Monterey Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Monterey, California.
- Location
- 1575 Skyline Drive, Monterey, California 93940
- CMS Provider Number
- 055962
- Inspections on file
- 35
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Monterey Post Acute during CMS and state inspections, most recent first.
A resident reported not receiving scheduled pain medication, leading to increased pain and emotional distress. Review of the MAR for the relevant month showed that a 10:00 a.m. medication pass on a specific day was not documented as given, with the system indicating the medications were not administered. The DSD confirmed that there was no notation of administration, refusal, or the resident being out of the building, and an RN verified the absence of documentation for the scheduled dose. Facility policy requires timely administration of medications as prescribed and documentation, including initials on the MAR, whenever medications are given, withheld, refused, or administered at a different time.
A resident with severe cognitive impairment and a history of exit-seeking behavior was able to leave the facility unsupervised and was missing for several hours before being found wandering along a road. Despite interventions such as a wander guard device and hourly visual checks, staff failed to adequately monitor the resident, and the wander guard was found to be nonfunctional. Facility exit doors were inadequately supervised, with one alarmed but unlocked and the entrance code posted publicly, contributing to the resident's ability to elope.
The facility failed to serve fried chicken at the correct temperature during a lunch meal. The morning cook's thermometer read 168°F, while the surveyor's thermometer showed 152°F. Both the dietary manager and the visiting registered dietician confirmed that the chicken should be at 165°F, as per facility policy. This discrepancy had the potential to cause food-borne illness.
The facility failed to follow proper food handling practices, as multiple food items in the refrigerator lacked appropriate labeling, such as opened on or use by dates. A carton of soy milk and a packet of parmesan cheese were among the items without dates, contrary to the facility's policy requiring all refrigerated foods to be covered, labeled, and dated. The dietary manager confirmed the need for proper labeling and mentioned a guide for discarding items.
The facility failed to maintain the dishwasher's water temperature at the required 120 degrees Fahrenheit for both wash and rinse cycles, as observed during a survey. The wash cycle temperatures were recorded below the required level, with only one instance reaching 120 degrees. Interviews revealed inconsistencies in understanding the temperature requirements, and the facility's policy on monitoring and reporting inadequate temperatures was not effectively implemented.
A privacy breach occurred when an RN left a computer screen open and unattended during a medication pass, displaying multiple residents' information. The RN acknowledged the privacy issue, which violated HIPAA regulations requiring the protection of e-PHI from unauthorized access.
A facility failed to provide necessary colostomy care for a resident with quadriplegia and a colostomy. The resident's care plan indicated a need for physician-ordered colostomy care, but no such orders were documented, nor was there evidence of care being performed. The DON confirmed the absence of documentation and orders, acknowledging that licensed nurses should document care and monitor the stoma. This oversight placed the resident at risk for complications.
The facility failed to post required oxygen signage for two residents using oxygen concentrators, posing potential hazards. One resident had an oxygen order for low oxygen or shortness of breath, while the other was observed using a nasal cannula. Staff confirmed the absence of signage, which is necessary due to the flammable nature of oxygen.
A facility failed to routinely assess a resident's arteriovenous fistula (AVF) for bruit, thrill, and signs of infection. The resident, with end-stage renal disease, was scheduled for dialysis three times a week, but there were no physician orders for AVF monitoring. The director of nursing confirmed that checks were only done on dialysis days, contrary to the facility's policy requiring regular monitoring.
The facility did not have an RN on duty for 8 consecutive hours on two days in October and December 2024. The nurse schedule showed no RN was scheduled or on duty on these days, and the administrator confirmed the absence and lack of a waiver for reduced RN hours, despite being aware of the requirement for RN coverage.
The facility failed to document the administration of controlled medications on the MAR for three residents, leading to discrepancies between the CDR and MAR. This issue was confirmed by the ADON, who acknowledged that the medications should have been documented on both records.
A facility failed to monitor side effects and target behaviors for a resident on psychotropic medications, including Seroquel, Bupropion HCL, and Depakote. The resident, diagnosed with Dementia, Alzheimer's, and Schizophrenia, had no documented monitoring of side effects or specified target behaviors for these medications. The DON confirmed the lack of documentation, which is against the facility's policy requiring monitoring for efficacy, risks, benefits, and adverse consequences.
A medication error rate of 11.9% was identified in an LTC facility, where several residents did not receive prescribed medications, and a G-tube was not flushed correctly. The errors were confirmed by an LVN, who acknowledged the unavailability of medications and incorrect procedures, leading to potential health compromises for the residents.
The facility failed to properly label and store medications, including insulin vials and pens, eye drops, and inhalation aerosols, as observed during inspections. Medications lacked open dates and resident identifiers, and a medication cart was left unlocked. Temperature logs for medication storage were incomplete. These deficiencies were confirmed by staff and were not in compliance with facility policies.
A facility failed to follow its infection prevention policy when a nebulizer mouthpiece was found uncovered on a resident's bedside table. An LVN confirmed the mouthpiece should have been cleaned and stored in a plastic bag. The Infection Preventionist also stated the mouthpiece should not be left exposed, as per the facility's infection control program.
A resident's bedside table was found to be damaged, with cracked surfaces and sharp edges, posing a potential risk to safety and psychosocial well-being. The resident, who has multiple health conditions, expressed dissatisfaction with the table's condition. The DON acknowledged the issue and stated that the table needed replacement.
The facility failed to ensure palatable food when undercooked brown rice was served to 18 residents. A lunch test tray confirmed the rice was undercooked, and residents complained about the food quality. The Certified Dietary Manager did not taste the food before serving, and discrepancies were found in the cooking process. The facility's policy on menu adherence was not provided.
A resident with a history of diabetes and poor wound healing experienced a reoccurrence of a right heel wound, but the LTC facility failed to document treatment for five days. Additionally, Weekly Summary Documentations inaccurately indicated the resident had no skin issues, despite the presence of the wound. These actions were not in line with the facility's policies on wound care and documentation.
A resident did not receive Enoxaparin Sodium Injections as ordered due to pending pharmacy delivery. The medication was not administered on multiple occasions, potentially due to late refill orders or delayed pharmacy delivery. Facility policies require timely medication administration and sufficient supply.
A resident with hemiplegia and high fall risk fell during a transfer from bed to shower chair due to inadequate support from a CNA, who failed to use a gait belt or position the shower chair correctly. Other staff confirmed proper procedures were not followed.
A facility failed to document and administer a physician-ordered antibiotic eye drop for a resident with blepharitis symptoms, including eyelid swelling and discharge. The physician intended to prescribe Cipro Ophthalmic drops, but the order was not found in the resident's records, as confirmed by the ADON.
A resident filed a grievance alleging that a nurse shouted at her and touched her leg roughly. The facility failed to report this abuse allegation to the CDPH within the required 24-hour timeframe, resulting in a delay in the investigation. The nurse received a written warning and was suspended.
The facility failed to provide appropriate social services support following an abuse allegation for a resident. An investigation showed no documented evidence of a social services assessment focused on the resident's psychosocial well-being after the abuse allegation. The DON confirmed that there should be 72 hours of nursing monitoring and social services follow-up, but no follow-up notes were found. The facility's job description for the Social Services Director indicated that residents should be assessed for social services needs, but this was not documented.
Failure to Administer and Document Scheduled Pain Medication
Penalty
Summary
Failure to provide scheduled pain medication occurred when a resident did not receive their ordered medications as documented on the Medication Administration Record (MAR). During an interview, the resident reported not receiving his medications on 2/13/26, which he stated caused increased pain over the weekend. Review of the resident’s February 2026 MAR showed that medications scheduled for 10:00 a.m. on 2/14/26 were not administered, with the MAR displaying a red indicator for that time, signifying the medications were not given. The Director of Staff Development confirmed that if medications had been administered, refused, or if the resident had been out of the building, the MAR would show documentation and a green background, but none was present. RN A also confirmed there was no documentation that the 10:00 a.m. medications were given on 2/14/26. The facility’s medication administration policy, dated 2001, states that medications are to be administered in a safe and timely manner as prescribed, and that any withheld, refused, or rescheduled doses must be documented, with the administering individual initialing the MAR after each medication is given. This lack of administration and documentation of the resident’s scheduled pain medications resulted in the resident experiencing increased pain and emotional distress.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of exit-seeking behavior, and multiple psychiatric and neurological diagnoses was able to leave the facility without staff awareness or supervision. The resident was missing from the facility for several hours and was later found wandering unprotected along a road, eventually being located approximately three miles away. The resident's medical records indicated a history of wandering, exit-seeking, and recent admission with poor adjustment, as well as a history of substance abuse and homelessness. The care plan identified the resident as an elopement risk and included interventions such as a wander guard device and hourly visual checks. Despite these interventions, facility staff failed to adequately monitor the resident. Monitoring records showed that checks for exit-seeking behaviors and the function and placement of the wander guard device were ordered and documented, but the resident was still able to elope. Upon return, it was discovered that the wander guard device was not functioning. Additionally, the facility's entrance/exit doors were found to be inadequately supervised during certain hours, with one exit door alarmed but unlocked, and the entrance door code posted publicly. There was no receptionist present to supervise the entrance door overnight, and staff acknowledged that more frequent visual checks could have been performed. The resident was evaluated at a local emergency department after being found, presenting with increased confusion and alcohol intoxication. The facility's policy required systematic monitoring and management of residents at risk for elopement, including assessment, intervention, and monitoring for effectiveness. However, the failure to ensure the effectiveness of interventions and adequate supervision directly led to the resident's unsupervised exit and subsequent elopement.
Failure to Serve Chicken at Safe Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for one of the seven food items served during a lunch meal, specifically fried chicken. During an observation, the morning cook measured the temperature of the fried chicken at 168 degrees Fahrenheit using his thermometer, while the surveyor's thermometer read 152 degrees Fahrenheit. Both the morning cook and the surveyor acknowledged that the correct temperature for chicken should be 165 degrees Fahrenheit. Interviews with the dietary manager and the visiting registered dietician confirmed that the chicken should be at 165 degrees Fahrenheit, as per the facility's policy on food preparation and service. This discrepancy in temperature had the potential to cause food-borne illness due to the chicken not being at the correct temperature.
Improper Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a survey. Multiple food items in the refrigerator were found without appropriate labeling, such as opened on or use by dates, which is against the facility's policy. Specifically, a carton of soy milk was half full with an open cap but lacked a date, and a packet of parmesan cheese had no date written on it. Additionally, a container of grated cheese had a date of 1-28-25, but it was unclear whether this was the received date or the use by date. During an interview, the dietary manager confirmed that all food items should have both a received date and an opened on date, and mentioned that there is a guide posted on the refrigerator for discarding items, with dairy products to be discarded one week after opening. The facility's policy requires all refrigerated foods to be covered, labeled, and dated, which was not followed in this instance.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher's water temperature consistently reached the required 120 degrees Fahrenheit for both the wash and rinse cycles, as observed during a survey. On two separate occasions, the dishwasher was tested, and the wash cycle temperatures were recorded below the required 120 degrees, with temperatures reaching only 110, 95, and 108 degrees Fahrenheit. The rinse cycle temperatures varied, reaching 124, 131, and 144 degrees Fahrenheit, with only one instance of the wash cycle reaching the required 120 degrees. Interviews with the dietary manager and the regional registered dietician revealed inconsistencies in understanding the dishwasher's temperature requirements. The dietary manager initially stated that the dishwasher should not exceed 130 degrees, but later expressed a desire for the temperature to reach 120 degrees for both cycles. The regional registered dietician indicated that the dishwasher needed to be run three times to achieve the desired wash cycle temperature. The facility's policy required operators to check and record temperatures for each cycle and report inadequate temperatures immediately, which was not effectively implemented, leading to the deficiency.
Privacy Breach of Resident Records
Penalty
Summary
The facility failed to maintain the privacy of a resident's clinical records when a registered nurse (RN) left a computer screen open and unattended during a medication pass. On February 10, 2025, at 4:20 p.m., a medication cart containing an open laptop was left unattended in the hallway outside a resident's room. The laptop displayed information about multiple residents while RN E left to wash her hands at the nurse's station after taking residents' blood sugar levels. During an observation and interview with RN E at 4:34 p.m., she confirmed that the laptop was on and displaying residents' information, acknowledging that it should have been closed to prevent privacy issues. This incident was a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which requires the protection of electronic protected health information (e-PHI) from unauthorized access.
Failure to Provide Colostomy Care
Penalty
Summary
The facility failed to provide necessary colostomy care for a resident who required such services. The resident, who was admitted with a colostomy and quadriplegia, did not have any physician orders for colostomy care documented in their clinical record. The care plan for the resident indicated a risk for complications related to altered elimination due to the colostomy, and it specified that colostomy care should be provided as ordered by a physician. However, a review of the resident's Physician Order Sheet and Treatment Administration Record (TAR) for February 2025 revealed no documentation of physician orders or evidence that colostomy care was being performed. During an interview, the Director of Nursing (DON) confirmed the absence of physician orders for the resident's colostomy care and acknowledged that licensed nurses should document colostomy care on the TAR and monitor the stoma each shift. The facility's policy on colostomy care, revised in October 2010, outlined the need to record the date and time of care, any skin issues, and the signature of the person providing care. The lack of documentation and physician orders for colostomy care placed the resident at risk for complications such as infection, skin breakdown, and pain.
Failure to Post Oxygen Signage for Residents
Penalty
Summary
The facility failed to provide proper oxygen care and treatment services for two residents, leading to a deficiency in safety protocols. Resident 25 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. During an observation, it was noted that the nasal cannula was inside a plastic bag and not in use. The resident had an order for oxygen at 2 L/min via nasal cannula as needed for low oxygen or shortness of breath. A Licensed Vocational Nurse confirmed the absence of the required oxygen signage, and the Infection Preventionist stated that signage is necessary for safety due to the flammable nature of oxygen. Similarly, Resident 224 was observed using a nasal cannula connected to an oxygen concentrator, but there was no visible signage outside the door indicating oxygen use. Interviews with a Licensed Vocational Nurse and the Assistant Director of Nursing confirmed that signage should be present for residents using oxygen. The lack of signage for both residents posed potential hazards and accidents, as oxygen is highly flammable and requires clear identification to prevent smoking or other dangerous activities near the oxygen source.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to routinely assess the arteriovenous fistula (AVF) for a resident who required dialysis services. The resident, who had end-stage renal disease and other medical conditions, was scheduled for dialysis treatment three times a week. However, there were no physician orders in place to assess and monitor the resident's AVF for bruit and thrill, or for signs and symptoms of infection. This lack of orders and monitoring was confirmed during an interview with the director of nursing (DON), who acknowledged that nursing staff should check the AVF every shift, every day. Observations and record reviews revealed that the nursing staff only monitored the AVF on dialysis days, and there was no documentation of checks on non-dialysis days. The facility's policy on hemodialysis catheters indicated that signs of infection and patency should be checked at regular intervals, but this was not being followed. The DON confirmed the absence of physician orders and the need for regular monitoring, highlighting a deficiency in the facility's care for the resident's dialysis access site.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours on two separate days during the months of October and December 2024. Specifically, the facility's nurse schedule documents indicated that no RN was scheduled or on duty on October 31, 2024, and December 18, 2024. During an interview, the administrator confirmed the absence of an RN on these dates and acknowledged that the facility did not have a waiver for reduced RN nursing hours. The administrator also stated that the facility was aware of the requirement for an RN to provide resident care for 8 hours a day, 7 days a week.
Controlled Medication Documentation Deficiency
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for on the medication administration record (MAR) for three residents. For Resident 4, a Hydromorphone tablet was signed out of the Controlled Drug Record (CDR) but not documented on the MAR. Similarly, for Resident 58, three Tramadol tablets were signed out of the CDR but not recorded on the MAR on three separate occasions. Resident 67 had two Oxycodone tablets signed out of the CDR but not documented on the MAR. These discrepancies were verified by the Assistant Director of Nursing (ADON) during a concurrent interview and record review. The facility's policy and procedures require that the individual administering the medication initials the MAR after giving each medication. The failure to document the administration of these controlled medications on the MAR had the potential for unauthorized access to medications by residents and visitors. The ADON acknowledged the discrepancies and confirmed that the medications should have been documented and signed off on both the CDR and MAR.
Failure to Monitor Psychotropic Medication Effects and Target Behaviors
Penalty
Summary
The facility failed to monitor side effects and target behaviors for a resident receiving psychotropic medications, which compromised the ability to determine the effectiveness of these medications. The resident, who was admitted with diagnoses including Dementia with behavior disturbance, Alzheimer's disease, and Schizophrenia, was prescribed Seroquel, Bupropion HCL, and Depakote. However, there was no documentation of side effects monitoring for any of these medications, nor were target behaviors specified for Bupropion HCL and Depakote. During an interview with the Director of Nursing (DON), it was confirmed that there was no documentation of side effects or target behavior monitoring for the resident's psychotropic medications. The facility's policy requires that all medications used to treat behaviors must have a clinical indication and be monitored for efficacy, risks, benefits, and adverse consequences. The DON acknowledged that nurses should monitor for side effects and target behaviors every shift and document this information, which was not done in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.9% during a medication administration observation, exceeding the acceptable threshold of 5%. This was due to five medication errors occurring out of 42 opportunities. Specifically, Resident 7 did not receive three prescribed medications: Amlodipine Besylate, Acidophilus Xtra, and Methenamine Hippurate. Resident 63 did not receive Ferrous Gluconate as scheduled, and Resident 75 did not receive Ferrous Sulfate as scheduled. Additionally, the nursing staff failed to flush Resident 67's gastrostomy tube with the correct amount of water as ordered by the physician. The errors were confirmed through interviews with the Licensed Vocational Nurse (LVN) involved, who acknowledged the unavailability of the medications and the incorrect procedure followed for the G-tube flushing. The facility's policy and procedure for administering medications were not adhered to, as medications were not administered in a safe and timely manner, nor in accordance with prescriber orders. The failure to administer medications as prescribed had the potential to compromise the health of the residents by not providing the full therapeutic effect of the medications.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during inspections and interviews. An insulin vial was found in the medication refrigerator without an open date or vial flip-off cap, which was confirmed by the Assistant Director of Nursing (ADON). Additionally, an insulin pen was found expired in the medication cart without any patient-specific labeling, and several insulin pens in different medication carts lacked open dates. Licensed Vocational Nurses (LVNs) confirmed these observations, acknowledging that the lack of labeling was not in accordance with the facility's policy. Further deficiencies were noted in the labeling and storage of other medications. Several bottles of Artificial Tears and a bottle of Brimonidine 0.2% Eye drops were found without open dates or resident identifiers. An Albuterol Sulfate HFA Inhalation Aerosol also lacked a resident identifier. The Pharmacy Consultant confirmed that medications should have open dates and resident names on the bottles. Additionally, the medication storage temperature log was incomplete, with no temperature monitoring recorded for two specific days, as confirmed by the ADON. The facility also failed to maintain secure storage of medications. A medication cart was left unlocked in the hallway, which was confirmed by a Registered Nurse (RN), who stated that the cart should always be locked. An open bottle of mucus relief DM tablets was found in the medication storage room without an open date, which was confirmed by the ADON. These practices had the potential to lead to medication errors and reduced potency of medications, as they were not in compliance with the facility's policies and procedures.
Infection Control Breach with Nebulizer Mouthpiece
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy when an uncovered nebulizer mouthpiece was found on a resident's bedside table. During an observation, the mouthpiece was noted to be exposed, which was confirmed by a Licensed Vocational Nurse (LVN). The LVN acknowledged that the mouthpiece should have been cleaned, washed, dried, and stored in a plastic bag to prevent infection. The Infection Preventionist also confirmed that the nebulizer mouthpiece should not be left exposed. The facility's policy, dated September 18, 2023, mandates maintaining an infection prevention control program to ensure a safe and sanitary environment, which was not followed in this instance.
Damaged Bedside Table Poses Risk to Resident
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident 17, as evidenced by the condition of his bedside table. The table was observed to be damaged, with the surface material cracked and brownish material exposed beneath the original surface. Additionally, the plastic material that contours the edges of the tray table was broken, leaving sharp plastic edges exposed. This condition was noted during an observation on February 10, 2025, at 10:18 a.m., while Resident 17 was lying upright in bed with the table positioned in front of him. Resident 17, who was admitted to the facility with multiple diagnoses including Parkinsonism, epilepsy, major depressive disorder, and anxiety disorder, expressed dissatisfaction with the condition of his bedside table, describing it as 'ugly' and 'not smooth.' The Director of Nursing (DON) confirmed the poor condition of the table during an observation and interview on the same day, acknowledging that the table needed to be replaced. The failure to maintain the bedside table in a safe and sanitary condition had the potential to impact Resident 17's psychosocial well-being and self-esteem.
Undercooked Brown Rice Served to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, specifically when brown rice was undercooked and served to 18 residents. This issue was identified through observations, interviews, and record reviews. During a lunch test tray conducted with the Certified Dietary Manager (CDM), it was confirmed that the brown rice was undercooked and had a rough texture. The CDM admitted to not tasting the food prior to serving on that day. Resident interviews corroborated the issue, with complaints about the rice being undercooked and the chicken being tough. Further investigation revealed discrepancies in the cooking process. The Dietary Cook (DC) stated that the brown rice was cooked for one hour, although the facility's recipe indicated a shorter cooking time using a convection oven. The CDM acknowledged that there was no recipe for cooking brown rice for one hour and that the Registered Dietician (RD) was responsible for checking lunch trays. However, the RD stated that the CDM was responsible for tasting the food. The facility's document on Cook/Kitchen Staff duties emphasized the importance of preparing and serving meals that are palatable and appetizing, yet the policy for following menus was not provided upon request.
Failure to Document and Treat Resident's Wound
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with a right heel wound. The resident, who had a history of diabetes and poor wound healing, experienced a reoccurrence of a previously resolved right heel wound. Despite the reoccurrence being documented on 6/6/24, there was no documentation of treatment being provided until 6/11/24, five days later. This lack of documentation and treatment was confirmed during an interview with a licensed nurse, who acknowledged the absence of records indicating treatment during this period. The facility's policy on Skin Integrity Management required the implementation of wound care treatments as indicated, which was not adhered to in this case. Additionally, the facility failed to accurately complete Weekly Summary Documentations for the resident. Despite the resident having a documented right heel wound, the Weekly Summary Documentations incorrectly indicated that the resident did not have skin issues on several occasions. This discrepancy was confirmed during a review of the resident's medical record with a licensed nurse. The facility's policy on Guidelines for Charting and Documentation required documentation to be concise, accurate, and complete, which was not followed, leading to inaccurate assessments of the resident's condition.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received a prescribed medication, Enoxaparin Sodium Injection, as ordered by the physician. The resident, who was admitted with multiple fractures and a dislocated hip, had a physician's order for the medication to be administered subcutaneously every 12 hours to prevent deep vein thrombosis. However, the medication was not documented as administered on several occasions in December 2023 and January 2024, as it was pending delivery from the pharmacy. During an interview, a licensed nurse confirmed that the medication was not administered because it had not been delivered from the pharmacy. The nurse acknowledged that the failure could have been due to either the nurses not ordering the medication refills on time or the pharmacy not delivering the refills on time. The facility's policies on medication administration and pharmacy services indicated that medications should be administered according to established schedules and that residents should have a sufficient supply of their prescription medications.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from bed to shower chair, as the Certified Nursing Assistant (CNA A) did not provide appropriate physical assistance and support according to the resident's needs. The resident, who had a medical history of hemiplegia, hemiparesis, abnormal gait, and muscle weakness, was assessed as high risk for falls. Despite this, CNA A did not use proper techniques or equipment, such as a gait belt, and did not position the shower chair close enough to the resident, resulting in the chair being kicked backward and the resident falling to the floor. Interviews with other staff members, including another CNA and a Licensed Vocational Nurse (LVN), indicated that proper procedures for transferring residents include using a gait belt and ensuring the shower chair is positioned close to the resident. The Director of Staff Development acknowledged that CNA A should have provided more support by placing a hand under the resident's armpit and ensuring the shower chair was appropriately positioned. The facility's policies on personal nursing care and safe lifting and movement of residents emphasize the need for staff to assist residents according to their needs and to be trained in the use of manual and mechanical lifting devices.
Failure to Administer Prescribed Antibiotic Eye Drops
Penalty
Summary
The facility failed to ensure that a physician's order for an antibiotic eye drop was documented and administered for a resident experiencing symptoms of blepharitis. The resident had complained of right upper lid swelling and discharge, leading the physician to plan for the administration of Cipro Ophthalmic drops. However, a review of the resident's records showed no documentation that the antibiotic was ordered or given. Interviews conducted with the physician and the assistant director of nurses (ADON) confirmed the oversight. The physician indicated that he would have ordered the antibiotic due to the resident's symptoms, while the ADON, upon reviewing the records, found no evidence of such an order. This lapse in documentation and administration of the prescribed treatment had the potential to cause health complications for the resident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 24-hour timeframe. Resident 1, who had no cognitive impairment and was self-responsible, filed a grievance on 1/27/24, alleging that a nurse shouted at her and touched her leg roughly. Despite the grievance being documented on the same day, the facility did not report the incident to the California Department of Public Health (CDPH) until 2/2/24. This delay in reporting resulted in a delay in the investigation of the abuse allegation. Resident 1 had been admitted to the facility following a motor vehicle accident and required high doses of opiates for chronic pain. The grievance detailed that the nurse entered Resident 1's room shouting and touched her leg roughly. The nurse received a written warning and was suspended from 2/2/24 to 2/7/24. During an interview, the Assistant Director of Nurses acknowledged the delay in reporting and confirmed that the grievance should have been reported within 24 hours, as per the facility's policy revised in August 2022.
Failure to Provide Social Services Support After Abuse Allegation
Penalty
Summary
The facility failed to provide appropriate social services support following an abuse allegation for a resident. An investigation into an employee-to-resident abuse allegation was conducted, and a review of the resident's medical record showed no documented evidence of a social services assessment focused on the resident's psychosocial well-being after the abuse allegation. During an interview, the Director of Nursing (DON) stated that there should be 72 hours of nursing monitoring every shift and social services psychosocial follow-up for 72 hours after an incident. However, the DON could not find any social services follow-up notes for the incident. The facility's job description for the Social Services Director indicated that residents should be assessed upon admission, quarterly, and upon a change of condition for social services needs, with thorough and timely psychosocial history and assessment completed for each resident. This documentation was not found in the resident's records.
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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