Millbrae Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Millbrae, California.
- Location
- 33 Mateo Avenue, Millbrae, California 94030
- CMS Provider Number
- 056122
- Inspections on file
- 36
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Millbrae Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop person-centered care plans for two residents related to smoking and going out on pass, despite active MD orders permitting these activities. One resident with heart failure and diabetes, cognitively intact and independent in ADLs, had orders allowing smoking and passes, but the care plan lacked any related interventions. Another resident with cellulitis, minimal cognitive impairment, and independence in ADLs had an order to smoke, yet no smoking care plan was in place. RN 1 confirmed these omissions during record review, and the Administrator reported that the DON was responsible for ensuring completion of resident care plans, in contrast to the facility’s policy requiring comprehensive, measurable, IDT-developed care plans that address individual needs and risk factors.
A resident with dementia, muscle weakness, and gait/mobility abnormalities had two documented fall incidents, but the care plan was not revised to address these events as required by facility policy and practice. The resident was observed alert and in a wheelchair, able to state his name but not his location or reason for being at the facility, and reported feeling sleepy and attempting to walk to use the bathroom at the time of the falls. An LVN stated that care plans should be initiated and updated after changes in condition such as falls, yet both interviewed LVNs confirmed the resident’s care plan did not reflect the recent falls and reported they had not received in-service training on care planning, despite the DON and DSD being responsible for such education under facility policy.
Due to insufficient social work staffing, required IDT care conferences were not conducted for multiple residents over several months. As a result, residents and their families were not included in regular care planning discussions, and updates on care plans and medications were not communicated as required by facility policy.
Staff did not consistently mark or track residents' personal belongings, resulting in missing items for three residents. Clothing was not labeled, and inventories were not updated as required, leading to unaccounted-for possessions and confusion about ownership. Interviews confirmed that several personal items were missing for extended periods before some were recovered.
The facility failed to maintain infection control for three residents. A CNA did not wear a gown for a resident on Enhanced Barrier Precautions, a mattress was not sanitized after a CNA stepped on it, and a blood pressure cuff was not disinfected between uses for multiple residents. The staff involved were aware of the protocols but did not follow them due to misunderstandings and lack of training.
The facility failed to enforce its smoking policy, allowing residents to smoke in non-designated areas without necessary safety equipment. Two residents, both with intact cognition, kept their smoking materials, including lighters, against policy. Staff interviews revealed that residents often smoked in front of the building due to the designated area being too far, and there was uncertainty about fire safety equipment in these areas.
A facility failed to complete a discharge MDS assessment for a resident discharged to a hospital. The resident had a complex medical history and was expected to return after a hospital stay. The MDS Coordinator did not complete the assessment, assuming the resident would return. The DON and Administrator were unaware of the oversight, despite policies requiring timely completion of discharge assessments.
A facility failed to accurately code a resident's behavioral symptoms on the MDS, despite documented incidents of hitting, scratching, and taking items. The resident, with a history of dementia and psychotic disorder, exhibited these behaviors during the seven-day look-back period, but the MDS did not reflect them. Staff interviews confirmed the presence of these behaviors, highlighting a lapse in adherence to the facility's MDS accuracy policy.
A facility failed to resubmit a Level I PASRR for a resident with schizophrenia after receiving a letter indicating a Level II evaluation was not scheduled. The resident's PASRR Level I screening was positive, but the case was closed incorrectly by the state, as the resident had not been discharged. Interviews with staff revealed that the facility did not complete another PASRR, leading to the deficiency.
A resident with impaired vision was left with medications at their bedside without being assessed for self-administration. The RN left the medications, stating the resident preferred to take them after breakfast, contrary to facility policy. The resident, who had a history of legal blindness and other health issues, admitted to forgetting to take their medication, highlighting the risk of this practice. Interviews revealed staff were unaware of the policy requiring assessments for self-administration.
A resident with a history of epilepsy had an order to check their Keppra level every six months, but the facility failed to obtain the test in the required timeframe. Despite the Keppra level being checked in March and found within the therapeutic range, no follow-up test was conducted in September as ordered. Interviews with staff, including the LVN, MD, and DON, indicated an expectation for compliance with physician orders, but the test was not performed.
A facility was found non-compliant with regulations limiting resident room capacity to four residents. Room [ROOM NUMBER] had six beds but was occupied by four residents. The facility requested a waiver, citing adequate space per resident, but lacked a policy on room variances. The DON noted no prior citation for this issue, and the Administrator confirmed a waiver application was submitted.
The facility failed to ensure that RNs conducted post-fall assessments for several residents after fall incidents. Instead, LVNs performed these assessments, which is outside their scope of practice as they should operate under RN supervision. This deficiency could potentially harm resident safety and well-being.
A resident with multiple health conditions did not receive necessary social services due to the absence of a social worker for several weeks. The facility lacked a contingency plan, resulting in no social services documentation for the resident during their stay, as confirmed by the DON and SSD.
The facility failed to effectively assess and address a resident's weight loss, resulting in a gradual, unintended, progressive weight loss over time. Despite the resident's frequent walking and good meal consumption, the recommended nutritional supplements and interventions were not administered, and the care plan was not updated. Inconsistent documentation and a backlog in social services further contributed to the issue.
The facility failed to provide preventive treatment and services to maintain and improve ROM for 18 residents. Despite physician orders for an RNA Program, the program was not implemented, potentially limiting residents' ROM and leading to contractures. Interviews with staff confirmed the RNA program had not been in place since October.
The facility failed to implement its Restorative Nursing Assistant (RNA) Program, resulting in non-compliance with F688. The absence of RNAs since October 2023 was not addressed during QAPI meetings, potentially limiting residents' range of motion and leading to contractures. The Director of Nursing was unavailable for an interview.
The facility failed to respond to a resident's call for assistance in a timely manner, resulting in a resident waiting over half an hour for peri-care. Additionally, the facility did not ensure a functional communication system for 17 residents, as call lights in their bedrooms were broken, preventing them from calling for help.
The facility failed to maintain a safe and sanitary environment in shower room [ROOM NUMBER], which was found with mold, exposed rusty metal, and various substances on the walls and floor. Staff interviews revealed that this was the only shower room in use, leading to infrequent showers for residents and inadequate cleaning due to understaffing.
A resident with multiple medical conditions had to wait half an hour for peri-care, despite the facility's policy to promptly respond to call lights. The resident and his wife reported consistently slow response times, and the Infection Preventionist did not provide an explanation for the delay.
The facility failed to provide tissue paper for a resident with multiple medical conditions for two days, despite the resident's requests and the availability of the Supply Supervisor to retrieve supplies if notified.
A resident with multiple diagnoses experienced a fall resulting in a traumatic brain injury, which was not reported to the State Agency as required by the facility's policy. The incident led to significant medical intervention, including surgery and transfer to another rehab center.
A resident with a history of stroke, dysphagia, dementia, epilepsy, and sepsis experienced significant weight loss, but the facility failed to update the care plan with new interventions since 2019. Despite an IDT meeting noting the weight loss, the recommended interventions were not included in the care plan, and the weight loss was not adequately addressed in subsequent assessments.
The facility failed to provide OT services to a resident with multiple diagnoses, despite a physician's order. The resident did not receive any OT treatments between 9/3/22 and 9/11/22, and the facility lacked a policy and procedure for rehabilitation services.
The facility failed to comply with the regulation limiting the number of residents per room to four, as one room was observed to contain six residents. The room was dark, crowded, noisy, and lacked privacy, with visitors contributing to the lack of space. One resident expressed frustration with the situation. The Administrator planned to apply for a room waiver to allow the six-resident room.
Failure to Develop Person-Centered Care Plans for Smoking and Pass Privileges
Penalty
Summary
Surveyors identified a failure to develop person-centered comprehensive care plans addressing smoking and going out on pass for two residents. For the first resident, who was admitted with heart failure and diabetes and was assessed on the MDS as cognitively intact and independent in all ADLs, physician orders dated in January 2026 authorized the resident to smoke and to go out on pass. During a concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not contain any interventions or approaches related to smoking or going out on pass, despite these active physician orders. For the second resident, who was admitted with cellulitis of the back and assessed on the MDS as having little to no cognitive impairment and being independent in all ADLs, physician orders dated in January 2026 also authorized the resident to smoke. During interview and record review, RN 1 confirmed that there was no care plan addressing smoking for this resident. The Administrator stated that the DON was responsible for ensuring resident care plans were completed, but the DON was not available for interview. The facility’s written policy on comprehensive plans of care required development of a comprehensive, measurable, interdisciplinary care plan that addresses resident needs, strengths, preferences, and risk factors, and is periodically reviewed and revised with resident participation.
Failure to Revise Care Plan After Resident Fall Incidents
Penalty
Summary
The facility failed to update the person-centered care plan for a resident after two fall incidents, as required by its policies and regulatory standards. The resident had diagnoses including dementia, muscle weakness, and abnormalities in gait and mobility. Interdisciplinary Team notes documented that the resident experienced two falls on 1/14/26. During an observation and interview, the resident was alert, verbally responsive, and sitting in a wheelchair in the hallway, able to state his name but unable to identify his current location or the reason for residing in the facility. When asked about the falls, the resident reported feeling sleepy, attempting to walk, and needing to use the bathroom at the time of the incidents. In interviews, LVN 1 stated that care plans are initiated when there is a change in condition such as a fall and that care plans are reviewed and updated after each fall, but also stated she had not received in-service training on care planning. LVN 2, upon reviewing the resident’s care plan, confirmed that it did not address the two fall incidents. LVN 2 also stated she had not received in-service training on care planning. The Administrator reported that the DON and DSD were responsible for providing in-services to licensed nurses, but they were not available for interview. Facility policies on person-centered plans of care and post-fall management required that care plans reflect current standards of practice, include interventions to manage risk factors, and be reviewed and revised by the IDT when changes in the resident’s care and treatment occur, including after falls, but this was not done for the resident following the two fall events.
Failure to Provide Timely Social Services and Care Conferences
Penalty
Summary
Facility staff failed to provide medically-related social services to all sampled residents due to inadequate staffing, specifically having only one social worker on site for approximately three months. During this period, the social worker was unable to coordinate and conduct required interdisciplinary team (IDT) care conference meetings for at least 14 residents. These meetings are essential for discussing and managing resident care, involving various healthcare professionals and family members or responsible parties. A review of medical records revealed that the last IDT/care conference for the affected residents occurred between six to eight months prior, well beyond the required quarterly interval. Interviews with staff confirmed that the social worker was solely responsible for scheduling and coordinating these meetings, and the workload prevented timely completion. The administrator acknowledged that daily standup meetings, which addressed acute care issues, did not substitute for the comprehensive discussions held during IDT/care conferences, especially for chronic or ongoing care needs. Additionally, a family member of one resident reported not being invited to recent IDT meetings and not being updated on the resident's plan of care or current medications. Facility policy requires care plan conferences to be held within seven days of the initial assessment, every 90 days thereafter, and with any significant change in resident status or condition. The failure to conduct these meetings as required resulted in residents not receiving appropriate and personalized care planning.
Failure to Safeguard and Track Residents' Personal Belongings
Penalty
Summary
The facility failed to properly manage and safeguard residents' personal belongings for three out of six sampled residents. Staff did not follow the facility's policy regarding the identification and marking of residents' clothing and personal items. Observations revealed that residents' clothing was not labeled to indicate ownership, and staff were unable to account for items listed on the residents' admission inventories. For example, one resident was admitted with specific clothing items, but at the time of review, only unmarked donated clothing was present, and the original items could not be located. Interviews with residents and their responsible parties confirmed that personal belongings, such as jackets, shoes, sweatpants, and shirts, had gone missing for extended periods. In one case, a resident reported missing a flannel jacket and a shoe, while another resident's responsible party stated that several items had been missing for at least two weeks before some were recovered. Staff were unable to explain the whereabouts of the missing items or why the clothing was not properly marked as required by facility policy. A review of the facility's policy on residents' personal property indicated that while items are to be inventoried and marked upon admission, there was no directive for staff to periodically update the inventory list. The administrator confirmed that the facility did not have a process for regularly updating residents' inventories and relied on families to inform staff when new belongings were brought in. This lack of systematic updating and marking contributed to the loss and mismanagement of residents' personal property.
Plan Of Correction
F 557 Millbrae Care Center makes its best effort to operate in substantial compliance with both Federal and State Law. Preparation and/or execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by provisions of 42 CFR 483, et seq., and Health and Safety Code 1280. In response to the Department's findings, we submit the following Plan of Correction which shall constitute the facility's credible allegation of compliance. The facility has submitted this plan of correction to comply with its regulatory obligation under Title 18 and 19 and to meet the ten (10) days of survey condition mandate. Likewise, the facility does not waive any objections to the merits or form any allegations contained herein. Please note that the facility may contest the merit and/or form of any of the deficiency findings alleged below and may take reasonable steps to appeal them.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents. For Resident #83, who had a history of clostridium difficile and was on Enhanced Barrier Precautions (EBP), a Certified Nursing Aide (CNA) did not wear a gown while providing incontinence care, despite the requirement to do so. The CNA was aware of the need for personal protective equipment (PPE) but mistakenly believed the signage outside the resident's room was for another resident. This oversight occurred despite the presence of gowns and gloves outside the room and the facility's policy on EBP. In another instance, the facility did not have a policy for sanitizing a mattress on the floor, which was used for Resident #81 due to a history of falls. During an observation, a CNA stepped on the resident's mattress with shoes and did not change the sheets or sanitize the mattress afterward. The CNA acknowledged the mistake but noted a lack of training on maintaining mattress hygiene. The Infection Preventionist and Director of Nursing confirmed that the sheets should have been changed in such situations, but the staff had not been trained for this specific scenario. Additionally, the facility failed to disinfect a blood pressure cuff between uses for multiple residents. A Registered Nurse (RN) used the same cuff on three residents without cleaning it between uses. The RN admitted to forgetting to disinfect the cuff due to nervousness. The Director of Nursing stated that the facility provided two vital sign machines per medication cart to prevent such issues, but it was unclear why the second machine was not used. The Administrator confirmed the expectation for staff to disinfect equipment between resident uses.
Failure to Enforce Smoking Policy and Designated Areas
Penalty
Summary
The facility failed to ensure residents adhered to the designated smoking areas and did not enforce its smoking policy regarding the storage of lighters. The facility's policy, released in June 2022, specified that residents should be informed about smoking limitations and designated areas, and that metal containers with self-closing covers should be available in smoking areas. However, observations revealed that residents were smoking in non-designated areas, such as the garden area near the front door, which lacked necessary safety equipment like ashtrays and fire extinguishers. Two residents, identified as smokers, were found to be keeping their smoking materials, including lighters, contrary to the facility's policy. Resident #39, with a history of tobacco use and intact cognition, stated they smoked wherever they wanted as long as it was 25 feet from the doorway and kept their own smoking materials. Similarly, Resident #106, with a diagnosis of nicotine dependence and intact cognition, also kept their smoking materials, including a lighter, with them. Both residents were assessed as safe smokers, yet they did not adhere to the designated smoking area. Interviews with staff, including CNAs, RNs, and the DON, revealed a lack of enforcement of the smoking policy. Staff acknowledged that residents often smoked in front of the building due to the designated area being too far, especially for those with mobility issues. The DON and Administrator confirmed the designated smoking area was out back but admitted that residents frequently smoked out front. The facility's approach to managing this issue was limited to reeducating residents, and there was uncertainty among staff about the presence of fire safety equipment in the non-designated smoking areas.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident who was discharged to a hospital. The resident, who had a medical history including pressure ulcers, type two diabetes mellitus, acute kidney failure, essential hypertension, difficulty walking, and a history of falling, was admitted to the facility in October 2023 and discharged to an acute care hospital in August 2024. Despite the resident's discharge, the facility did not complete the required discharge MDS assessment within the stipulated timeframe, resulting in a deficiency. The MDS Coordinator, responsible for completing discharge MDS assessments, did not complete the assessment for the resident, as she assumed the resident would return to the facility after a hospital stay. The Director of Nursing and the Administrator both expected MDS assessments to be completed timely and according to the schedule, but were unaware that the discharge MDS was not completed. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument Manual require discharge assessments to be completed when a resident is discharged to a hospital, which was not adhered to in this case.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect the presence of behavioral symptoms during the seven-day look-back period. The resident, who had a medical history including adjustment disorder, senile degeneration of the brain, psychotic disorder with hallucinations, and dementia, exhibited behaviors such as hitting, scratching, and taking items from the nurses' station. Despite these documented behaviors, the quarterly MDS assessment did not reflect any physical or verbal behavioral symptoms or rejection of care. Interviews with staff, including Certified Nursing Aides (CNAs) and the Director of Nursing (DON), confirmed that the resident exhibited behaviors that should have been coded on the MDS. The facility's policy on MDS accuracy required that the interdisciplinary team verify coding accuracy, but this was not adhered to in this case. The failure to accurately code the resident's behaviors on the MDS was identified during a review of the resident's medical records, progress notes, and interviews with facility staff.
Failure to Resubmit PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) for a resident after receiving a letter indicating that a Level II Mental Health Examination was not scheduled. The resident, who was admitted to the facility with a diagnosis of unspecified schizophrenia, had a positive Level I PASRR screening completed by a local hospital. However, the State of California Department of Healthcare Services closed the case, stating that a Level II evaluation was not scheduled because the individual was discharged from the facility, which was incorrect as the resident had not been discharged. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the facility did not complete another PASRR for the resident. The DON and the Administrator confirmed that the hospital typically completed the PASRR before admission, and the facility accessed the results online. The Administrator stated that if a Level I PASRR was positive, the facility should request a Level II PASRR and respond to recommendations in the Level II results letters. The failure to ensure the completion and accuracy of PASRR paperwork led to the deficiency.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for a resident who had impaired eyesight and had not been assessed as safe to self-administer medications. During a medication administration observation, a registered nurse (RN) was seen preparing and placing multiple medications on the bedside table of a resident with impaired vision, who was legally blind and had not been evaluated for self-administration of medications. The RN left the medications with the resident, stating that the resident preferred to take them after breakfast, despite the facility's policy requiring that medications be administered at the time they are prepared and that residents must be assessed as safe to self-administer medications. The resident involved had a medical history that included legal blindness, glaucoma, and other significant health conditions such as hypertension and diabetes. The resident's care plan noted impaired visual function and directed staff to assist in promoting independence by placing items consistently. However, there was no documentation of a self-administration assessment or a care plan indicating the resident was safe to self-administer medications. The resident admitted to forgetting to take their medication the previous night, highlighting the risk of leaving medications unattended. Interviews with facility staff, including the RN and the Director of Nursing (DON), revealed a lack of awareness and adherence to the facility's medication administration policies. The RN was unaware of the requirement for a special assessment before leaving medications with residents, and the DON confirmed that staff had been instructed not to leave medications at the bedside. The facility's administrator also emphasized the expectation that nurses ensure residents take medications as ordered and return them to the medication cart if not taken immediately.
Failure to Obtain Timely Laboratory Services for Keppra Level Monitoring
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident who had an order to check their Keppra level every six months. The resident, who had a medical history of convulsions and epilepsy, was admitted to the facility with an order to administer Keppra 1000 mg twice daily for seizures and to check the Keppra level every six months. Although the Keppra level was checked in March 2024 and found to be within the therapeutic range, there was no documented evidence that the facility obtained another Keppra level in September 2024, as required by the physician's order. Interviews with facility staff, including the LVN, Medical Director, and DON, revealed that there was an expectation for nursing staff to follow through with physician orders for laboratory testing. The LVN mentioned that laboratory orders should be visible in the resident's electronic medical record to ensure compliance. The Medical Director and DON both expressed that the facility should have obtained the Keppra level as ordered. The Administrator also stated that nursing staff were expected to follow standing orders for laboratory tests.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulatory requirement that resident rooms hold no more than four residents. Room [ROOM NUMBER] was equipped with six beds, although it was occupied by only four residents at the time of the survey. The facility had requested a waiver from the California Department of Public Health to allow more than four residents per room, citing that the room had 86 square feet per resident and a total floor area of 544.7 square feet. Despite this, the facility did not have a policy addressing room variances, and the Director of Nursing noted that the facility was not cited for this issue during the last recertification survey. The Administrator confirmed that a waiver application had been submitted for the room in question.
Failure to Ensure RN Conducts Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed the necessary assessments for seven out of nine sampled residents following a change in their condition, specifically after fall incidents. The review of the facility's fall incidents revealed that these residents experienced falls, and the post-fall assessments were conducted by Licensed Vocational Nurses (LVNs) instead of RNs. This practice was confirmed during interviews with the Director of Nursing (DON) and the Administrator, who stated that LVNs performed the assessments and evaluated the residents for injuries without the presence of an RN. The job description for LVNs, dated May 2017, indicates that they operate under the direct supervision of an RN and are responsible for implementing established care plans, administering medications, and performing treatments. However, the scope of their practice includes basic assessment and data collection, which does not extend to the comprehensive assessments required after a change in a resident's condition, such as a fall. This deficiency in practice has the potential to harm resident safety and well-being, as the assessments were not conducted by the appropriately qualified personnel.
Absence of Social Worker Leads to Deficiency in Resident Care
Penalty
Summary
The facility failed to provide medically-related social services to a resident due to the absence of a social worker from April 22, 2024, to May 10, 2024. During this period, Resident 1, who was cognitively intact and had diagnoses including peripheral vascular disease, heart failure, and diabetes mellitus, did not receive necessary social services. The resident was admitted, transferred to a hospital, readmitted, and then discharged again to the hospital without the assistance of a social worker. Interviews with the Ombudsman and the complainant confirmed the absence of a social worker during this time, and the Director of Nursing (DON) acknowledged the lack of a contingency plan for the social worker's absence. The facility's organizational chart indicated that the social service was directly under the Administrator, and the facility's policy outlined the social worker's role in meeting the psychosocial needs of residents and families. Despite this, there were no social services notes for Resident 1 during their stay, as verified by the DON and the newly hired Social Services Director (SSD). The SSD described the range of services typically provided, including discharge planning, psychosocial support, and grievance resolution, none of which were documented for Resident 1 during the period in question.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to effectively assess and address the weight loss of Resident 19, who experienced a gradual, unintended, progressive weight loss over time. Despite the facility's policy requiring immediate action for significant weight changes, Resident 19's weight loss was not adequately monitored or managed. The resident, who had dementia and osteoarthritis, was observed to be active and eating well, yet her weight continued to decline. The facility's staff, including CNAs and LVNs, noted her frequent walking and meal consumption but did not follow through with the recommended nutritional supplements and interventions. The RD's notes indicated a significant weight loss, but the care plan was not updated accordingly, and the supplements were not administered as prescribed. Additionally, the facility's documentation practices were inconsistent, with numerous omitted entries in the CNA flow sheets and a lack of follow-up on the RD's recommendations. The social services department also had a backlog, and the last care conference for Resident 19 was held in 2022. The facility's failure to address these issues resulted in Resident 19's continued weight loss without appropriate intervention or documentation.
Failure to Implement Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for 18 residents. Despite physician orders for a Restorative Nursing Assistant (RNA) Program, the program was not implemented for any of the residents. This failure had the potential to limit the residents' ROM and possibly lead to the development of contractures, which could interfere with their daily functioning. Resident 1, who was admitted with rheumatoid arthritis and muscle weakness, reported that there had been no RNA services for months. The resident had to request a physician's order for physical therapy due to the lack of RNA services. Similarly, Resident 2, who had difficulty walking and a history of a left femur fracture, stated that no one helped them exercise, and the RNA program was not implemented for several months. Other residents, including those with diagnoses such as muscle weakness, epilepsy, repeated falls, and osteoarthritis, also did not receive the RNA services as ordered. Interviews with staff confirmed that the RNA program had not been in place since October, and no one had stepped up to fill the role. The facility's standards for the Restorative Nursing Program were not followed, leading to a significant lapse in care for the residents involved.
Failure to Implement Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA) Program. This failure resulted in non-compliance with F688, which had the potential to limit residents' range of motion (ROM) and possibly lead to the development of contractures. During an interview, the Administrator acknowledged that there had been no Restorative Nurse Assistants (RNAs) since October 2023, and the issue was not addressed during the Quality Assurance and Performance Improvement (QAPI) meetings. The Director of Nursing was unavailable for an interview. A review of the facility's Policy and Procedure for the QAPI Program indicated that the facility is required to maintain an ongoing, systematic, and proactive process to improve resident care, outcomes, and safety. The QAPI program is supposed to facilitate an interdisciplinary, interdepartmental collaborative approach to improve the quality of resident life and care. However, the facility's administration and QAPI committee failed to identify and prioritize the problem of the missing RNA program, leading to the deficiency.
Failure to Respond to Call Lights and Ensure Functional Communication System
Penalty
Summary
The facility failed to respond to a resident's call for assistance in a timely manner, resulting in Resident 38 waiting for over half an hour to receive peri-care due to soiled undergarments. Resident 38, who has multiple diagnoses including diabetes, congestive heart failure, and brain disease, expressed that the call light response time has consistently been slow, with wait times usually being 30 minutes or more. The resident's wife corroborated this, stating that he often experiences pain and requires medication, repositioning, or peri-care. The Infection Preventionist was unable to provide a reason for the delay in response time. Additionally, the facility failed to ensure a functional communication system for 17 of 128 sampled residents, as call lights in their bedrooms were found to be broken. This resulted in residents being unable to call for help with their needs or in case of a fall injury. For instance, Resident 1, who has rheumatoid arthritis and muscle weakness, had to yell or make phone calls to the receptionist to get help because her call light had not worked for six months. Similar issues were observed with other residents, including those with severe cognitive impairments and those requiring substantial assistance with activities of daily living. The facility's Policy and Procedure on Answering Call Lights, dated August 2017, and the Policy and Procedure on Equipment Repair and Maintenance, dated December 2016, were not adhered to. These policies emphasize the importance of responding to residents' requests promptly and ensuring the proper functioning of all equipment. Despite these guidelines, the maintenance supervisor acknowledged the nonfunctioning call lights and stated that a new system was being procured, but no immediate corrective actions were taken to address the current deficiencies.
Unsanitary Conditions in Shower Room
Penalty
Summary
The facility failed to provide a safe and sanitary environment in shower room [ROOM NUMBER], which was found unclean and unhygienic. During an observation, all four shower stalls had black and gray substances on the grout, red splatters on the walls, brownish clay smeared on the floor, and exposed rusty sharp pieces of metal. The fabric curtains were damaged with holes surrounded by black substances and brown smears at the bottom. Six large containers were also found inside the shower room. Interviews with staff revealed that this shower room was the only one in use, as the other had been closed for years, making it difficult to shower all residents adequately. The red substance had been present for about three months, and the brown substance on the floor for a week. A resident reported infrequent showers, expressing frustration over the lack of adequate staffing and resources. The Maintenance Supervisor confirmed that shower room [ROOM NUMBER] had been out of service for two weeks due to plumbing issues and was locked without available keys. The room contained mold, and repairs were ongoing. The supervisor also mentioned that the housekeeping staff could not accommodate the cleaning schedule due to understaffing. Another CNA stated that dirty linens and garbage were stored in the shower room until pickup, but was unsure of the pickup schedule. The overall condition of the shower room and the lack of adequate cleaning and maintenance staff contributed to the unsanitary environment, impacting the residents' bathing experience.
Resident Waits Half an Hour for Peri-Care
Penalty
Summary
The facility failed to treat a resident with dignity when the resident had to wait for half an hour to receive peri-care for soiled undergarments. The resident, who was admitted with diagnoses including diabetes, congestive heart failure, brain disease, an open lower leg wound, and liver disease, had a cognition score of 10 and required assistance with toileting hygiene and repositioning in bed. During an observation and interview, the resident and his wife reported that the call light response time was consistently slow, with wait times usually being 30 minutes or more. The Infection Preventionist did not provide a response for the lengthy wait time. The facility's policy on answering call lights, dated August 2017, indicated that steps should be taken to ensure residents' needs and requests are considered and responded to promptly.
Failure to Provide Tissue Paper for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 37, who did not speak English, by not providing tissue paper for two days. Resident 37, who had diagnoses including hemiplegia, bed confinement, stroke, diabetes, depressive disorder, and high blood pressure, had been asking for facial tissues over the weekend but was told by staff that none were available. The Supply Supervisor stated that he could have retrieved the supplies if he had been notified. The facility's Central Supply Program policy indicated that supplies should be ordered from approved suppliers and that the Supply Supervisor should be contacted if the required item was not available.
Failure to Report Fall with Injury
Penalty
Summary
The facility failed to promptly report an incident involving a fall with injury to the State Agency as required by their policy. Resident A, who was admitted with multiple diagnoses including lymphoma, spinal cord compression, diabetes, and anemia, experienced a fall on 12/22/23. Despite the initial assessment indicating no severe injury, the resident later complained of a headache and was subsequently sent to the hospital where a traumatic brain injury was diagnosed, necessitating a craniotomy. The incident was not reported to the California Department of Public Health (CDPH) within the required timeframe. Interviews and record reviews revealed that the facility's staff did not follow the established protocol for reporting incidents involving serious bodily injury. The resident's family confirmed that the fall resulted in significant medical intervention, including surgery and transfer to another rehabilitation center. The facility's policy mandates that such incidents be reported immediately, but this was not adhered to, leading to a deficiency in the facility's compliance with state regulations.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to identify and document changes in a resident's condition, specifically regarding significant weight loss. The resident, who had a history of cerebral infarction, dysphagia, dementia, epilepsy, and sepsis, experienced weight loss starting on January 12, 2023. Despite an IDT meeting on August 14, 2023, the care plan had not been updated with new interventions since 2019. The resident was admitted to the hospital on November 16, 2023, with septic shock, acute respiratory failure, and acute kidney injury, and returned to the facility on November 30, 2023. The care plan on nutritional problems was revised on November 12, 2023, but no new interventions were added, and the weight loss was not adequately addressed in the care plan or the MDS assessment dated December 7, 2023. Interviews and record reviews revealed that the resident had a significant weight loss of 16 pounds in 180 days, which was noted in the Weight Variance IDT Review on August 14, 2023. However, the interventions recommended, such as a fortified diet and weekly weights, were not found in the care plan. The LVN confirmed that there was no change of condition record for the weight loss in the resident's chart. The facility's Comprehensive Plan of Care indicated that care plans should be re-evaluated and modified as necessary to reflect changes in the resident's status, but this was not done in this case, leading to the deficiency in care for the resident's weight loss and overall condition management.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) services to a resident (Resident 20) despite a physician's order. Resident 20, who had diagnoses including atrial fibrillation, diabetes, and diastolic heart failure, was admitted on 8/31/22. An OT evaluation on 9/1/22 indicated a need for therapeutic exercises and self-care management training three to five times a week for four weeks. However, no OT treatments were provided between 9/3/22 and 9/11/22, as confirmed by the Rehabilitation Services Department staff. The Occupational Therapist responsible for the treatment had terminated her employment, and the facility lacked a policy and procedure for rehabilitation services. Interviews with the Infection Preventionist and the Rehab Director revealed that the facility could not locate a policy and procedure for rehab services. The Rehab Director confirmed that the facility should have such a policy. The failure to provide the ordered OT services had the potential for further physical decline in Resident 20 during their stay at the facility.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as one room was observed to contain six residents. During an observation, the room was described as dark, crowded, noisy, and lacking privacy. Visitors were present, further contributing to the lack of space and privacy, and one resident expressed frustration with the visitors' presence and noise. The room's condition and the number of residents exceeded the acceptable limit, leading to potential issues with privacy, care, and attention for the residents. An interview with the Administrator revealed that she intended to apply for a room waiver to allow the six-resident room. The facility's Quality Assurance and Performance Improvement (QAPI) program, which aims to enhance the quality of care and life for residents, was reviewed. The QAPI program emphasizes safety, high-quality clinical interventions, and resident autonomy and choice. However, the facility's failure to adhere to the room occupancy regulation indicates a lapse in maintaining these standards.
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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