the Maintenance Director, and the Director of Nursing, revealed inconsistencies in the process of reporting and documenting maintenance issues. While some staff members stated that maintenance issues should be documented in a log kept at the nurse's station, others denied the existence of such a log. The Maintenance Director confirmed the missing slats and stated that he checks the maintenance book daily, aiming to resolve issues within 24 hours. However, the missing slats in Resident 2's room were not recorded in the maintenance log, indicating a lapse in the facility's maintenance reporting and documentation process.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to personal and medical records for a resident, identified as Resident 3, within the required two working days. The deficiency was identified during an unannounced visit to investigate a resident's rights issue. Resident 3 was admitted to the facility and later discharged, and during their stay, a request for their medical records was made by their legal representative. The initial request was made on May 28, 2024, but due to a mismatch in the resident's name, the request was not processed. A new request was submitted on June 10, 2024, but the Medical Records Director (MRD) did not forward it to the facility's legal team until June 14, 2024, delaying the release of the records. The facility's policy requires that medical records be released within 72 hours of a valid request, and the resident or their legal representative should have access to the records within two days. The Interim Director of Nursing confirmed that the MRD did not follow the facility's policy and procedure, resulting in the delay. This failure to adhere to the policy potentially impacted the resident's physical wellbeing by delaying care and treatment. The report highlights the inaction of the MRD in processing the request promptly, which contributed to the deficiency.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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